The Bermuda Hospitals Board has invested in a new pilot programme aimed at helping address chronic diseases.

According to a spokeswoman, the Patient-Centred Medical Home programme offers outpatient referral services for individuals with chronic diseases such as diabetes who are not seeing a GP and who are uninsured or underinsured.

The pilot programme formally was launched in November, and so far 28 patients have been registered. It is scheduled to operate for one year, after which a decision will be made if it should be continued or modified.

Venetta Symonds, BHB CEO, said: “The goal is to keep this at-risk group as healthy as possible and help them manage their chronic diseases

“This will help reduce emergency department visits, hospitalisations and complications, such as amputation and dialysis, which impact quality of life and are costly to the healthcare system.”

In order to register, patients must be referred to the service by GPs, the emergency departments or the hospitalist service.

Stanley James, medical director for the programme, said: “These patients have complex chronic health conditions and the length of each of their visits correlates to the complexity of their medical and social needs.

“The complex nature of these patients is served by the co-operation of various healthcare providers — pharmacists, dedicated medical social workers, consultants, along with laboratory and diagnostic facilities that are readily available on-site.”

Dr James added that the programme was intended to increase the patients’ adherence to treatment while preventing them from falling between the cracks.

“With regularly scheduled follow-up calls and return-to-clinic visits, we are better able to provide reassurance to patients, as well as assess compliance early in their journey towards control of their chronic conditions,” he said.