At a celebratory luncheon last month, nurses, doctors, MetroPlus staff and nearly 80 of their patients with diabetes were honored for their team work. But no one recognized each other. Socorro C., a diabetic with high A1C levels of 11.9 just one year ago, listened carefully across the room to find the familiar voice that coached her back to health over the phone.

When nurse Marva Ortiz-Wade spoke, Socorro immediately recognized the caring voice of the person who speaks to her over the phone every week and helped her reach healthy blood sugar levels, avoiding trips to the ER and hospitalizations.

"By teaching us how to manage our diabetes, you have helped us avoid complications and saved our lives,” Socorro said in gratitude.

Socorro is among 500 New Yorkers who have participated in an innovative telemedicine program -- known as House Calls - that is helping diabetics self-manage their condition with the help of HHC nurses they never meet face to face.

“The thanks and gratitude expressed by our patients during the celebration speaks to a genuine and trusting relationship that exists between the nursing staff and our patients,” said nurse Ortiz-Wade. “We take complex scientific principles and break them down to language and mental images that are applicable to our patients' every day life.”

House Calls participants use a glucometer that connects to a telephone modem the size of a flip phone installed in their home. A bathroom scale and blood pressure cuff can also be connected to the modem. The equipment measures their blood sugar, weight, and blood pressure and transmits the automated readings to the House Calls nurses by phone. Readings outside acceptable levels trigger automatic alerts to the nurses' Blackberries and computer terminals and clinicians like nurse Ortiz-Wade work to guide the patient back to controlled levels before a health crisis occurs.

Nurses call each patient one or more times a week to discuss readings, design weekly meal plans and develop strategies to control their weight, blood sugar and blood pressure. They receive one on one, personalized healthcare without leaving the comfort of their home.

Seventy six percent of patients enrolled in House Calls for at least six months have significantly decreased their A1C levels, or blood sugar, and of those, 22% reached the recommended goal of an A1C of 7, a healthy level according to healthcare providers. When patients first started the program A1C levels ranged from more than 9 to as high as 14.

The latest data show that unplanned doctors' visits, hospitalizations and emergency room visits by House Calls patients were reduced by 50%, a savings of thousands of dollars per patient.

House Calls is available free to the 16,479 diabetics enrolled in MetroPlus, HHC's insurance plan, if their blood tests indicate the need to improve their self management and if they are referred by their doctor. HHC cares for more than 50,000 diabetics and hopes eventually to make House Calls available to all patients who might benefit from it.

November 2009