An option for a more patient-centered telemedicine experience is continuous remote care (CRC). This approach includes a data-driven, proactive outreach to patients, which represents a decisive step forward in contrast to the currently available episodic, reactive, patient-initiated care. In CRC, patient biometric and symptom data (ie, patient entered and connected data) are assimilated in real time by artificial intelligence–enabled clinical platforms to bring physicians’ and other health care team members’ attention to those patients who need intervention, whether this is via medication adjustments, acute care management, or lifestyle coaching. The care team can review hundreds of patients a day instead of just one or two dozen; proactively engage the patient to develop a care plan; and support patient empowerment, safety, and achievement of optimal health outcomes. As a result of the CRC model’s connectedness, the care team can reassess progress in real time.

In this paper, we discuss how this innovative CRC approach has improved outcomes in another deadly pandemic—type 2 diabetes mellitus.

Patients with chronic diseases such as diabetes require ongoing, aggressive, team-based management to optimize health outcomes and ongoing support to ensure long-term adherence to their care plan. Patients with diabetes must make decisions many times a day related to their care, and for those on insulin and other diabetes medications, each decision can be quite complex. Furthermore, these decisions impact what will happen to the trajectory of their disease over time and may determine if they are destined to have a diabetes-related emergency and need to use emergency services at that time. This type of complex disease is an ideal fit for the CRC approach, as it requires more than the episodic care that our health care system has built upon in order to address the day-to-day, meal-to-meal needs of patients.

Advances in diabetes technology, such as blood sugar monitoring apps and continuous glucose meters, have already improved patient care [1,2]. However, provider advice based on data from these devices is generally delivered during traditional episodic visits. Asynchronous virtual feedback from a health coach or certified diabetes educator has been shown to add additional improvements in glucose control [3,4]. To date, the most significant improvements in glucose control have been seen when remote monitoring is tied to a physician-led care team, as our published results demonstrate [5].

Our CRC model was created to provide multifaceted, holistic patient support, ranging from medication adjustments to transformational lifestyle changes (Figure 1). Physicians are alerted by algorithmic prioritization to situations that may be a safety concern or where medications need to be adjusted based on incoming biomarkers, thereby allowing proactive outreach to patients. Health coaches operate in pods so that many specialists (eg, nurse practitioners, behavioral health providers, dieticians, and exercise physiologists) allow for specialized and personalized care for each individual by using the same prioritization system as physicians to guide lifestyle interventions. This high-touch care, including personalized nutrition advice, has allowed for medication de-escalation, often culminating in complete elimination of medication [5]. Moreover, integral to CRC are moderated peer-support groups and readily accessible patient resources that include education on many topics, such as recipe and menu planning, and behavior-focused content. This model has shown a retention and engagement rate of 74% at a 2-year timepoint [5].

Proactive outreach to patients based on incoming biomarker data has successfully been used for congestive heart failure (CHF) in many trials, with results demonstrating decreased hospitalization rates for CHF exacerbations and lower mortality [6,7]. This model can also track biomarkers for other chronic diseases, such as obesity and hypertension.