Diabetes: increasing primary care capacity with digital and automated care journeys.
The prevalence of diabetes is increasing, posing a growing and challenging health concern. In primary healthcare, managing chronic conditions like diabetes for several decades places a significant burden on general practitioners (GPs) or family physicians, especially in units with limited human resources. Discover how UpHill has enhanced the capacity of the Amadora-Sintra Local Health Unit by digitizing and automating the care journey for people with diabetes, including remote monitoring and automatic prescription management.
Hospital Insights
Time constraints, increasing patient volume, growing complexity of cases, and administrative burdens are some primary challenges facing general practitioners and family physicians today. Managing chronic diseases in this context is a challenge, and diabetes is one of the most pressing examples. In the European Union, 32 million adults live with diabetes, and prevalence continues to rise, projected to reach 35 million by 2030.1 In Portugal, data suggests that over one million people have the disease.2
In the case of the Amadora-Sintra Local Health Unit, approximately 10,000 diabetic patients lack an assigned family physician, making disease control difficult and posing an increased risk for complications and hospitalizations.
Problem
A high volume of patients without assigned family physicians
Inability to prioritize appointments for unstable patients
Limited visibility over patient progress between care episodes
Through this program, the Amadora-Sintra Local Health Unit addressed two major areas: team capacity and patient stratification.
Project Goals
Profile the diabetic population based on their metabolic control level.
Prioritize in-person appointments for patients with greater needs.
Enhance asynchronous patient monitoring capacity.
Ensure regular follow-up for patients without a designated family physician.
Empower patients with increased self-management confidence in their daily lives.
Avoid preventable complications and hospitalizations.
Prevent long-term disease deterioration.
Solution
In this specific use case, we focus on automating three essential elements of the care journey: gathering digital medical history, prescribing medical exams or adjusting medication, and stratifying patients by their risk level. Throughout the care journey, UpHill ensures that all gathered information is accurately interpreted and used to suggest the best next action for health teams.
Automated digital medical history assessment to evaluate people's needs
Leveraging comprehensive questionnaires with straightforward questions, UpHill gathers the necessary information to confirm each patient's eligibility for the program and collects clinical data for population characterization.
Automated prescriptions and therapeutic adjustments facilitated by a decision support system
Based on the answers, UpHill identifies patients requiring clinical tests and, if necessary, pharmacological prescriptions. Healthcare professionals have a decision support system to double-check which clinical tests should be prescribed and, if needed, the most appropriate pharmacological therapy for each patient. Moreover, these actions can all be performed collectively, saving considerable time for the teams.
Patient stratification enabling prioritization based on risk
When test results are ready, UpHill automatically interprets them, enters them into the clinical records software, and categorizes patients according to their risk level. The next steps of the journey are then adjusted accordingly, offering four distinct options: medical in-person consultation, nursing in-person consultation, reassessment in 3 months, or reassessment in 6 months.
“The patients who seek assistance the most are those who are most concerned but are actually in good health, while those who are not doing well don't always reach out to our services. With this algorithm, we can prioritize individuals with poorer control who require more timely intervention.”
Ana Rita Brochado
General and Family Medicine
Introducing UpHill Assist
UpHill Assist is a medical service provided by UpHill to its clients. It goes beyond the benefits of clinical automation, acknowledging that some tasks still require the expertise of healthcare professionals, for which health units may lack available capacity. With a specialized and trained team, UpHill Assist offers invaluable support, ensuring patients receive timely and appropriate care. Ultimately, this service leads to improved health outcomes and reduces the burden on healthcare professionals.
“Having this team of UpHill doctors carrying out tasks that inevitably need to be performed by a healthcare professional throughout the care journey ensures that our patients receive assistance, which would not be possible otherwise.
”
Gonçalo Envia
Medical Director for Primary Care
Solution details and highlights
Automation of two stages: sending and interpreting the digital medical history, as well as interpreting test results and stratifying patients according to their risk.
An omnichannel approach to obtain patient information, using familiar patient channels (SMS, phone call, and email).
No invasive medical devices or procedures.
Use of validated and automated questionnaires and scores.
Intelligent application of the information collected to update patient status.
Automatic notification generation to warn health teams of patients’ red flags.
Interoperability capabilities linking different systems reduce task repetition.
Compliant with relevant industry-standard certifications.
Disclaimer
This data is specific for this use-case in this institution and is presented as an example of how UpHill Route indirectly improves patient management processes in a context in which clinical decision support systems are used. The institution itself collected data. UpHill Route does not claim any direct clinical benefit leading to cost reduction, access increase, unnecessary appointment reduction, or hospitalization reduction.
References
Sociedade Portuguesa Diabetológica. (2019).
Diabetes: Factos e números – O ano de 2016, 2017 e 2018 − Relatório anual do Observatório Nacional da Diabetes. Retrieved from
https://www.spd.pt