NYC Health + Hospitals Launches Primary Care-Centered Diabetes Management Program | NYC Health + Hospitals

NYC Health + Hospitals Launches Comprehensive, Primary Care-Centered Diabetes Management Program to Improve Care for More Than 60,000 New Yorkers with Diabetes

20 new clinical pharmacists will be integrated in primary care to help patients manage diabetes medications between primary care visits

New smartphone technology services and peer mentoring offers tools and support for patients with diabetes to self-manage their disease

Advanced equipment will make teleretinal screening a routine part of primary care for all patients with diabetes, eliminating having to schedule screening appointments with ophthalmologists

Jul 24, 2019

New York, NY

NYC Health + Hospitals today announced the launch of a comprehensive, primary care-centered diabetes management program, including investing in new clinical pharmacy staff, equipment, and technology to improve health outcomes and expand services through telehealth techniques for more than 60,000 New Yorkers with diabetes who receive care in the City’s public hospitals and community-based health centers. Diabetes is a complex medical problem and uncontrolled diabetes can lead to health complications, including heart disease, blindness and kidney failure. Committed to improving the care of patients with diabetes, the public health system will deploy a new cadre of clinical pharmacists to care for patients as an extension of their primary care teams, and purchase new advanced equipment to make teleretinal screening part of routine care for all patients with diabetes. NYC Health + Hospitals is also piloting a diabetes self-management app and a program that provides telephone based peer mentorship, putting an emphasis around telehealth techniques. The new services for New Yorkers with diabetes are part of the health system’s population health strategies and its broader multi-year redesign to build a competitive, sustainable organization that will continue to offer high-quality and accessible health care to the people of New York City.

“We’re investing in these new programs to make primary care more robust and effective for patients with uncontrolled diabetes, and help them adhere to their medications, take care of their vision, get counseling from someone who has experienced the same challenges, and ultimately feel empowered to take charge of their health,” said Mitchell Katz, MD, NYC Health + Hospitals President and CEO. “Our commitment to guarantee health care to all New Yorkers will be supported with smart and responsive clinical care strategies to help patients manage some of the most common chronic conditions that affect their ability to live, work, and play.”

“There isn’t a single silver bullet for treating diabetes, a disease that impacts many areas of one’s health and lifestyle, requiring a comprehensive approach to health management,” said Dave Chokshi, MD, Vice President and Chief Population Health Officer at NYC Health + Hospitals. “With this multi-pronged approach, we can help many patients who are struggling to manage their diabetes streamline their care by tracking their blood sugar levels and food intake, customizing their medication, and being more proactive around preventative screenings.”

The new NYC Health + Hospitals initiatives to help improve health outcomes for New Yorkers with diabetes include:

  • Integrating Clinical Pharmacists in Primary Care – Twenty new clinical pharmacists will be added throughout the public health system by the end of 2020 to work as integrated members of primary care teams with a focus on medication management. Clinical pharmacists act as part of patients’ care teams but operate independently to help patients, in this case with uncontrolled diabetes or complicated diabetes medication regimens, to manage their medications between primary care visits. The public health system is investing approximately $3M to help hire the initial 20 clinical pharmacists as part of their first phase of implementation. They will be supported by existing patient care associates.
  • Teleretinal Screening in Primary Care – Primary care sites across the City will offer advanced teleretinal screenings as part of routine primary care visit for patients with diabetes. Patients will be able to get their preventive care in a more convenient way instead of having to schedule a separate ophthalmology appointment. Annual retinal screening is an important component of comprehensive diabetes care. Those with consistently uncontrolled diabetes are at risk for developing diabetic retinopathy, the leading cause of blindness in U.S. adults aged 20-74. Diabetic retinopathy may not cause symptoms immediately; therefore, early detection through screening is the best way to prevent vision loss in patients. The program will be implemented throughout the latter half of 2019 across the system’s 11 hospitals, two Gotham Health centers in Brooklyn and Manhattan, and the system’s Correctional Health Services facility.
  • Peer Mentors a Phone Call Away – Partnering with InquisitHealth, a social therapeutics company, patients with diabetes can now speak to peer mentors on the phone to help enhance their diabetes self-management. Peer mentors are patients who are successfully living with diabetes who are trained to help other patients who are struggling with their diabetes. This remote workforce of peer mentors helps address each patient’s barriers related to the social determinants of health while inspiring healthy lifestyle behavioral changes. Once a patient is referred to InquisitHealth by their primary care doctor, they are matched to a culturally appropriate mentor, scheduling regular check-in and touching base more frequently as needed. The end goal for each patient is sustained improvements in diabetes management, improved HbA1c, and a higher quality of life. The peer mentoring program is offered at NYC Health + Hospitals/Kings County and NYC Health + Hospitals/Gotham Health, Cumberland as of December of 2018.
  • A Coach in Your Pocket Smartphone App – BlueStar is an app that provides real-time, individualized coaching, reminders and support, as well as diabetes educational tools that are actionable and personalized for each patient to monitor and manage their type-2 diabetes. The app helps to bridge the gap between patients and their providers outside of the clinic visit. With integrations to devices and apps, patients can connect to their pharmacies medication tracking, blood glucose meters, labs, and activity trackers. Based on the collected information, BlueStar provides patient feedback, guidance and education for better patient self-management and clinical decision support. The data analysis and feedback are evidence- and theory-based, and tailored to the individual’s clinical needs, goals, and lifestyle. The app also provides diabetes articles and videos, healthy recipes and access to the user’s own care team via the app. The app was launched in December 2018 at NYC Health + Hospitals/Metropolitan and NYC Health + Hospitals/Queens.

