Mobile Models for Chronic Disease Management

Mobile programs for chronic disease management provide services to manage and support post-acute care for people with diabetes, heart disease, hypertension, lung disease, and other conditions. Mobile chronic disease management programs can benefit people with limited mobility, those living in rural areas with limited providers, and those needing increased care coordination.

Services

Mobile programs for chronic disease management commonly provide services such as:

Health monitoring (for example vitals, blood glucose, weight)
Medication prescription and management
Education and counseling on chronic disease treatment and management plans
Screening and laboratory testing
Post-acute care management

Delivery Approaches

Mobile programs for chronic disease management often support patients who need ongoing monitoring and clinical support to manage their disease, such as vital sign monitoring and nurse visits outside the hospital. These programs often include in-person home visits by a provider, and they also leverage technology, including telehealth, mobile apps, and Bluetooth health screening devices, for virtual communication and patient monitoring. Programs can also support disease management and reduce hospital admissions and readmissions by providing screenings and resources for addressing social determinants of health, including home safety.

Common models for mobile chronic disease service delivery include mobile units, community paramedicine, and healthcare in the home.

Mobile units travel to important community gathering places like faith-based organizations, grocery stores, or community-based organizations to provide chronic disease care and management services where they are most convenient. Care provided on mobile units can help patients monitor their conditions over time, support adherence to treatment plans, and identify complications early, reducing the need for emergency care or hospitalization.

Models that use community paramedicine allow EMS professionals to provide preventive and follow-up care, identify social or environmental factors that contribute to disease control, and connect patients to appropriate community resources. By providing services following medical visits, community paramedics can play a key role in preventing readmission and supporting patients in chronic disease management strategies and lifestyle changes.

Healthcare in the home approaches allow nurses, paramedics, and other clinicians to provide regular services and social support resources to patients in their homes. While healthcare in the home includes in-person check-ins, it also often involves virtual components, including telehealth. To support healthcare in the home models, mobile applications are available for remote patient monitoring, self-management, and medication management that patients can utilize from the comfort of their own home. For example, apps can help people with diabetes manage their insulin levels and injections by connecting various data points like blood glucose levels, food intake, and more.

See the Rural Chronic Disease Management Toolkit for more information about rural models that address chronic disease.

Examples of Mobile Chronic Disease Programs

St. Mary's Legacy Clinic is a mobile clinic serving East Tennessee that offers free primary care services to people without medical insurance. The clinic treats both acute and chronic conditions such as diabetes and high blood pressure, with services including lab testing, medication assistance, patient education, and disease prevention. The clinic also offers telehealth visits between appointments and aims to connect patients to partner services.
In West Virginia, the Kanawha County Ambulance Community Paramedicine Program was developed to reduce costs from hospital readmissions and frequent emergency room visits. Community paramedics coordinate to provide post-discharge assessments, disease management education, medication assistance, and address social determinants of health and home safety issues.
The Sanford Health Hospital at Home program allows patients living in rural North Dakota to transfer from the hospital to home and still receive care. In their homes, patients who participate in the program can receive intravenous fluids, antibiotics, medications, treatments, and ongoing care and observation until they are discharged. The program provides daily in-person visits from a nurse or community paramedic and routine virtual visits with a provider.

Implementation Considerations

Since mobile chronic disease management programs often rely on telehealth visits and at-home monitoring and screening, programs should ensure access to reliable Internet for both providers and patients. Some programs have equipped mobile vehicles with Internet capabilities or installed Wi-Fi hotspots in patients’ homes to meet connectivity requirements.

Mobile chronic disease management programs must consider the resources necessary to procure, maintain, and support the proper use of equipment and telehealth software. Necessary equipment may include mobile phones or tablets, blood pressure monitors, glucometers, pulse oximeters, or condition-specific devices, like a CPAP machine. Both patients and providers may need guidance, training, and ongoing support to use tools like mobile apps and at-home monitoring devices.

Rural communities implementing mobile chronic disease management programs should consider how to build partnerships and leverage a variety of staff (for example nurses, community paramedics, community health workers) to lower costs and support consistent and sustainable care. This can help address the costs associated with staffing, travel, and equipment needed for providing ongoing care over long time periods.

Program Clearinghouse Examples

Resources to Learn More

Bringing Hospital Care at Home to Rural Communities
Document
Describes how the North Texas Medical Center implemented a phased hospital-at-home model to provide primary and post-operative care and discusses the requirements, benefits, and considerations for implementing the model in a rural community.
Organization(s): National Rural Health Association
Date: 8/2024

Diabetes Management for Community Paramedics: Development and Implementation of a Novel Curriculum
Document
Describes the development of a diabetes management training curriculum for community paramedics and its implementation across Minnesota and Wisconsin.
Author(s): Kasper, A., Myers, L., Carlson, P., Johnson, R., Schultz, J., Meyer, D., Liedl, C., Juntunen, M., & McCoy, R.
Citation: Diabetes Spectrum, 35(3), 367-376
Date: 3/2022