Objective: The mission of this initiative is to get to know each participant behind their diagnoses - through telehealth and home visits - for enhancing the personalized healthcare delivery in chronic disease management. The initiative emphasizes on the management of type 2 diabetes (T2D) , hypertension, chronic kidney disease, COPD, heart failure, and asthma. This abstract focuses on evaluating outcomes relating to T2D.

Methods: The evaluation uses a cross-sectional design to summarize the baseline demographic data pertaining to participants and analyze outcomes from June to December 2021. Descriptive statistics were used to study the current outcomes of the initiative.

Results: The selected process and impact outcomes are summarized along with demographic information.

Conclusion: Many participants increased frequencies on blood glucose and pressure monitoring. These behavioral changes are translated into A1c improvement. Through connecting with participants, their urgent medical needs were met when primary care providers (PCPs) were unavailable, e.g., resolving hypoglycemia episodes, medication titrations for managing hyperglycemia. Findings have shown that this model refines the care delivery for patients with diabetes going beyond the walls of clinics by partnering clinical pharmacists with diabetologists and PCPs at a safety-net clinic system.


C.F.Young: Advisory Panel; Sanofi-Aventis U.S. S.Wong: None.


Sutter Health

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