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  1. Kirkland, Elizabeth Barnhardt MD, MSCR
  2. Dericke, Dawn BSN, RN
  3. Bays, Chloe Cooper BS
  4. Wallinger, Caroline BSN, RN
  5. McElligott, James MD, MSCR
  6. Slaughter, Sabra PhD
  7. Moran, William P. MD, MS


Context: Remote patient monitoring (RPM) for diabetes and hypertension may reduce barriers to patient care, leading to improved disease control and decreased morbidity and mortality.


Program: We describe the implementation of a community-academic partnership to improve diabetes and hypertension control for underserved populations using RPM.


Implementation: In 2014, our academic medical center (AMC) began working with community health centers (CHCs) to implement a centrally monitored RPM program for patients with diabetes. AMC nurses recruited, trained, and supported community partners through regular communication. Community sites were responsible for enrollment, follow-up visits, and all treatment adjustments.


Evaluation: More than 1350 patients have been enrolled across 19 counties and 16 predominantly rural CHCs. The majority of patients reported low annual household income and African American or Hispanic background. It took about 6 to 9 months of planning at each CHC prior to first enrolled patient. More than 30% of patients utilizing the newer device continued to transmit glucose readings regularly at week 52 of enrollment. Hemoglobin A1c data reporting was completed for more than 90% of patients at 6 and 12 months postenrollment.


Discussion: Partnering of our AMC with CHCs enabled dissemination of an effective, inexpensive tool that engaged underserved populations in rural South Carolina and improved chronic disease management. We supported implementation of clinically effective diabetes RPM programs at several CHCs, reaching a large number of historically underserved and underresourced rural CHC patients with diabetes. We summarize key steps to achieving a successful, collaborative RPM program through AMC-CHC partnerships.