Abstract
Purpose :
Identify care coordination and patient navigation for participants at high risk for diabetic retinopathy (DR).
Methods :
The Sight-saving engagement and evaluation in New Haven (SEEN) lab is a care coordination, risk stratification and patient navigation program in coordination with Project Access New Haven. Participants >18 and older are identified via EMR and community events. These potential participants are risk stratified using our COX model algorithm. Participants who are at high risk for DR (the highest quartile) are screened into the pilot program. The program consists of a fundus exam with photography, a comprehensive eye exam, patient education, and patient navigation. Patient navigation is facilitated by Project Access New Haven. Each care coordination encounter is documented by the patient navigator, the study will continue to follow patients for one year with intentional follow up at 3, 6, 9 and 12 months.
Results :
To date we have enrolled 7 participants. The average age of our patients is 51. Thus far we have enrolled 29% women, 29 % black, 71% non- Hispanic. The average HbA1c is 9.9. Our average 3-year risk for patients is 0.1951. Our average 5-year risk for patient is 0.2462. We also ran our patients thru the ADA diabetic retinopathy risk calculator, our average patient risk was 4.2. The average amount of times that each patient and patient navigator interacted was 4.3. The average time of each patient encounter was half an hour. (See figure 1).
Conclusions :
Care coordination and patient navigation may address social determinants of health and the population that is at high risk of diabetic retinopathy. Patient navigation requires a patient- navigator relationship to be formed and nourished. As these relationship continues to progress patient patient navigation may be a successful tool in helping patients who underutilize a busy medical system get the care they deserve. A larger program maybe a helpful mechanism for evaluating the success of patient navigation in helping those screen high risk for DR.
This abstract was presented at the 2023 ARVO Annual Meeting, held in New Orleans, LA, April 23-27, 2023.