Real-World Examples of Patient-Centered Healthcare

Published on: 
Evidence-Based Diabetes Management, March/April, Volume 19, Issue SP2

Many healthcare communities have implemented programs to help patients with the plethora of issues that arise during the course of their medical care. Craig Brammer, a member of the Senior Leadership Team at the Office of the National Coordinator for Health Information Technology in Washington, DC, moderated a session at Diabetes Innovation 2012 entitled State Based Solutions and Beacon Communities, which provided examples of how different healthcare communities have helped their patients with diabetes.

Montana Cardiovascular Disease and Diabetes Prevention

The roots of the Montana Cardiovascular Disease and Diabetes Prevention Program began in 2007, when Montana’s legislature authorized the use of state funds to evaluate whether or not it was feasible to provide Montana with a diabetes prevention service consistent with the evidence-based Diabetes Prevention Program (DPP), according to Steve Helgerson, MD, state medical officer and Medicaid medical director of the Montana Department of Public Health and Human Services. The feasibility of this initiative has been demonstrated in Montana. Starting in 2008, Montana has continued to increase the number of diabetes and cardiovascular disease prevention sites across its state each year. Some sites have associated telehealth sites, which are especially important for delivering services to Montana’s geographically large but sparsely populated state.

At present there are 15 locations for the preventive program. The program lasts 16 weeks and is administered by trained healthcare professionals. The participants are selected only after meeting specific criteria. The key criterion is that the patient has to want to change their current lifestyle. Also, the program is limited to those recommended by their primary care physician to be at risk for developing diabetes.

The program itself is similar to the DPP developed by the National Institutes of Health, which reported a 58% reduction in the incidence of diabetes among participants.1 The 16-week DPP program focuses on diet, exercise, and behavior change to work toward the goals of 7% weight loss and 150 minutes per week of physical activity. The Montana program also includes 6 monthly follow-up classes.

The results of the program in Montana have been very impressive. Dorothy Gohdes, MD, a consultant for the Montana Chronic Disease Program, said that the latest statistics on the program (2008-2011) show that over 2700 participants completed the 16-week program and lost an average of 12 pounds. Furthermore, 34% of the participants met the program’s weight loss goal (loss of 7% of their starting weight) and 54% met the physical activity goal. Improvements have also been observed in blood glucose, blood pressure, low-density lipoprotein cholesterol (LDL-C), triglycerides, and total cholesterol. More information about this program can be found at

The challenges facing the state of Montana in trying to start (and maintain this type of program are similar to those facing other public and private institutions, and they include securing reimbursement and training program leaders. Moving forward, Dr Gohdes is optimistic that this program will continue to be successful in teaching participants how to lead healthier lifestyles. Dr Gohdes also hopes the program will have a ripple effect in getting family members to adopt the program as well. To learn more about Montana’s Cardiovascular Disease and Diabetes Prevention Program, visit


Beacon Communities

Healthcare providers generally have the same 3 aims: 1) to provide better healthcare, 2) to help patients achieve better health, and 3) to do that at a reduced cost. According to Craig Brammer, a member of the Senior Leadership Team at the Office of the National Coordinator for Health Information Technology, a key component to achieving these 3 goals is the use of information technology (IT). Beacon Communities are leading the way in using IT to provide better healthcare at a reduced cost to improve the health of their participants. The Beacon Community Cooperative Agreement Program demonstrates how health IT investments and meaningful use of electronic health records (EHRs) can advance the vision of patient-centered care. At present, there are 17 Beacon Communities in the United States and the National Coordinator for Health IT is providing $250 million over 3 years to develop secure, private, and accurate systems for EHR adoption and health information exchange (HIE). For more information on how the federal government is helping to advance health IT integration and about the Beacon Communities, visit

Described below are 2 Beacon Communities that use IT in unique ways to help patients with diabetes.

Hawaii Island Beacon Community

The Hawaii Island Beacon Community (HIBC) is a federally funded collaborative project administered through the College of Pharmacy at the University of Hawaii at Hilo. The collaboration brings together healthcare professionals, hospitals, community organizations, and residents to eliminate barriers to quality healthcare on Hawaii Island. The main goal of HIBC is to empower residents to take control of their health and wellness. Part of that process is allowing patients to have easy access to their EHRs. HIBC is working with healthcare providers and clinicians to assist them in integrating health IT into their practices.

