Pilot program blends coaching with technology

Primary care practices continue to evolve as key centers for managing chronic diseases such as diabetes.
During Monday’s “Make the Primary Care Connection with Health Coach Support, Care Coordination & Digital Health” education session, three of the leaders of a pilot study that used a digital health app to connect health coaches and care coordinators with patients receiving chronic care management for diabetes will share their success story. The session will review data from the program and discuss specific outcomes from patient engagement and provider engagement along with clinical outcomes.

The project involved a collaboration of a digital health technology company, WellDoc, a regional primary care practice, Vanguard Medical Group, and a leading public health and research university, the University of North Carolina- Chapel Hill. It also used best practices from peer programs from around the world and WellDoc’s BlueStar, an FDA-cleared mobile healthcare prescription app for management of type 2 diabetes.

Patients used the app either on their phone or computer. The app provided 24-hour guidance and support while also sharing data with the care team to help focus patient-team interactions.


Malinda Peeples, RN, MS, CDE

The study started in 2015 and was funded by the Gillings Innovation Labs at the University of North Carolina. Two heath coaches were recruited and trained, with the official program launch at Vanguard in mid-September, with coaching wrapping up at the end of April this year.

Malinda Peeples, RN, MS, CDE, Vice President of Clinical Advocacy at WellDoc and a former AADE president, said that this project delivered the “ultimate patient-centric approach,” using digital tools to augment care coordination, diabetes education and health coaching with everybody’s focus on the person with diabetes.

“I think there’s some challenges right now as to how does diabetes education get integrated into primary care, and I think this a really good example of how to meet the patients’ education and support needs through the multiple pathways,” she said.


Janet Duni, RN, BSN, CCM, MPA

Janet Duni, RN, BSN, CCM, MPA, Director of Care Coordination for Vanguard Medical Group, said that the model used in this pilot program aligns well with the patient-centered medical home environment. This and other similar programs offer more avenues for patient access to self-management support through a stronger connection with a primary care provider.

In the primary care environment, care coordinators are well versed in chronic disease management and implement health education and disease education as part of their daily patient interactions. Medical assistants who have received additional training also participate in chronic disease management with patients.

“We are always looking for ways to increase the patient’s access to the practice and the provider, which ultimately improves a patient’s self-management,” she said. “As a care coordinator, my role in this study was to coordinate and connect the patient’s participation and BlueStar data with their provider so that office visits could be more robust. I think that helps to drive patient behavior in the right direction, and encourages the patient to continue using the BlueStar digital tool and participate in peer support.”

AADE and ADA have promoted the distinction between diabetes self-management education and diabetes self-management support. Edwin Fisher, PhD, a professor at the University of North Carolina School of, said that this program extends and embellishes both.

The next step is to find ways of implementing that support in real-world setting. He hopes that diabetes educators see the opportunity to stimulate, create, guide and manage resources and expertise to deliver their valuable education.

“Large numbers of patients are not accessing the things we have,” Dr. Fisher said. “What we don’t need are a few best practices. What we need are many good practices to give people choice and flexibility so that they can find educational and support services that mesh with their lives.”

Monday Session
Make the Primary Care Connection with Health Coach Support, Care Coordination & Digital Health
11:45 am – 12:45 pm | Room 6B

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