Remote Patient Monitoring And Coaching Pilot Makes Way For Smarter, Better Care in Endocrinology


​Through an internal innovation grant, the Northwestern Medicine team partnered with Glooko® and Pack Health® to develop a telehealth-enhanced continuous care model for patients with diabetes.


In the spring of 2020, when much was unknown about COVID-19, clinicians were forced to quickly leverage telehealth to reduce risk of infection and spread. But Northwestern Medicine had already been investigating ways to implement telehealth services above and beyond simply conducting office visits online via a 2018 internal innovation grant, which funds leading-edge approaches to transform patient care. Through a second grant, the endocrinology team at Northwestern Medicine Lake Forest Hospital developed a continuous care model that uses remote patient monitoring (RPM) and coaching to help make diabetes management safer, smarter and more efficient.

Comprehensive Out-of-Office Care

The pilot focuses on helping clinicians move away from reactive in-office care for patients with diabetes. The team worked with Glooko, an app that syncs blood glucose data, and Pack Health, a patient engagement platform, to create a telehealth solution. Using data provided by connected blood glucose monitoring devices combined with educational lifestyle coaching, the care team can help patients set and achieve health goals that can improve their quality of life.

Many people with diabetes struggle to consistently track their blood glucose levels and other important metrics that can help physicians tailor treatment plans. The pilot program improves the accuracy and efficiency of capturing critical data, taking pressure off patients while giving physicians reliable information within existing workflows. The program is enrolled at full capacity with Medicare-eligible patients who have Type 2 diabetes.

Moving forward, the team plans to build on the pilot’s success to remotely monitor additional physiological parameters, including body weight, blood pressure, continuous tissue glucose monitoring and activity tracking, as well as nutrition, exercise, mindfulness and behavioral change for metabolic-related diseases. The project is also designed to demonstrate sustainability and added value by leveraging the new Medicare codes, which help foster innovation in management of long-term conditions.

Innovation Beyond Endocrinology

The Northwestern Medicine pilot program has added a new dimension to existing telehealth practices by integrating RPM and coaching services. The team behind its creation is exploring ways to use the continuous care model in other areas of medicine, such as primary care, which has limited bandwidth for helping patients with diabetes and obesity. Bringing this type of team-based remote care into routine practice gives clinicians the tools, technology and support needed to improve how telehealth is provided for patients across specialties.