Egede LE, Williams JS, Voronca DC, et al. Randomized Controlled Trial of Technology-Assisted Case Management in Low Income Adults with Type 2 Diabetes. Diabetes Technol Ther. Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine; effects on professional practice and health care outcomes.

Cochrane Database Syst Rev ;9:CD Polisena J, Tran K, Cimon K, et al. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes Obes Metab ;— Managing Diabetes With Telehealth Lily Mercer. The Promise Of Technology Proper management of diabetes is critical to both patient health and efficient healthcare spending.

Tackling Diabetes With Telehealth A recently published randomized controlled trial explored the use of telehealth in the management of patients with type 2 diabetes.

At 6 months follow up, the patients in the telehealth intervention group demonstrated: Significantly lower HbA1c levels than the usual care group A significantly faster rate of decline in HbA1c levels compared to the usual care group Increased adherence to therapy Improved communication between patients and providers These results suggest that the combined approach of telehealth and nurse case management is more beneficial than usual care for patients with type 2 diabetes.

April is grateful for DSMES and her diabetes care team. William was diagnosed with type 2 diabetes when he was 18 years old. He used medication to help maintain his blood sugar levels, but it became harder to manage his diabetes as he became an adult.

When William went on an insulin pump 3 years ago, he received a referral for DSMES. This was the first diabetes education William ever received. Even during the pandemic, William was able to still receive help with his diabetes care and treatment plan through telehealth services. Mary was diagnosed with type 1 diabetes after going to the hospital because of diabetic ketoacidosis DKA earlier this year.

DKA is a serious diabetes complication that can happen when the body produces acids called ketones, which can build up to dangerous levels in the body. With a referral for DSMES from her doctor, Susan and Janet, diabetes care and education specialists in South Carolina, reached out to Mary to teach her how to manage her diabetes.

Susan and Janet taught Mary about insulin , carbohydrate counting, continuous glucose monitors, and insulin pumps and pens. They also taught her about healthier food choices , shared recipes, and taught her how to apply for financial assistance through the proper channels.

Currently, Mary stays in touch with her diabetes care and education specialists virtually through telehealth appointments. Everyone at the diabetes center who Mary worked with were knowledgeable and professional. Telehealth appointments let me meet with my diabetes care and education specialist while my kids slept upstairs.

Telehealth allowed Lori, a diabetes care and education specialist in Florida, to meet virtually with Tess, who was diagnosed with gestational diabetes.

Tess received important information on how to check her blood sugar and how to count carbohydrates. The telehealth option enabled Lori to talk with Tess at home early in the morning while her children were still asleep.

Lori then emailed materials to Tess and recommended some smartphone apps she could download to help keep track of her carbohydrate intake to help Tess on her journey.

Learn more about DSMES as emergency medicine , as provided via telehealth. During times of emergency, people may not be able to leave their homes for extended periods of time. This social isolation can create anxiety, which may make it more challenging for people with diabetes to manage their health.

Hence, when telehealth visits were available, these adults with T2D felt content as they no longer needed to rely on others for in-person visits. This quote highlights the experience of 1 participant who had a right leg amputation:.

A provider also acknowledged the barriers of in-person visits, saying:. The fourth subtheme efficient visits, fewer delays, and more time with adults with T2D was unique to providers. Providers described how telehealth visits can be conducted more efficiently than in-person visits, thereby reducing delays in their daily schedule and allowing them to maximize their time spent with each patient.

One provider participant contrasted their use of time during in-person and telehealth visits and the beneficial impact on their daily workflow:. The fifth subtheme good fit for data-driven diabetes care was unique to providers.

Most providers mentioned that diabetes care was suitable for telehealth visits as it focused more on the behavioral and cognitive perspectives. However, providers also specifically expressed the requirement of having home blood glucose data to provide optimal diabetes care and a treatment plan to their patients.

This practice is particularly important in telehealth visits as most adults might not have an available glycated hemoglobin HbA 1c measurement for the telehealth visits as compared with in-person visits, where a point-of-care HbA 1c is taken.

Advances in diabetes technology allow most people with diabetes to share their blood glucose data before telehealth visits. Despite the aforementioned benefits, patient and provider participants all faced some challenges related to technology during telehealth visits. To complete a successful telehealth visit in diabetes care, people with T2D needed to have a digital device, know how to get online, navigate the patient portal to the nested telehealth platform, upload their glucose data via a cloud or patient portal, and have familiarity with manipulating the video camera and volume.

