PORTLAND, Ore. -- This year marks the 25th anniversary of a unique program that provides in-home care for some of Oregon's most vulnerable residents.

Housecall Providers has expanded to three programs since it began in 1995. At any given time, its primary-care arm serves 1,500 to 1,600 patients. It also has about 120 hospice patients, and provides community-based palliative care for 150 people with serious but non-life-threatening conditions that require wraparound services.

Chief executive Rebecca Ramsay said staff is on call for patients' serious needs.

"If the patient has the flu or is having any kind of exacerbation of their chronic illness, we can make urgent visits as well," she said. "So the difference there is that we're going to the patient on an urgent basis, instead of the patient having to come to an office setting."

In 2017, the nonprofit community-benefits company CareOregon acquired Housecall Providers.

The program's primary-care medical director, Dr. Pamela Miner, said they serve homebound elderly Oregonians, people coping with physical or developmental disabilities, and those with medical or behavioral health challenges. She said the ability to provide house calls allows them to care for so-called "super-utilizers" -- the handful of Medicare beneficiaries that makes up the majority of hospital visits.

"We help prevent expensive trips to the hospital and unnecessary nursing-home stays," she said. "Not only does this set a new standard for the quality of care that patients can expect at home, it improves patient health outcomes, lowers health-care costs and improves the care team's satisfaction as well."

Miner said her team takes COVID-19 precautions on home visits and uses teleconferencing as much as possible.

In 2012, Housecall Providers began participating in the federal Independence at Home demonstration, a Medicare shared-savings model. Still, Ramsay said it's hard to remain financially viable and the program relies on donations. She said home-based service is an option many people want, and it is likely to be in even greater demand as the population ages.

"There's a lot of work to do," she said, "in order to really make sure that the health-care financing system is coming along with us in the recognition of the value of this type of care."

By Phil Galewitz for KFF Health News.
Broadcast version by Trimmel Gomes for Florida News Connection reporting for the KFF Health News-Public News Service Collaboration

Just a few years ago, children with Type 1 diabetes reported to the school nurse several times a day to get a finger pricked to check whether their blood sugar was dangerously high or low.

The introduction of the continuous glucose monitor (CGM) made that unnecessary. The small device, typically attached to the arm, has a sensor under the skin that sends readings to an app on a phone or other wireless device. The app shows blood sugar levels at a glance and sounds an alarm when they move out of a normal range.

Blood sugar that's too high could call for a dose of insulin - delivered by injection or the touch of a button on an insulin pump - to stave off potentially life-threatening complications including loss of consciousness, while a sip of juice could remedy blood sugar that's too low, preventing problems such as dizziness and seizures.

Schools around the country say teachers listen for CGM alarms from students' phones in the classroom. Yet many parents say that there's no guarantee a teacher will hear an alarm in a busy classroom and that it falls to them to ensure their child is safe when out of a teacher's earshot by monitoring the app themselves, though they may not be able to quickly contact their child.

Parents say school nurses or administrative staff should remotely monitor CGM apps, making sure someone is paying attention even when a student is outside the classroom - such as at recess, in a noisy lunchroom, or on a field trip.

But many schools have resisted, citing staff shortages and concerns about internet reliability and technical problems with the devices. About one-third of schools do not have a full-time nurse, according to a 2021 survey by the National Association of School Nurses, though other staffers can be trained to monitor CGMs.

Caring for children with Type 1 diabetes is nothing new for schools. Before CGMs, there was no alarm that signaled a problem; instead, it was caught with a time-consuming finger-prick test, or when the problem had progressed and the child showed symptoms of complications.

With the proliferation of insulin pumps, many kids can respond to problems themselves, reducing the need for schools to provide injections as well.

Parents say they are not asking schools to continuously monitor their child's readings, but rather to ensure that an adult at the school checks that the child responds appropriately.

"People at the [school] district don't understand the illness, and they don't understand the urgency," said Julie Calidonio of Lutz, Florida.

Calidonio's son Luke, 12, uses a CGM but has received little support from his school, she said. Relying on school staff to hear the alarms led to instances in which no one was nearby to intervene if his blood sugar dropped to critical levels.

"Why have this technology that is meant to prevent harms, and we are not acting on it," she said.

Corey Dierdorff, a spokesperson for the Pasco County School District, where Luke attends school, said in a statement to KFF Health News that staff members react when they hear a student's CGM sound an alert. Asked why the district won't agree to have staff remotely monitor the alarms, he noted concerns about internet reliability.

