Our theme for 2023 was “Standing Up Services.” Since the launch of our full line of services in July, more than 90 people have received Individual Care Plans with access to peer support coaching, social work, counseling, insurance help, education, and medical care. Almost half of them received free trial CGMs and related education as part of our Intro to CGM program and we paid for T1D-related medications and supplies for 34 people as part of our Patient Assistance Program.
Our focus in 2024 is “Learning to Scale” and our goals are centered around expanding enrollment to help more people and putting systems and processes in place that will help us do so as safely and effectively as possible. Toward that end, I’ve shared two important areas of progress below.
And don’t forget to have a look at the hiring section – several new positions posted!
Expanding Enrollment
We are launching several new recruiting partnerships to raise awareness of our services and increase enrollment requests. To support this effort, we redesigned www.bluecirclehealth.org to offer more detail on our program and to include an easy-to-use self-referral page. We also added a clinical enrollment specialist to the team and streamlined the enrollment process. Enrollment will remain limited to Florida in the first half of the year with plans to expand to at least one more state in 2024.
Measuring What Matters
There are three questions that must be answered to improve anything: What are we doing? Is it working? What should we be doing? Unfortunately, the American healthcare system mostly reimburses based on the volume and complexity of care (i.e., “fee for service”). As a result, few clinics or hospitals invest in the systems, processes, and culture required to equip their team with answers to these critical questions.
Blue Circle Health has a fixed budget with which to improve the health of as many people with T1D as possible. Our success depends on our ability to discover what is or isn’t working, and then continuously improve. Our current approach includes the following areas of measurement:
- Operational dashboards (are the right things happening at the right time). We’re developing dashboards that span the patient journey and drill down on each service line. These are not just management tools but are used by all members of the clinical team to organize and deliver care effectively.
- Patient experience. We launched our first patient experience survey just after the new year.
- Clinical Outcomes. For patients on CGMs that have granted us access, we’ll have time in range (TIR) and a glucose management indicator (GMI) and will conduct analyses for this subset of patients.
- Total Cost of Care (outside of our services). We are working with a Medicaid plan in Florida that will provide the data we need to calculate each patient’s total cost of care (claims data).
- Diabetes Distress. We are capturing patients’ T1D-related distress via the Type 1 Diabetes Distress Assessment Scale for each patient on enrollment and again as they near the end of their individual care plans.
- Needs – Actions – Evidence Framework (are we meeting patient needs). In discussions about the goals of Blue Circle, the team concluded that we need a way to identify and address the specific needs of each patient. This led to the development of what we now call the Needs – Actions – Evidence framework which we embedded in our health record system.
Needs can be added by any member of the care team at any point in the patient journey. Different roles have permission to address specific needs by taking “actions.” For example, our physician, nurse practitioner, or educator can address needed insulin adjustments. Each need has related “evidence” of success that can be attributed to the need. For example, for carb counting, the bar of evidence of success is “successful teach back by patient.”
The goal of this framework is to more effectively address patient-specific needs, measure our effectiveness, and have greater confidence that people will complete our program with certain core competencies in place.
On behalf of the entire team, a most sincere thanks to everyone that continues to make our progress possible, including our Board of Directors, Clinical Advisory Committee, The Leona M. and Harry B. Helmsley Charitable Trust, our partners, and most importantly the people living with T1D that trust us to support and care for them.
Len D’Avolio, PhD
CEO, Blue Circle Health
Asst. Prof. Harvard Medical School & Mass General Brigham
