18-OR: Joslin Home: An Innovative Integrated Digital-Health Model of Diabetes Care in the Technology Era

Despite major advances in diabetes care and technology, the current clinic-based model is costly and at times inefficient with limited scalability. Joslin Home model (JH) includes 5 new pillars of diabetes interactions: short visits of 5-15 min conducted by telehealth, more frequent visits with a multidisciplinary team (MD, NP, RD, CDE, exercise physiologist (EP), and behavioral therapist (BT)), direct 2-way electronic scheduling, brief documentations and easy one-step billing.

In this 6-month pilot study, we tested the feasibility of JH among 17 patients with critically high A1C (average 9.5±1.6%), age 62±14 yrs, weight 225±35 lbs and 70.6% treated with insulin. Cellular glucose meter, body-weight scale and BP kit were delivered to subjects’ homes for self-reporting. Patients were instructed to self-schedule/cancel appointments using an electronic calendar. Five precise questions were asked before each encounter. Providers were asked to briefly document encounters.

Results: Virtual visits were completed in an average of 16 min, MDs and NPs concluded them in <15 min (∼11 min), but BT needed the longest time (20-30 min). Patients had an average of one encounter/week. Higher visit frequency was only seen in <25% of patients. Around 76% of scheduled encounters were completed (range 56-100%). Visit cancellation was the lowest with RD and EP (10-18%) and highest with BT and CDE (29-31%). A1C dropped significantly by 1.2% (to 8.2±1.5%, p<0.001). Patients’ satisfaction was high and they were willing to pay out-of-pocket of $50-200/encounter. We conclude that JH model is potentially acceptable alternative to clinic-based model and that is potentially scalable for remote and underserved areas where multidisciplinary approach is lacking. Frequent and short encounters of <20 min resulted in significant A1C improvement. JH may be ideal for high-risk patients who require frequent encounters with a diabetes team. Larger adoption in a randomized clinical study warrants consideration.