In September, Calidonio filed a complaint with the U.S. Justice Department against the district, saying its inability to monitor the devices violates the Americans with Disabilities Act, which requires schools to make accommodations for students with diabetes, among other conditions. She is still awaiting a decision.

The complaint comes about four years after the Connecticut U.S. attorney's office determined that having school staffers monitor a student's CGM was a "reasonable accommodation" under the ADA. That determination was made after four students filed complaints against four Connecticut school districts.

"We fought this fight and won this fight," said Jonathan Chappell, one of two attorneys who filed the complaints in Connecticut. But the decision has yet to affect students outside the state, he said.

Chappell and Bonnie Roswig, an attorney and director of the nonprofit Center for Children's Advocacy Disability Rights Project, both said they have heard from parents in 40 states having trouble getting their children's CGMs remotely monitored in school. Parents in 10 states have filed similar complaints, they said.

CGMs today are used by most of the estimated 300,000 people in the U.S. with Type 1 diabetes under age 20, health experts say. Also known as juvenile diabetes, it is an autoimmune disease typically diagnosed in early childhood and treated with daily insulin to help regulate blood sugar. It affects about 1 in 400 people under 20, according to the American Academy of Pediatrics.

(CGMs are also used by those with Type 2 diabetes, a different disease tied to risk factors such as diet and exercise that affects tens of millions of people - including a growing number of children, though it is usually not diagnosed until the early teens. Most people with Type 2 diabetes do not take insulin.)

Students with diabetes or another disease or disability typically have a health care plan, developed by their doctor, that works with a school-approved plan to get the support they need. It details necessary accommodations to attend school, such as allowing a child to eat in class or ensuring staff members are trained to check blood glucose or give a shot of insulin.

For children with Type 1 diabetes, the plan usually includes monitoring CGMs several times a day and responding to alarms, Roswig said.

Lynn Nelson, president-elect of the National Association of School Nurses, said when doctors and parents deem a student needs their CGM remotely monitored, the school is obligated under the ADA to meet that need. "It is legally required and the right thing to do."

Nelson, who also manages school nurse programs in Washington state, said schools often must balance the students' needs with having enough administrative staff.

"There are real workforce challenges, but that means schools have to go above and beyond for an individual student," she said.

Henry Rodriguez, a pediatric endocrinologist at the University of South Florida and a spokesperson for the American Diabetes Association, said remote monitoring can be challenging for schools. While they advocate for giving every child what they need to manage their diabetes at school, he said, schools can be limited by a lack of support staff, including nurses.

The association last year updated its policy around CGMs, stating: "School districts should remove barriers to remote monitoring by school nurses or trained school staff if this is medically necessary for the student."

In San Diego, Taylor Inman, a pediatric pulmonologist, said her daughter, Ruby, 8, received little help from her public school after being diagnosed with Type 1 diabetes and starting to use a CGM.

She said alerts from Ruby's phone often went unheard outside the classroom, and she could not always reach someone at the school to make sure Ruby was reacting when her blood sugar levels moved into the abnormal range.

"We kept asking for the school to follow my daughter's CGM and were told they were not allowed to," she said.

In a 2020 memo to school nurses that remains in effect, Howard Taras, the San Diego Unified School District's medical adviser, said if a student's doctor recommends remote monitoring, it should be done by their parents or doctor's office staff.

CGM alarms can be "disruptive to the student's education, to classmates and to staff members with other responsibilities," Taras wrote.

"Alarms are closely monitored, even those that occur outside of the classroom," Susan Barndollar, the district's executive director of nursing and wellness, said in a statement. Trained adults, including teachers and aides, listen for the alarms when in class, at recess, at gym class, or during a field trip, she said.

She said the problem with remote monitoring is that staff in the school office doing the monitoring may not know where the student is to tend to them quickly.

Inman said last year they paid $20,000 for a diabetes support dog trained to detect high or low blood sugar and later transferred Ruby to a private school that remotely tracks her CGM.

"Her blood sugar is better controlled, and she is not scared and stressed anymore and can focus on learning," she said. "She is happy to go to school and is thriving."

Some schools have changed their policies. For more than a year, several parents lobbied Loudoun County Public Schools in Northern Virginia to have school nurses follow CGM alerts from their own wireless devices.

The district board approved the change, which took effect in August and affects about 100 of the district's more than 80,000 students.