Any disruption could happen during this process, which could result in a suboptimal experience. We identified 3 subthemes related to technological challenges from both adults and providers and 1 subtheme unique to providers.

Regarding the first subtheme disparities in digital health literacy and lack of devices as barriers to telehealth visits , when navigating technology aspects of telehealth eg, using a digital device, patient portal, telehealth platform, uploading glucose data throughout COVID, some people with T2D were proficient from the beginning, while others required additional support from staff at the diabetes clinics or other family members.

For other patient participants, the repeated practices over time made them more comfortable with telehealth-related technology:. However, 2 people with T2D specifically cited computer illiteracy as the reason for not utilizing the patient portal Adult06, Adult In this case, they would rely on providers to contact them using alternate video platforms eg, Doximity, FaceTime without going through the patient portal.

All providers acknowledged that the use of telehealth required digital health literacy and were prepared to use different ways to connect with their patients. A provider discussing the limitations of telehealth visits mentioned the following:. Both people with T2D and providers acknowledged that the lack of digital devices was a barrier to telehealth visits.

At the time of the interview, 3 adults did not have a digital device with a camera capacity Adult02, Adult07, Adult Of these adults, 2 had only phone visits during the peak of COVID, while the other person had only in-person visits as he established care after in-person visits resumed.

One person who only had experiences with phone visits stated the following:. Regarding the second subtheme frustration caused by unstable internet connection , once people with T2D and providers were connected, echoing in voices and delay in transmission due to unstable internet connection were other issues that undermined the quality of conversation and sometimes caused frustration for both parties involved.

As most of the allotted time was spent on nonmedical issues ie, trying to get connected with each other , people did not have enough time to ask questions, and providers were unable to properly deliver care. A provider provided the following quote when discussing the disadvantages of telehealth visits:.

A person with T2D discussing this frustration in her previous telehealth experience mentioned the following:. The third subtheme phone visits not encouraged was unique to providers.

At the time of the interview, phone visits were not encouraged due to the complexity of the reimbursement and compliance issues. Although phone visits were the least preferred method for providers to connect with their patients, it was a necessary backup when connection issues or the other abovementioned technical issues persisted.

Regarding the fourth subtheme difficulty sharing glucose data , both people with T2D and providers mentioned the potential obstacles of sharing glucose data in telehealth visits. Depending on the devices ie, CGM or glucometer a person uses, sharing glucose data can be either easy or very troublesome.

Patient participants with a CGM generally reported a smooth and easy process for sharing data compared with those with a traditional glucometer.

However, not everyone with T2D was eligible for insurance coverage for a CGM, which is expensive for a person paying out of pocket. Many adult participants using a glucometer reported sending handwritten documents ahead of the telehealth visits or reading their daily glucose data in the past few weeks aloud during the telehealth visits.

A person with T2D with experience using both glucose monitoring systems shared his experience:. Either way, this process took extra time for providers to make sense of the glucose data eg, time in range, average, trends before a clinical judgment was made. The aforementioned benefits and challenges of telehealth had clinical implications for diabetes care.

The first subtheme a double-edged sword for care continuity was unique to providers. With all the needed information on hand, telehealth visits allowed providers to offer more frequent quality diabetes care to adults with T2D who traditionally could not attend in-person visits often due to geographic barriers or other transportation-related issues:.

Provider participants also noticed that telehealth visits decreased missed appointments, which increased care continuity.

Additionally, due to the unpredictable nature of technical issues in telehealth visits, providers were more likely to outreach to adults despite an initial absence on the telehealth platforms. A provider described missed appointments and provided the following quote:.

On the other hand, the current telehealth workflow in the diabetes clinics requires adults with T2D to take the initiative to schedule their next appointment after a telehealth visit, instead of scheduling the next appointment at the front desk on the way out of the office after an in-person visit.

Although it did not bother people with T2D in this study, a person described how her other health conditions delayed her scheduling the next appointment:. The delay in scheduling the next appointment could sometimes lead to discontinuity in diabetes care because there was no follow-up mechanism at the time of the interview by the clinics after each visit.

A provider discussing the impact of telehealth in diabetes care described this phenomenon:. Regarding the second subtheme, perceived incomplete visits due to no diabetes quality measures , both people with T2D and providers viewed being unable to complete a thorough physical evaluation as a major limitation of telehealth visits.

The American Diabetes Association recommends each person with T2D undergo a physical exam eg, foot exam and biofeedback eg, BMI, blood pressure, HbA 1c , lipid panel, microalbumin quarterly or annually [ 3 ]. Instead of getting their point-of-care HbA 1c or other biofeedback at their in-person visits lab facilities are available in the same building for all diabetes clinics , the responsibility of completing the required lab work shifted to adults with T2D after a telehealth visit; they must remember to make an additional trip to a lab facility.