Since communication is local, the HIBC adapted a program that is uniquely Hawaiian. Its concept, according to Susan Hunt, chief executive officer of the HIBC, drew on the traditional Hawaiian land divisions, or ahupua‘a: wedge-shaped areas running from the mountains to the sea, following natural watershed boundaries.

Ms Hunt noted that the key to their success has been recruiting participants to embrace EHRs. That began with the primary care providers. At the start of the program, approximately one-half of their 184 primary care providers were using EHRs at a “meaningfully useful” level. One year later, 86% had adopted the use of EHRs.

Equally important, patients have joined the program in record numbers and the registry for diabetes and cardiovascular disease has grown steadily since the beginning of the year. That increase coincides with improvements in various diabetic and cardiovascular outcomes.

To create HIBC, leaders in the public and private sector joined together, including federal, state, and private hospitals, the Native Hawaiian Health Care System, the Hawaii Island Care Coordination Services, the National Kidney Foundation of Hawaii, and the state’slargest health plans (eg, AlohaCare, Medicaid). Together, they are working on a variety of ways to improve the flow of information to: 1) improve healthcare; 2) improve health; and 3) reduce costs.

A key component of HIBC is innovation. Ms Hunt talked about a pilot project that started in 2011 that involves 10 offices that use a software program (more info at as well as other measures to identify gaps in care and to obtain real-time feedback on quality care process measures. The success of that project has led to the adoption of Cozeva by all offices in the program.


Ms Hunt ended her presentation by stating that HIBC is truly a community. Working together, the group has had great success in a number of other areas, as shown in the .

Western New York Beacon Community

Patient Perspective

The Western New York Beacon Community ( beacon) has been at the forefront of improving clinical outcomes and safety in patients with diabetes through the use of healthcare IT and health information exchange. Their efforts to improve care of patients with diabetes in the community were exemplified by Beacon project director Bob Hoover, who told the audience about “Kenneth,” a 54-year-old patient who participated in one of their telemonitoring pilot programs (see box).

One of the major advantages of telemonitoring is that it requires the patient to be compliant. Otherwise, the patient gets a phone call from a health professional to ask if there is a problem. The telemonitoring program currently has over 100 high-risk patients who have equipment in their homes to monitor glucose, blood pressure, and body weight. These patients belong to 1 of 3 participating home healthcare agencies and 1 of 6 practices. The data are monitored by nurses and other healthcare professionals who can report critical information to treating physicians if necessary. The data are also available through virtual health records to any of the participating patients’ healthcare providers.

This program was initiated using funding from the Beacon Program. According to Mr Hoover, once that funding stops, healthcare providers in the community plan to continue to fund the telemonitoring program, based on its success.

The Western New York Beacon Program is a collaborative effort between HEALTHeLINK (regional health information organization for Western New York) and more than 40 partner organizations that are marrying clinical technology with clinical transformation to improve diabetes care at the practice level. So far, the involved organizations have embraced the use of EHRs. According to Mr Hoover, there has been a 650% increase the usage of virtual health records from December 2010 to December 2011. Mr Hoover ended his presentation with data from the diabetes registry they now have in place. At last count, there were 91 practices in the registry. Data from 3 phases of the program show a reduction in the percentage of patients that have poorly controlled diabetes and an increase in the percentage of patients that have control of LDL-C in just one 3-month period.

Concluding Remarks

Creating programs that allow patients, doctors, and providers to interact via electronic means provides benefits to all parties. The pilot programs seen in Montana as well as the various Beacon communities show that the use of EHRs and telemonitoring can improve both healthcare and patients’ health, with the potential for reduced overall costs.

Reprinted from A Special Report on Diabetes Innovation 2012. Am J Manag Care. 2012;18:14-16.

Patient Perspective: “Kenneth,” 54-Year-Old Participant in Telemonitoring Pilot Program

“Telemonitoring has worked well for me because I know someone is monitoring me daily. If I don’t monitor, I know that the nurse through telemonitoring will call me, which gives me incentive and motivation to do it. In the last few months my A1C has decreased remarkably and has been the best it has been in many, many years. My blood pressure has also decreased from 150s to 130s and although slower than I might like, my weight has decreased also. Nurses from the Visiting Nurses Association and Elmwood Health Center offer me encouragement, support, and assistance in obtaining supplies and medications. I see all of this as one big puzzle and without all of the pieces it falls apart. I have maintained better blood sugar control, blood pressure control, and weight loss since beginning on telemonitoring.”

1. US Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes Prevention Program. NIH Publication No. 09- 5099. preventionprogram/. Published October 2008. Accessed November 16, 2012.