By PATRICIA CORRIGAN
Tina Rank Dikoff, an early participant in Avera Health's eGestational Diabetes Program, and baby Irelynn visit with obstetrician Dr. Michael Krause in this 2018 photo. The telehealth program provides nutrition education and close glucose monitoring to pregnant women who live far from health care services.
Nathan Johnson/Avera Health
It can be difficult to monitor and manage patients with gestational diabetes who live in remote rural areas, but Avera Queen of Peace Hospital in Mitchell, South Dakota, has developed a telemonitoring program so successful that it has expanded it throughout the state.
Digital telehealth visits with diabetes educators and registered dietitians are part of the program, as are educational videos that teach patients how to test blood sugar levels and even inject insulin. Blood sugar readings from a glucometer are automatically uploaded to an app, which eliminates the need for patients to track and report their own blood sugar levels. Even in rural areas where there is poor cell service, patients can get to a cafe or library in town for a Wi-Fi connection to transmit their data to clinical staff for review.
"Micromanaging of blood sugars early on is important," said Angie McCain, director of the Women's Center at Avera Queen of Peace and also director of the hospital's education services and telemedicine. "If a woman shows a spike two days in a row, whoever is on intake will call to review her diet."
McCain continued, "If a woman made a bad choice for an evening snack, one of our dietitians can talk with her about a better choice. If we continue to see a spike after her diet is adjusted, then we can refer the woman to a tertiary care center. We do feel our program is the gold standard, and our goal is that every Avera provider will refer into it."
The program was initiated in 2016 after a request from a physician having difficulty managing the care of rural obstetrics patients with gestational diabetes, said Dr. Kimberlee McKay, clinical vice president of Avera's obstetrics service line and medical director of the gestational diabetes program.
"From the beginning, our hope has been to achieve the same result as with usual care in a traditional program," McKay said. She noted that South Dakota has a higher gestational diabetes rate than the rest of the nation, 10 – 15%, compared to 6 – 8%. Three counties in the program's service area have a large population of Native Americans, who have a higher rate of gestational diabetes than other groups.
McKay emphasized that when caring for patients with gestational diabetes, physicians have just a small amount of time to affect a big change in the physiology of the mom and baby. "There is a lot of programming of the metabolism of the fetus in uteri," she said, "and for a mom to have well-controlled gestational diabetes also reduces her risk for diabetes over her lifetime. That requires tight controls."
McKay said to date, some 350 patients have participated in the diabetes monitoring program. Avera received a four-year grant from the Health Resources and Services Administration's Federal Office of Rural Health Policy and a three-year innovation grant from the South Dakota Department of Social Services to offset the costs. McCain, project director for the grants, noted that the program has expanded to all parts of South Dakota served by Avera and also is moving into Avera's Minnesota markets.
"What's special about the program," McKay noted, "is the concept of bringing immediate medical expertise to patients who otherwise would have to travel or not have access to care."
From the beginning, the program's goals have included reductions in the instances of large-for-gestational-age infants, shoulder dystocia, postpartum hemorrhage and primary Caesarian sections and also fewer admissions to the neonatal intensive care unit. Those goals are being met, McKay and McCain reported.
"Most of our babies are normal size at birth now," McCain said. "We also recently had a patient who'd had to go on insulin for gestational diabetes with a prior pregnancy, but this time we intervened more quickly and monitored her more closely than in a traditional clinical model. She had her baby at 39 weeks with no complications, the baby was normal size and there were no issues after the birth. She was very happy."
Patients report that one big benefit of the program is the telehealth appointments, which allow those who have smartphones or laptop computers to check in while at home or at work. That saves time and money for patients, McCain said, because they no longer have to drive to a clinic or pay for the gas those trips require. "In a two-year period, patients saved 58,000 miles of travel, $5,600 in gas money and over 200 days of work that otherwise would have been missed," she said.
Part of the state grant may be used to provide more patients with laptops or tablets.
"We've also seen increased physician satisfaction due to the program," McCain said. "Our core team touches base about our patients with the providers every week, so they are in the loop. Also, the program has allowed physicians a lot of clinic time back, which means the clinics are operating more efficiently." And soon, the program will add a patient health navigator.
McKay said Avera "believes that where you live should not influence the care you receive." She added that the remote gestational diabetes program has achieved financial viability and quality patient care.
Noting the success of the remote monitoring program, McKay issued a challenge to policy makers, insurance chief executives and health systems. "We've had people willing to innovate and try new things to put a process in place to meet the patients where they are," she said. "We've made this program easy for our patients to use, and that allows them to enjoy their pregnancy while doing what's best for the baby. I would ask health care leaders this: If you know a program like this would make a difference, what barriers will you remove to use the technology?"
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