This session highlights two innovative, scalable approaches to chronic disease management that integrate education, technology, and care coordination to improve outcomes for diabetes and hypertension. Presenters will share how Diabetes Self-Management Education and Support (DSMES) and Remote Patient Monitoring (RPM) programs have expanded access, driven clinical improvement, and addressed social determinants of health—offering practical strategies for implementation in both academic and community-based care settings.

One case study features a DSMES program that scaled from a few hundred to over 30,000 visits in under three years, resulting in an average A1C reduction of 1% and significant cost savings. The program embedded community health workers, partnered with food and transportation services, and integrated DSMES across primary care, inpatient, and specialty settings. The second case study focuses on an RPM program supporting over 12,000 patients annually with smart devices, virtual visits, and real-time data sharing. Among patients enrolled in RPM for hypertension, 85% achieved blood pressure control—compared to 69% overall.

Attendees will learn how to build sustainable DSMES and RPM programs, increase patient engagement, and use real-time data to personalize care and close gaps. Presenters will also discuss infrastructure, workflows, and partnerships that support whole-person care, and share lessons learned to help others replicate success in diverse care environments.