System Expands Remote Services for Management of Chronic Diseases During Pandemic | NYC Health + Hospitals

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NYC Health + Hospitals Expands Remote Services to Improve Management of Chronic Diseases, Facilitate Connection to Resources During COVID-19 Pandemic

The health system’s Office of Population Health expanded access to diabetes peer mentoring program to improve management of sugar levels, distributed at-home blood pressure monitors, and launched virtual pediatrics exercise classes. NYC Health + Hospitals further integrated referrals through the system’s electronic medical record system to connect patients to additional resources and wrap-around services

Nov 13, 2020

New York, NY

NYC Health + Hospitals today announced its expansion of remote services during the COVID-19 pandemic to improve monitoring of chronic diseases and enhance connection to wrap-around services from home. Led by the system’s Office of Population Health, access to a diabetes peer mentoring program was expanded at NYC Health + Hospitals/Elmhurst to help patients monitor sugar levels. Over 2,000 at-home blood pressure monitors have been distributed to patients across the system. The expansion of remote monitoring resources allows patients to eliminate some in-person clinic visits, while still being proactive about chronic diseases management and necessary interventions. In addition, the Office of Population Health launched virtual pediatrics group exercise classes, which were previously held in-person at five hospitals across the public health system. NYC Health + Hospitals also further integrated social service referrals through the system’s electronic medical record (EMR) system to connect patients to additional resources and wrap-around services in the community, such as SNAP registration assistance and immigration legal services. The expansion of remote and electronic resources continues to provide necessary care and services to NYC Health + Hospitals’ patients who are unable to have in-person visits during the pandemic.

“Ongoing management of chronic diseases are critical for all patients, especially now given our knowledge of the role such diseases play in COVID-19 outcomes,” said NYC Health + Hospitals Chief Population Health Officer Nichola Davis, MD. “The City’s public health system is continuing to make strategic investments in remote health services and connection to important support to ensure everyone remains as healthy and strong as possible against the threats of the ongoing pandemic.”

Expansions to remote services in response to the spring 2020 COVID-19 surge included:

  • Expanded Diabetes Peer Mentoring Program: In May, the system’s Office of Population Health expanded its diabetes peer mentoring program to NYC Health + Hospitals/Elmhurst to ensure that patients with diabetes had the necessary resources and support to continue to monitor and address their diabetes at home during the surge. Partnering with InquisitHealth, a social therapeutics company, patients with diabetes have access to peer mentors over the phone to help support and enhance their diabetes self-management. Peer mentors are patients who are successfully living with diabetes and are trained to help other patients who are struggling with their diabetes. This remote workforce of mentors helps address each patient’s barriers related to the social determinants of health, while inspiring healthy lifestyle behavior changes. Once a patient is referred to the program by their primary care doctor, they are matched to a culturally appropriate mentor, scheduling regular check-ins by phone, and touching base more frequently as needed.

    Since its launch at NYC Health + Hospitals/Elmhurst in May, a total of 181 patients with an A1c of nine or greater were enrolled in the mentoring program. The program, which was launched at NYC Health + Hospitals/Kings County and Gotham Health, Cumberland in December 2018, has seen nearly 500 patients go through the program.

  • Distributed At-Home Blood Pressure Monitors: NYC Health + Hospitals purchased more than 10,000 at-home blood pressure (BP) monitors in June 2020 to be distributed to uninsured patients with uncontrolled hypertension. To-date, over 2,000 monitors have been given to patients system-wide. The remaining monitors will be distributed on a rolling basis to patients.

    Providers recommend the at-home monitors to patients with uncontrolled hypertension during their in-person clinic visits. This allows the provider and chronic disease nurse to train the patient on how to use the monitor and record the information for their clinical team. Once received, the patient periodically monitors their BP and adds the reading to their patient portal page on MyChart or another type of log. A member of the patient’s care team then reaches out to them to discuss the home BP values and any needed medication changes, along with general hypertension self-management strategies. NYC Health + Hospitals plans on acquiring more BP at-home monitor machines to continue to distribute them to patients who can benefit from home BP monitoring.

  • Shifted to Virtual Group Exercise Classes: In September, NYC Health + Hospitals launched virtual pediatrics group exercise classes, transitioning them from their traditional in-person setting prior to the pandemic. The system’s health educator and exercise specialist facilitate once-a-week group classes for the Train, Exercise, Engage N’ Shape-Up (TEENS) group, as well as the Family Weight Management Exercise & Nutrition groups. Each class goes for one-to-two hours, and includes nutrition education. There are four types of classes: cardio-respiratory, total body conditioning, strength and high intensity interval training, and flexibility and balance training.

    With approximately 10 participants per class, the health instructor is able to provide real-time guidance on the exercise moves and then conduct a nutrition dialogue with the group. Participants are referred to the classes by their provider for weight and nutrition management. The Office of Population Health is hoping to expand the virtual exercise and nutrition service to post-bariatric surgery patients and other groups in the months to come. Prior to the pandemic, classes were held at individual hospitals in-person.

  • Integrated Social Service Referral Platform into Electronic Medical Record: In September, the Office of Population Health further integrated social service referrals into the system’s electronic medical record system, facilitating a remote referral process for patients to community supports. The integration leverages NowPow, a social service directory and referral software, to identify resources for patients based on their unmet social needs, and to share resource information via text and email in the patient’s preferred language. During outpatient visits, the integration automatically generates the resource recommendations for patients. The recommendations are based on the patient’s address, age, and gender, as well as facility preferences for local resources.

    Some resources that a patient can be referred to include mental health counseling, food pantries, SNAP registration assistance, and immigration legal services. Since the integration, there have been an average of about 200 staff using NowPow per day, and in the first month of the integration, nearly 1,000 resource lists were generated. All resources have been vetted by the NowPow team and include a COVID-19 status so that patients know if services are being offered in person, telephonically or by delivery/pick up.

“We’re very fortunate to be able to safely work with patients remotely to continue to manage their chronic diseases, which is critical during the pandemic,” said Parvin Begum, RN, a chronic disease nurse at NYC Health + Hospitals/Queens. “Over the summer, we worked with one patient who has uncontrolled hypertension and also has a limited English proficiency. Our team trained him to use the BP monitor and log-in his BP readings onto MyChart in Spanish. With that information, in addition to our frequent telephonic visits, we were able to successfully get his BP down to a healthy level and he graduated from our Treat-2-Target program.”

“Patients need timely care and telemedicine helps to provide that safely during the pandemic,” said Assembly Health Committee Chair Richard N. Gottfried. “Expanding remote services will connect more patients with the services they need. I commend NYC Health + Hospitals for building critical social service referrals into its remote programs.”

The expansion of these remote services and programs build on the City’s public health systems’ recent investments in telemedicine services. Offering primary care and over 90 specialty care services, all NYC Health + Hospitals patients now have the option to access care from their home through a phone or tablet when it’s clinically safe to do so. Phone and video visits offer a safe alternative for many patients. The City’s public health system was able to quickly scale up its telemedicine services, going from just 500 billable virtual visits in the month prior to the COVID-19 pandemic, up to nearly 57,000 in the first three weeks of the pandemic, and over 300,000 televisits through May.

Further, in September 2020, the system launched its virtual ExpressCare services, further ensuring New Yorkers have convenient, one-click access to the most appropriate care where they are safest during the pandemic – at home.


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