Before, Lauren Valentine would get alerts from 8-year-old son Leo's CGM and call the school he attends in Loudoun County, not knowing if anyone was taking action. Valentine said the school nurse now tracks Leo's blood sugar from an iPad in the clinic.

"It takes the responsibility off my son and the pressure off the teacher," she said. "And it gives us peace of mind that the school clinic nurses know what is happening."


Phil Galewitz wrote this story for KFF Health News.


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Proposed Medicaid cuts could seriously impact New York hospitals and health-care workers. President Donald Trump and congressional Republicans are proposing $880 billion in cuts, ending health-care access for around 73 million Americans. More than a quarter of New Yorkers use Medicaid for their insurance.

Amy Lee Pacholk, a surgical and trauma critical-care nurse at SUNY Stony Brook Hospital, said losing these funds means hospitals can't maintain proper staffing levels to care for patients.

"Corners are often cut with staffing," she said. "For a long time, we have been working toward minimum staffing standards and safe patient ratios so that nurses can take care of patients at safe environments both for themselves and for the patients."

But, a New York State Nurses Association report finds between January and October 2024, hospitals failed to staff intensive-care units and critical-care patients at state-mandated ratios more than 50% of the time. These cuts will pay for extending Trump's first administration tax cuts. The Economic Policy Institute notes that private-market health plans can cost 20-percent of families more than their yearly earnings.

Statewide, hospitals are projecting zero operating margins. Although it's a mild improvement, it's insufficient for hospitals to handle patient care. But, Medicaid's low reimbursement rates are responsible for SUNY Downstate's financial issues. 90% of the hospital's patients use Medicaid or don't have insurance. Pacholk said because of reimbursement structure, the hospital hasn't gotten its due.

"Just because of the population that goes there doesn't mean they should close the institution down," she explained. "It just means that you should facilitate the money flow in a different way to continue to serve the people who live in the community."

Part of the Medicaid cut proposal would involve adding work requirements to the program. But, this is part of a common misconception about Medicaid users, that they don't work. Pacholk said these programs are too important to cut for the sake of slash-and-burn style budget cutting.

"Isn't this why we pay taxes? Isn't this why we pay Medicare insurance,?" she said. "Isn't it to protect people or to help us out in the future if something happens and we become financially destitute? Isn't that the rationale? Isn't the goal to help people here? Why do we have to take things away that are actually helping people?"

The GLP-1 medication trend has taken the health and wellness world by storm, largely hailed as a game-changer for weight loss.

Now, new research suggested the benefits of the drugs extend beyond shedding pounds. They could also be powerful tools for improving heart health, particularly for individuals at risk of cardiovascular conditions such as heart disease, stroke and heart failure.

Heart disease remains the leading cause of death worldwide, including among Hispanic Americans, prompting experts to seek innovative ways to reverse the trend. GLP-1 receptor agonists, originally developed to manage Type 2 diabetes, now offer promising cardiovascular benefits by addressing multiple risk factors at once.

Dr. Francisco Parrilla, a cardiologist at Orlando Health, described GLP-1 medications as a game-changer in managing both diabetes and heart health.

"These benefits can be achieved through several mechanisms, improving the glycemic and lipid level control through weight reduction, lowering the blood pressure and decreasing the inflammation in the blood vessels," Parrilla outlined. "The control of all of these factors is fundamental to decreasing the development of cholesterol plaques in the arteries."

The potential of GLP-1s to address health disparities is particularly relevant for Hispanic communities, where rates of Type 2 diabetes and cardiovascular disease exceed national averages.

The link between weight loss and heart health underscores the significance of GLP-1 medications.

Gayle Smith, a bariatric dietitian at Orlando Health, said losing excess weight often brings additional health benefits.

"Because as you lose weight, you improve your heart health and other functions in your body as well as having more energy, ability to get out and exercise, eat healthy," Smith emphasized. "All of that goes together."

Despite their benefits, GLP-1 medications remain out of reach for some patients. The high cost can be a significant obstacle, although Parrilla noted more insurance companies are beginning to cover these drugs as evidence of their cardiovascular benefits grows.

"The benefits from the cardiovascular standpoint are amazing, so in the long term, that will continue to improve, I'm pretty sure about that, and the access will be easier in the future for all the patients. "

Parrilla stressed GLP-1s are not a replacement for traditional heart-disease treatments but rather a complement to established therapies such as cholesterol-lowering drugs, blood pressure medications and lifestyle changes. For patients considering the medications, the advice from both Parrilla and Smith is the same: Consult a health care provider to weigh the risks and benefits.


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