The Key to Improved

Diabetes Control:
Clinically Relevant
Patient Engagement
Engaging Diabetes Patients Through an Accessible
Tool Results in Better Health Outcomes —
Including a 1.15% Drop in A1C Test Results

1
INTRODUCTION
Success in value-based care requires long-term,
clinically relevant patient engagement. When care
managers can’t sufficiently and proactively engage
patients, they have poorer clinical outcomes. As
a result, organizations don’t meet their quality
benchmarks and can’t succeed financially.
As healthcare organizations grow their value-
based care populations, it’s difficult for care
managers to achieve the engagement needed to
identify worsening patients — there simply isn’t
enough staff for the growing number of cases.
This difficulty also results from the fact that care-
management teams lack information technology
tools that can engage patients in a standardized
manner and collect real-time data from those
experiencing worsening symptoms. Better data
can help care managers proactively shift focus
toward higher-risk patients (instead of patients
whose conditions are under control).
Automated monitoring from text messaging
platforms can improve patient engagement and
collect real-time data, which helps reach more
patients and standardizes communication.
Additionally, it frees up care managers to support
the patients who need it most. When care
managers have the right tools to better monitor
patient symptoms and biometrics, they can work
to the top of their license and care for more
patients with efficiency.
Better data can
help care managers
proactively shift
focus toward
higher-risk patients.
Healthcare administrators
must adopt a new care
model that incorporates
technology to empower
care-management staff
to better engage patients
and improve outcomes.
Diabetes, which affects 30.3 million people
in the United States, perfectly exemplifies this
pressing need.
Healthcare administrators must adopt a new care
model that incorporates technology to empower
care-management staff to better engage patients
and improve outcomes. As case numbers
continue to increase for diabetes and other
chronic conditions, care-management staff will
become overwhelmed if the status quo remains
intact.
A large health system in the Midwest
implemented CareSignal’s automated text
message-based platform to engage patients
with diabetes. This use case demonstrated that
better patient engagement can transform care
management to accommodate larger patient
populations and improve diabetes outcomes.
2
 CARE-MANAGEMENT METHODS
Before and After
Existing diabetes management processes require
patients to test and track their blood glucose
readings in a journal and remember to bring that
information to each provider visit. Patients often
forget to regularly check readings and tend to
share months of results at their appointments.
This makes it difficult for care managers or
physicians to tie changes in blood sugar to specific
events. In turn, it’s harder to adjust medications to
fit the patient’s needs.
Ultimately, this misalignment leads to inaccurate
blood sugar management and an increased
chance of hospitalization for patients under a care
manager’s supervision.
The existing model isn’t suited to efficiently
identify at-risk individuals among growing
diabetes patient populations. It also doesn’t allow
care managers to do their jobs effectively. On the
other hand, CareSignal provides care managers
with real-time data that helps them engage with
and prioritize patients who need the most help.
As a whole, CareSignal created a
powerful feedback loop between
patients and care managers.
Partner CareSignal
Provides a list of Has patient
eligible patients engagement
to CareSignal via specialists call
secure transfer. patients, gather
consent, and enroll
them in the program.
In our study, CareSignal sent automated phone
calls and text messages to proactively collect
relevant biometric data from patients. After
patients received the messages, they responded
by self-reporting their fasting blood glucose
levels via text or voice. CareSignal then stratified
patient-reported biometrics over time by risk, and
patients fell into the red (danger), yellow (urgent),
or green (controlled) categories. This real-time
patient data automatically created status alerts
about individuals in the red category and sent
those alerts to the patient’s care manager. The
care manager could then reach out to provide
education or escalate the situation to a healthcare
provider to adjust medications, thus lowering the
patient’s blood sugar. For example, if a patient
experienced a hypoglycemic or hyperglycemic
event, the system sent a notification to the care
manager. The manager could then reach out to
that high-risk patient to provide care.
Red
Yellow
Green
Patients CareSignal Care Managers
Answer prompts Categorizes at-risk Respond with
on the phone to individuals and appropriate
send clinically triggers alerts interventions.
relevant data. in real time.
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 RESULTS FROM IMPROVED ENGAGEMENT
The five-month study of 396 patients showed a 1.15% drop in A1c at the four-month
mark among those with a baseline A1c of 8% or greater. Given that the study was five
months long, these results suggest that CareSignal can make a significant impact on
diabetes control over a short time period.

Weeks
0 2 4 6 8
0
Delta in Blood Sugar

-10

-20

-30 Care team

outreach

-40
mg/dl

Furthermore, the average weekly patient engagement rate was around 71%,
indicating that the text messages and phone calls were convenient and accessible.

1.15% Average Drop in A1C

Change in average A1C among
uncontrolled diabetics (A1C>8.0)

12.00%

10.00%
9.81%

8.00% 8.66%

6.00%
Baseline Month
Four

Care managers received the first reports during the second week of patient
engagement. Patients’ blood sugar dropped significantly around this time. Blood sugar
decreased again around the four-week mark when care managers received another
report. Touchpoints from care managers speed up dosage adjustments, which helps
patients reach lower, more controlled blood sugar levels faster.

4
BETTER OUTCOMES
CareSignal improved diabetes care by
consistently engaging patients and providing
care managers with prioritized, real-time
biometric data. This empowered care
managers to meaningfully engage patients
with education or escalation to control
worsening symptoms in high- and
rising-risk individuals.

Get in touch
with our team today to see how
CareSignal can empower your
care managers to engage any
patient with chronic disease.