“We all need comprehensive primary care, but patients with diabetes need management assistance to help them avoid dangerous and expensive complications,” said Assembly Health Committee Chair Richard N. Gottfried. “This program will connect patients served by NYC Health + Hospitals with pharmacists and practitioners in person and remotely, improving the quality of care and helping patients manage their condition. It’s a model for other health care providers.”

“By creating this comprehensive, primary care-centered diabetes management program, NYC Health + Hospitals will provide 60,000 New Yorkers with diabetes the resources they need to ensure they effectively manage such a complex health condition,” said State Senator Gustavo Rivera, Chair of the Senate Health Committee. “This innovative approach will connect patients to expert clinical pharmacists, advanced diabetes screenings, and a helpful smartphone application that will help them to improve their health outcomes.”

“I use the BlueStar app every day and particularly like the instant responses when I add my glucose levels,” said Barbara Abioye, a NYC Health + Hospitals patient and user of the diabetes self-management app. “Before the app, managing my diabetes was a mystery, but the feedback and education makes it much easier to adjust my lifestyle to help control my diabetes.”

“I’m grateful to have a program like peer-to-peer mentoring available to help me manage my diabetes,” said Helen Augustus, a NYC Health + Hospitals patient and participant in the InquisitHealth mentoring program. “Knowing that my mentor has successfully managed her diabetes and understands my lifestyle and culture makes me feel confident that the advice shared will be easy to apply to my everyday life.”

The BlueStar app and peer-to-peer mentoring program have both shown success in significantly reducing A1c levels. They currently each have approximately 300 enrollees and are under evaluation to determine future expansion in additional NYC Health + Hospitals facilities.

In addition to these new initiatives, NYC Health + Hospitals offers expert diabetes care at all acute health facilities and neighborhood health centers, which may include education classes, one-on-one sessions, and patient support groups. NYC Health + Hospitals/Kings County, Jacobi, Lincoln, Metropolitan, North Central Bronx, and Queens, as well as NYC Health + Hospitals/Gotham Health, Sydenham, are accredited for providing high-quality, evidence-based education to patients with diabetes.

The prestigious accreditation from the American Association of Diabetes Educators or the American Diabetes Association verifies that the hospitals’ programs meet national standards for diabetes self-management education, which have been shown to be cost-effective and improve clinical outcomes and patients’ quality of life.

Nearly one million New Yorkers have diabetes, and about 19 percent are undiagnosed. Uncontrolled diabetes can cause blindness, and chronic kidney disease, which may require dialysis, and lower extremity amputations in adults. Obese New Yorkers are two times more likely as other adults to have diabetes. Black, Hispanic, and Asian New Yorkers are also at least twice as likely to have diabetes as white New Yorkers. The average medical expenditures for people with diagnosed diabetes are about $13,700 per year, with about $7,900 of this being attributed to diabetes management directly.[1]


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