Additionally, it is not feasible to assess diabetes-related complications and other physical exams via telehealth. A person weighing in on telehealth visits mentioned:. Providers admitted the same limitation, adding this additional effort sometimes led to incomplete diabetes quality measures.

When comparing in-person and telehealth visits, a provider provided the following quote:. Although telehealth visits had the potential to enhance care continuity through proactive outreach from a provider, provider participants felt that sometimes their patient was distracted during a telehealth visit—they might be driving with an intermittent internet connection, walking down the street, or having other commitments—so it was difficult to assess their lifestyle management during that environment.

In addition to the inattention, people with T2D might not have their glucose data ready to share, as mentioned previously.

Therefore, provider participants sometimes felt that a telehealth visit could compromise the care quality. A provider discussing frustration in telehealth visits mentioned the following:.

Regarding the fourth subtheme needs and preferences for in-person visits , both patient and provider participants shared the need for in-person visits. Although people with T2D in this study generally perceived that the conversations and interpersonal relationships during both telehealth and in-person visits were similar, only 5 participants noted a preference for telehealth visits; more than one-half of the participants specifically noted a preference for in-person visits because of the challenges and clinical implications discussed above:.

Similarly, provider participants also mentioned that adults with T2D should have an in-person visit at least once a year:. This qualitative study outlined the perspectives of both providers and patients with T2D on the benefits and challenges of telehealth in diabetes care.

Although people with T2D and their providers acknowledged the convenience and efficiency of telehealth visits for promoting care continuity in diabetes care, telehealth also had challenges that could compromise the quality of diabetes care.

Consistent with previous literature [ 18 ], both adults with T2D and providers in this study acknowledged that telehealth visits addressed the barriers of transportation and work commitments with in-person visits. Beyond these benefits, providers in this study generally viewed intermittent telehealth visits as appropriate for diabetes care in the setting of a stable internet connection and the absence of technical issues.

A cross-sectional study using national data and census data found that neighborhood broadband internet subscription was highly associated with the use of telehealth [ 29 ]. To mitigate widening disparities in access to care via telehealth services, state and federal governments should progressively invest in affordable household broadband internet infrastructure [ 30 ] and programs aiming to increase digital health literacy for all [ 31 ].

In our study, many adults with T2D had problems navigating through their smart devices or patient portal due to limited digital health literacy, but they indicated a willingness to use telehealth services with additional support.

Quality improvement efforts to evaluate the uptake of telehealth services and specific measures to bridge digital literacy gaps, particularly among populations with limited resources, should be undertaken.

For example, clinical practices may implement validated satisfaction surveys to identify digital literacy shortfalls and inform the development of staff training to better support patients in navigating through the platform [ 33 , 34 ].

Additionally, telehealth or health information platforms should seek to simplify the navigation of their systems with end user experiences in mind eg, fewer layers to get to the actual link for telehealth visits [ 35 ].

Last, clinical practices should consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion that include the perspectives of adults with T2D [ 36 ]. Several temporary policy flexibilities broadened access to diabetes care during the COVID pandemic [ 15 , 16 ], including the coverage of audio-only visits [ 37 ] and the suspension of geographic requirements for patients [ 38 ].

However, with those flexibilities being phased out [ 39 , 40 ], telehealth care will be more limited, particularly to underserved populations. Additionally, we found that audio-only visits in diabetes care became necessary when technical issues arose, even though phone visits were not encouraged at the time of the interview due to reimbursement and compliance issues.

Eliminating audio-only visits disproportionately affects certain populations, such as racial minority populations, those with public insurance, and older adults [ 41 , 42 ]. To ensure equitable access to diabetes care, new legislation and licensure registration should provide more flexibility in telehealth delivery [ 38 ].

Our study revealed concerns about glucose data availability impacting the quality of diabetes care in telehealth visits. Sharing data, particularly from a glucometer, has been troublesome in telehealth visits as it requires extra steps and additional technological familiarity for people with T2D.

To enhance the quality of diabetes care and minimize burden, user experience and user-centered design should be considered in redesigning glucose-sharing platforms to minimize challenges faced by adults with T2D [ 44 ]. CGM, which is increasing in use for T2D, could also provide a convenient way to share glucose data in telehealth visits [ 45 ], but coverage for people with T2D remains limited [ 46 ].

