Pharmacist-Led Remote Patient Monitoring for Diabetes and Hypertension Management in Persistent Poverty Areas

Chloe Taub, Ph.D. 
University of Alabama at Birmingham

Project Goals and Relevance

Persistent poverty (PP) areas in the Deep South face a disproportionate rate of chronic medical conditions, including diabetes and hypertension, which are exacerbated by factors such as limited healthcare access, financial instability, transportation challenges, and medical mistrust. This project evaluates the 360Care Program, a pharmacist- and community-health-worker-led model that integrates remote patient monitoring (RPM) to support individuals with pre-diabetes, diabetes, or hypertension living in persistent poverty areas of Alabama. The 360Care Program aims to address patient health outcomes by improving medication adherence, self-efficacy, and care continuity through AI-enabled technology and individualized coaching.

Intervention/Approach

Wireless blood-pressure and glucose-monitoring devices transmit real-time data to pharmacists and community health workers who provide individualized counseling on medication use, nutrition, and stress management. The study assesses the feasibility, acceptability, and preliminary impact of the 360Care model among 15 participants, using both qualitative and quantitative data to guide future scaling.

Expected Outcomes

• Actionable Insights: Identification of best practices for integrating pharmacist-CHW collaborations with RPM in populations with high disease prevalence and limited resources.
• Improved Care Access: Increased use of RPM to monitor changes in blood pressure and glucose control.
• Patient Empowerment: Patients feel more engaged in their care and report improved satisfaction.
• Scalability: Generate evidence to guide adoption of pharmacist-CHW collaborations in underserved areas.

Eligibility Criteria:

Participants must be adults aged 19 years or older who have been diagnosed with pre-diabetes, diabetes, or hypertension and are willing to be paired with a Community Health Worker to receive individualized health coaching.

Practical Tips for Everyday Health

Not part of the study or don’t meet eligibility criteria? You can still take charge of your health by tracking key numbers, asking questions, and staying engaged with your care team.

Small actions can make a big difference.

Know Your Numbers
Get regular screenings for blood sugar, cholesterol, and blood pressure. Understanding your numbers helps you spot changes early and make informed decisions about your health.

Monitor Your Blood Pressure at Home
If possible, check your blood pressure regularly using a home monitor. Keep a log of your readings and share them with your healthcare provider.

Ask Questions About Your Medications
Talk with your doctor or pharmacist if you’re unsure how or when to take your medications. Clear understanding prevents mistakes and supports better health outcomes.

Communicate with Your Providers
Share your numbers, goals, and any concerns with your healthcare team. Open communication helps you work together to reach your health targets.

Good communication and regular monitoring empower you to stay on top of your health, and sharing these tips can help others do the same.