Inspired by Dr. Peter Sheehan’s vision of a community-based approach to diabetes care, the Sheehan Diabetes Care Model is a patient-centered, high-touch, comprehensive “hub-and-spoke” model for the prevention and management of diabetes in at-risk communities that promises to improve the standard of diabetes care.
- Create sustainable and effective linkages between clinical centers and at-risk communities for the extension of the care continuum into the community setting and the reduction of the use of emergency services.
- Improve patient engagement, compliance, safety, and health outcomes with community access to preventive services, ongoing health and medication monitoring, and individual outreach through digital health points-of-care in the community.
- Empower and educate patients with clinical lifestyle intervention programs and health and wellness support delivered through digital health and community-based strategies.
- Collect health and patient-centered data for research to support physician decision-making, further personalize care, and reduce health disparities.
Care Model Strategies
Facilitating risk assessments allows communities to better manage diabetes, prevent hospitalizations, and increase primary care enrollment. Patients can more readily engage in the healthcare system, and receive expert specialty care consultation at each of the community points-of-care. The examinations are all non-invasive and can be coordinated by a healthcare provider, health promoter, or technician.
Behavior and compliance information will be input from the patient’s home and personal devices for a better understanding of the patient’s health needs. Individual outreach for intervention is facilitated through the digital and community-based services.
Data science can support physician decision-making, recognize important health and behavioral trends in communities and larger population groups, and make significant progress in reducing ethnic and racial health disparities.
Working with the Empire State Patient Safety Network and Mount Sinai Beth Israel Asian Service Program, we have collected data on over 100 patients and are proceeding with analysis of the data to determine any insight to improve health outcomes for the community. Documentation of use will allow further research on potential drug interactions in order to improve diabetes care with a culturally-competent approach.
TeleWound seeks to support patients and physicians, via smartphone or tablet, with timely consultation from wound care experts. The formula is simple. A group of wound care specialists manage the site where queries are sent and advice is sent out on an immediate basis. The specialist looks at the patient’s wound, analyzes its development, and delivers an expert risk assessment to the relevant physicians. The preventative wound care assessment will support physicians in their decision-making process and improve health outcomes for the patient.
TeleRetina eases patient access to preventive retinal care and serves as a low cost, non-invasive, and highly effective first line of detection for diabetic retinopathy. Identifying retinal disease occurring during the prediabetes or early diabetes stages can help prevent complications like kidney and heart disease. Through TeleRetina, patient care teams can better monitor eye care in patients with diabetes, refer to a specialist for proper care, and prevent the onset of early blindness.