We developed a text message-based diabetes program that provides self-management support and team-based care management for patients with diabetes (). The program is fully funded by UCHP and is offered free of charge to members with type 1 or type 2 diabetes who receive care at the University of Chicago Medicine (UCM). Each participant is enrolled in the program for a period of six months, after which UCHP will determine whether to extend the program. UCHP contracted with a software vendor mHealth Solutions, LLC (New York, NY) for a mobile health software program called CareSmarts. The following is an overview of the key features of this project.
Figure 1 Conceptual representation of the text message-based chronic care program. 1Health plan care managers enroll eligible member with type 1 or type 2 diabetes over the phone. 2Patient receives self-management support via automated text messages and respond (more ...)
4.1. Program Administration
The University of Chicago Health Plan serves as the primary site of the diabetes text messaging program. UCHP RN-trained administrators (henceforth referred to as “care managers”) enroll eligible members in the program, monitor system-generated alerts, and coordinate care with the primary and subspecialty care teams.
Members are eligible if they are English-speaking adults ages 18 and older and carry the diagnosis of type 1 or type 2 diabetes. Exclusion criteria include members who are not their own primary caregiver, live in a nursing home, or do not have access to a personal mobile phone. Physician consent is obtained prior to recruitment and physicians have the option to exclude individual patients or their entire panel. Enrollment in other DMSE programs or diabetes research studies is not an exclusion criterion and is in fact encouraged.
UCHP care managers enroll eligible members over the phone (, step 1). Enrollment is completely voluntary and members have the opportunity to leave the program at any time. The enrollment process takes between 15 and 20 minutes. While it would have been feasible for patients to enroll themselves online, care managers personally enroll patients to circumvent any patient barriers to Internet access and to foster a personal relationship with each patient. To further build rapport, patients are provided a web link to a YouTube video in which each care manager briefly introduces herself and explains why she is excited about participating in the program.
4.4. CareSmarts System Tutorial
Following enrollment, participants begin exchanging text messages with the CareSmarts system through their personal mobile phones (, step 2). During the first week, participants are trained on how to use the system. They are taught to respond to questions using a particular syntax (e.g., yes or no for yes/no questions or 1, 2, or 3 for multiple choice questions) and to respond within 1 hour of receiving of the query. When a patient responds in a form the system cannot interpret, she receives a follow-up text message to facilitate learning. For example, “We did not understand your response—in the future please only respond to yes/no questions with either a yes or no.” Nonresponses are logged and at the end of the tutorial week participants with less than an 80 percent response rate are contacted by phone to troubleshoot technical difficulties and encourage adherence. After the first week, an alert is generated for participants with low response rates, which prompts the care manager to reach out to the patient and reengage them in the program. Throughout the program, patients are reminded that the system is not an emergency response system and to only send messages in response to queries.
4.5. Self-Management Support
Text messages exchanged with patients are organized into four domains: education, medication reminders, glucose monitoring reminders, and foot care reminders. Each domain is comprised of two-week modules, which vary by topic and frequency of messages. Each two-week education module focuses on one diabetes self-management topic: medications, nutrition, glucose monitoring, foot care, or exercise. In addition, each module covers a specific topic relevant to living with a chronic illness such as navigating the health care system or coping with stress. The other three domains—medication reminders, glucose monitoring reminders, and foot care reminders—are designed to support behavior change. They consist largely of reminders (“Time to take your diabetes medication.”), tips (“Keep your medications next to the sink so they become part of your morning routine.”), assessments (“On how many of the last seven days did you take all of your diabetes medications?”), and feedback (“Great job!”). Medication reminders are sent up to twice a day based on the time participants indicate they prefer to take their medications and the frequency with which they want reminders.
4.6. Dynamic Tailoring
The modules patients receive in each domain are tailored every two weeks based on their preferences and ongoing interactions with the text messaging system (, step 3). During enrollment, care managers use a web-based dashboard to enter information about a patient's diabetes medication and glucose monitoring regimen, self-management behaviors, and message timing preferences, which are used to personalize the initial content of the program. Patients set preferences about the times of day they would like to receive reminder messages, based on the timing of their morning and evening doses of medications and their personal and work schedules on weekdays and weekends. Patients who do not take any medications for diabetes (e.g., diet-controlled diabetes) do not receive medication messages; similarly, those who are not prescribed glucose monitoring do not receive any glucose monitoring messages. Subsequently, every two weeks, the system queries patients about their preferences on the content of the texting program and collects self-reported adherence information (, step 4). For example, it will ask, “On how many of the past 7 days did you take all of your diabetes medications?” Patients' responses are used to enroll patients in a new set of modules for the following two weeks. For the education domain, patient preferences largely drive enrollment; for the three reminder domains, enrollment is based on patient preferences about the timing of reminders and self-reported adherence. The number of text messages participants receive varies based on the modules they are enrolled in and their individual preferences, but on average participants are expected to receive 2-3 messages per day for the first half of the program and 0-1 messages per day in the second half of the program.
4.7. Exception Alerts
Certain patient responses to queries trigger an alert to the care manager (, step 5). These messages are exceptions, defined as a patient response requiring the attention of the care manager. The care managers have protocols to respond to each type of exception alert and are expected to respond by the next business day (e.g., within 24 hours during the weekday or the following Monday during weekend). For example, if a participant reports suboptimal medication adherence during the weekly adherence assessment, an alert is triggered. Upon logging into the web-based dashboard, the care manager is notified of a new alert requiring her attention. Per protocol, care managers call the patient and administer a structured assessment to understand the reason(s) for the patient's low medication adherence (, step 6). This information is then communicated to the primary care and endocrinology teams over email (, step 7). For patients only seen in primary care, emails are sent to directly to their primary care physicians; for those seen in both primary care and endocrinology, emails are sent to an email account shared by a team of Kovler diabetes educators and the primary care physician is copied. Using existing clinical workflows, providers then decide the appropriate followup; this may include telephone reassurance, referrals to diabetes educators or dietitian, or scheduling an appointment (, step 8). Queries are sent to participants on all days of the week and at various times, depending on participants' timing preferences, and so alerts are also generated throughout the week. As care managers are only available Monday through Friday during usual business hours 8am to 5pm, exception alerts are not designed to identify clinically urgent events, which would require immediate followup.
4.8. Care Management
The automated and integrated nature of our program fosters care management, which, per CCM, we define as an intervention creating proactive, prepared care teams. Because our program is largely automated, the care managers are only responsible for enrolling patients and responding to alerts. Care managers focus on patients who need assistance and are able to manage a large panel of patients with limited time. Through alerts, the program helps to identify patients who need additional support. Because this information is immediately shared with providers via email, it facilitates between-visit care. The program is designed to monitor and support self-management rather than provide clinical care: this matches the skill sets of the care managers and allows clinicians to maintain an arm's length involvement with the text messaging program.