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.
The Sheehan Diabetes Care Model Model improves community-wide patient access to risk assessments for the prevention of complications associated with diabetes. Digital health strategies enable an efficient “hub-and-spoke” approach to community healthcare that eases patient access to care. Improved screenings through community points-of-care can serve as a community linkage to basic primary care services and identify individuals who poorly manage the disease and at-risk of developing serious complications.
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.
The Sheehan Diabetes Care Model implements personalized support to help patients meet their health and wellness goals. A clinical intervention protocol is developed and adjusted to the patient’s care plan, culture, and level of readiness for change. Digital health strategies are then utilized to empower patients in their mission to improve their lifestyle through the promotion of physical activity changes in eating habits, and community-building.
The extensive data collected in the Sheehan Diabetes Care Model provides a comprehensive ongoing picture of patient health and behavior that will ease the path for academia and industry to lead research for a more personalized, predictive, and preventive approach to diabetes care.
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.
