The numbers are staggering.

Treating diabetes in Michigan costs more than $8 billion annually, according to the 2010 report “The Economic Burden of Diabetes,” and affects approximately 93,000 individuals in the state’s underserved southeast region, according to the Centers for Disease Control and Prevention  Behavior Risk Factor Survey 2008 Age Adjusted Estimates. Most of these patients lack access to a range of resources needed for effective diabetes management, including financial resources, dietary guidance, and public fitness facilities.

Southeast Michigan Beacon Community

As a member of the ONC Beacon Community Program, the Southeast Michigan Beacon Community (SEMBC) is committed to leveraging innovative health IT solutions to create scalable, sustainable improvements in the quality of patient care. A cornerstone of our program is the Patient Health Navigator initiative, which is designed to improve the continuity, quality, and safety of care for underserved, high-risk patients while reducing associated costs.

About the Patient Navigator Program

Building upon a strong IT infrastructure and tools that include a targeted health information exchange and practice-level clinical decision support tools, the Patient Health Navigator program empowers select patients and their Patient Health Navigators with tools and timely information that help them with their diabetes management.

Some of the health IT tools and protocols that are being planned, tested, and implemented in the Southeast Michigan Beacon Community include:

• Testing electronic health record (EHR) physician reminder prompts that identify patients who may be qualified for a Patient Health Navigator based on defined clinical criteria
• Allowing patients to conduct a text message-based diabetes assessment and receive customized educational and goal setting and tracking messages through a mobile health campaign
• Leveraging patient information from a health information exchange, which helps guide patient interaction by allowing physicians and hospitals immediate access to laboratory, radiology, and clinical results
• Supplementing patients’ EHRs with information related to Patient Health Navigator engagement, so that doctors know about Patient Health Navigator interventions

How Patient Health Navigators Help with Diabetes Management

Here’s how the Patient Health Navigator initiative works:

• After being identified by their primary care provider as an uncontrolled diabetic, patients are offered the opportunity to enroll in the Patient Health Navigator Program
• Once they provide their consent and receive informational materials, patients are contacted by a Patient Health Navigator, a trained professional who can help outline healthy behaviors and improve compliance with treatment regimens

Patient Health Navigators provide a range of valuable services that extend beyond lifestyle and medication guidance, including:

• Engaging a patient population of “hot spotters” (underserved, needy individuals who have fallen outside of or failed to enter care)
• Following up with patients who miss appointments
• Providing emotional support and helping patients schedule and secure transportation to office visits

Behind the scenes, Patient Health Navigators also interact with physician office staff members, providing suggestions on how best to engage patients in their diabetes management and ensuring better coordination among various providers.

Case Study: Candace Hall, Trained Patient Health Navigator

Reports from the front lines have been promising. Candace Hall, one of the program’s trained Patient Health Navigators, was recently assigned a patient who had repeatedly refused to follow his doctor’s guidance for several months. As the patient’s condition continued to deteriorate, his physician called on Candace’s support to turn the situation around.

“By the time I was brought in, the doctor hadn’t seen the patient in a year,” Candace said. “He was such a difficult case that his physician said he would be impressed by any progress we could make. I saw that not only as a challenge, but an opportunity to put my training to work.”

After contacting the patient by phone, Candace agreed to meet him at his home. When she arrived, she found the patient nearly immobile—he  could only move between his bed and a non-functional electric wheelchair—and discovered that he was refusing to perform even basic self tests, such as measuring his blood sugar. Although the patient was initially resistant, Candace explained the importance of lifestyle changes and pointed out that even small steps could yield major improvements in his condition. After listening to Candace’s advice, the patient agreed to begin doing chair exercises to re-build lost muscle strength and said he would consider doing self-testing in the future.

Candace reported back to the patient’s physician, noting that the patient’s wheelchair was inoperable. She arranged for a new one to be delivered to his home and continued to follow up with him over the course of the next few weeks.

As a result of Candace’s efforts, the patient’s quality of life has improved significantly. His new wheelchair restored the mobility he had lost for months, allowing him to freely leave his home. He now regularly monitors his blood sugar, decreasing the likelihood of additional health complications or a costly hospitalization.

The patient was so impressed with Candace’s attentiveness, patience, and dedication that he contacted the Beacon office and asked to speak to senior leadership. During the call, he praised Candace for providing him with the individual guidance he needed to understand his condition and reduce the severity of his symptoms.

“The whole experience really proved the value of the Patient Health Navigator Program,” said Candace. “Interacting with these patients one on one and watching their lives improve as a result of your intervention—that’s what makes my work so gratifying.”

Referrals to the Patient Health Navigator Program

Currently, 340 patients have been referred to the Patient Health Navigator Program by 42 physician practices. SEMBC will continue to expand and refine the program by reviewing the Patient Health Navigator experience from the patient’s perspective and making continuous improvements. It is also anticipated that there will be a future linkage between the Patient Health Navigators and hospital emergency departments.

For more information, visit the Southeast Michigan Beacon Community at: www.sembc.org

For more information on how health IT visit http://www.healthit.gov/.