Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators. 1. Introduction Despite the availability of effective treatments, chronic diseases are often poorly controlled and remain a leading cause of preventable morbidity and mortality and excess costs worldwide [1, 2]. Outcomes are generally worse for patients of lower socioeconomic status, including racial and ethnic minorities, who experience higher rates of disease and complications, lower quality and access to care, and limited health literacy and social support [3, 4]. The Chronic Care Model (CCM) has been proposed as a multicomponent intervention to improve chronic care [5, 6]. Self-management support is a cornerstone of CCM and has been linked to improved health outcomes in a range of chronic conditions [7]. Yet, in practice, self-management support programs are poorly reimbursed, difficult to scale, and often unavailable [8]. Payers and providers recognize the need for self-management support programs, but often lack the human or financial resources needed to adequately provide them [8]. Existing programs may not be suitable for racial and ethnic minorities and traditionally rely on one-on-one or group sessions, which are resource intensive [8, 9]. In addition,
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