With the potential to reduce inequality in diabetes burden and relevant complications [ 1 ], future research is warranted to investigate the benefits of CGM among individuals with non-insulin-dependent T2D. Insurance policies should also consider expanding CGM coverage to people using any insulin or oral medications with a higher risk of hypoglycemia ie, sulfonylureas and adults with physical, cognitive, or emotional barriers to finger sticks [ 47 ].

Additionally, although data platforms such as Glooko have been developed to address interoperability, none of the platforms can synchronize with all the commercially available diabetes devices glucometers or CGMs. Moreover, diabetes data are not currently integrated in EHRs.

Proper management of diabetes is critical to both patient health and efficient healthcare spending. Emerging technological advances have the potential to improve quality of care and increase access to healthcare services for patients with type 2 diabetes. Self-management of diabetes is heavily tied to lifestyle modifications, which can be continuously monitored on telehealth platforms.

Additionally, telehealth allows providers to reach patients in rural or underserved communities and provide them with quality care. A recently published randomized controlled trial explored the use of telehealth in the management of patients with type 2 diabetes.

Study participants were comprised of low income adults living in rural communities with poorly controlled type 2 diabetes. Subjects were randomly divided into a control group and an intervention group. The control group received usual care for type 2 diabetes, while the intervention group received a combination of telehealth with nurse case management.

Study participants were asked to take daily blood glucose and blood pressure readings using a telehealth system for diabetes. The telehealth system allowed the nurse case manager to virtually monitor the patients in real time and adjust medication dosage when necessary, under the supervision of a physician.

The primary outcome of interest in this study was HbA1c levels average plasma glucose concentration , as higher HbA1c is indicative of an increased risk of developing diabetes-related complications. HbA1c was measured at baseline, and at 3 months and 6 months follow-up.

At 6 months follow up, the patients in the telehealth intervention group demonstrated:. These results suggest that the combined approach of telehealth and nurse case management is more beneficial than usual care for patients with type 2 diabetes.

Additionally, these results demonstrate that telehealth in rural communities is a safe and viable care delivery option for patients. The authors of this RCT attribute much of the success of the intervention group to improved patient adherence. Adherence to prescribed therapy and lifestyle modifications are necessary components of the management of type 2 diabetes.

It was concluded that telehealth improved patient adherence in a variety of ways:. The findings from this study are consistent with mounting evidence supporting the case for managing diabetes with telehealth.

A Cochrane Review that examined the efficacy and feasibility of using telehealth with patients with diabetes found that telehealth interventions result in significantly improved blood glucose control compared to usual care interventions.

Identifying partnership opportunities can help address the cost barriers of implementing telehealth programs. It can also help broaden the range of services available to patients. When using telehealth, it is also important to ensure patient comfort with using technology.

Strategies for supporting patients who are less comfortable with using telehealth technology include enlisting support from family, friends, or caregivers. Additionally, programs should communicate the benefit of telehealth to patients and ensure that telehealth programs meet patient needs related to diabetes care.

Telehealth in Rural Communities Website Describes how telehealth programs can provide better access to chronic disease prevention and management programs, and to specialty care including heart disease and stroke, diabetes, and diabetic retinopathy.

Organization s : National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Menu Search. Evidence-based Toolkits FORHP Funded Programs Economic Impact Analysis Tool Community Health Gateway Testing New Approaches Care Management Reimbursement.

In this Toolkit Modules 1: Introduction Diabetes Overview Rural Concerns Education and Care 2: Program Models Clinical Partnerships Model Self-Management Model Telehealth Model Community Health Worker Model School Model Faith-Based Model 3: Program Clearinghouse Mariposa Community Health Center Meadows Regional Medical Center Tri-County Health Network St.

Mary's Hospitals and Clinics St. Rural Health Tools for Success Evidence-based Toolkits Rural Diabetes Prevention and Management Toolkit 2: Program Models View more Telehealth Model Rural communities can use telehealth and telemedicine to support diabetes care and management.

Technologies include video conferencing, internet-based services and communication, store-and-forward imaging, streaming media, and terrestrial and wireless communications. This includes: Diabetes self-management — Telehealth can support diabetes self-management activities such as blood sugar glucose monitoring and tracking.

For example, the Community Preventive Services Task Force CPSTF recommends the use of mobile phone apps in healthcare settings for the self-management of type 2 diabetes. These interventions can improve communication.

Patients can enter data into mobile apps and receive automated or tailored feedback from healthcare providers. Medication adherence — Taking medications as prescribed is important for diabetes management.

