Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often\r\nlimited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there\r\nare few examples of successful health system implementation. Program Development. An iterative process of program design\r\nwas built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a ââ?¬Å?human faceââ?¬Â to the\r\npilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced\r\nconcerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health\r\nplan use automated text messaging to provide personalized self-management support for member patients with diabetes and\r\nfacilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a\r\nnurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the\r\nexisting health system to support a de novo care management program by leveraging mobile technology. The program supports\r\nself-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and\r\nneeds of health plan administrators.
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