Telehealth can help people with diabetes to take their medications correctly — at the correct dose and frequency — and remember to fill prescriptions.

Text messages are one way to improve medication adherence among patients with chronic disease, as recommended by the CPSTF. Specialty care consultations — Telehealth can help rural patients to connect with specialty care providers remotely.

Telehealth and telemedicine use a range of technologies — such as live video, mobile devices and applications apps , and computers — to overcome rural barriers to healthcare access and improve care.

RHIhub's Telehealth Use in Rural Healthcare topic guide provides information on how telehealth can help healthcare providers in rural communities. Telehealth and telemedicine can be used to deliver diabetes education, management, and monitoring services.

This includes:. For more information about identifying and implementing telehealth programs in rural communities, see the Rural Telehealth Toolkit. Many rural communities rely on clinical partnerships to deliver telehealth services.

Identifying partnership opportunities can help address the cost barriers of implementing telehealth programs. It can also help broaden the range of services available to patients.

When using telehealth, it is also important to ensure patient comfort with using technology. Strategies for supporting patients who are less comfortable with using telehealth technology include enlisting support from family, friends, or caregivers.

Additionally, programs should communicate the benefit of telehealth to patients and ensure that telehealth programs meet patient needs related to diabetes care.

Telehealth in Rural Communities Website Describes how telehealth programs can provide better access to chronic disease prevention and management programs, and to specialty care including heart disease and stroke, diabetes, and diabetic retinopathy.

Organization s : National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Menu Search. Evidence-based Toolkits FORHP Funded Programs Economic Impact Analysis Tool Community Health Gateway Testing New Approaches Care Management Reimbursement. In this Toolkit Modules 1: Introduction Diabetes Overview Rural Concerns Education and Care 2: Program Models Clinical Partnerships Model Self-Management Model Telehealth Model Community Health Worker Model School Model Faith-Based Model 3: Program Clearinghouse Mariposa Community Health Center Meadows Regional Medical Center Tri-County Health Network St.

Mary's Hospitals and Clinics St. Rural Health Tools for Success Evidence-based Toolkits Rural Diabetes Prevention and Management Toolkit 2: Program Models View more Telehealth Model Rural communities can use telehealth and telemedicine to support diabetes care and management.

Technologies include video conferencing, internet-based services and communication, store-and-forward imaging, streaming media, and terrestrial and wireless communications. This includes: Diabetes self-management — Telehealth can support diabetes self-management activities such as blood sugar glucose monitoring and tracking.

For example, the Community Preventive Services Task Force CPSTF recommends the use of mobile phone apps in healthcare settings for the self-management of type 2 diabetes.

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J diabetes Sci Technol — GlucoseZone: An Exercise App for People with Diabetes. Jothydev Kesavadev. Cited on 12 Aug Heintzman ND A digital ecosystem of diabetes data and technology: services, systems, and tools enabled by wearables, sensors, and apps. J Diabetes Sci Technol 10 1 — Kesavadev J, Shankar A, Krishnan G, David A, Sanal G, Jothydev K, Chandran GB, Basanth A, Sanal TS, Ajith J, Jothydev S Comparing telemedicine with conventional diabetes care in assessing long-term outcomes in patients over 15 years.

Diabetes Technol Ther 23 2 — Download references. Madras Diabetes Research Foundation and Dr. You can also search for this author in PubMed Google Scholar.

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Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Abstract The effect of an increasing diabetes population has resulted in escalated costs and overburdened physicians. Evidence-based European recommendations for the dietary management of diabetes Article 17 April Global trends in diabetes complications: a review of current evidence Article 31 August Diabetes and artificial intelligence beyond the closed loop: a review of the landscape, promise and challenges Article Open access 18 November Use our pre-submission checklist Avoid common mistakes on your manuscript.

Figure Components of telemedicine. Full size image. Seven elements to be considered before any telemedicine consultation. Table 1: Benefits and challenges of telemedicine in diabetes. Full size table. VCIP flowchart. Table 2: Benefits and challenges of technology in diabetes care.

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J Diabetes Sci Technol — Article Google Scholar Mohan V, Prathiba V, Pradeepa R Tele-diabetology to screen for diabetes and associated complications in rural india: the chunampet rural diabetes prevention project model.

J Diabetes Sci Technol — Article Google Scholar Pradeepa R, Rajalakshmi R, Mohan V Use of telemedicine technologies in diabetes prevention and control in resource-constrained settings: lessons learned from emerging economies. Diabetes Technol Ther S29—S Article Google Scholar Association AD 1.

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