From Home Visits to Health Victories: Global Health Tech Gets Personal

“Thank you so much for coming to my home. You saved my life.”

Those simple words from Bill Adams* spoke volumes to Karen Fernandez, one of the original community health workers with an in-home healthcare program called Healthy Neighbor in Camden, New Jersey. A few days before, she had met Bill for the first time at his home and discovered that his blood pressure was incredibly high. She called the triage line and was able to get him into the emergency department the same day.

Before that first visit, Bill called Karen to ask if she was really going to show up. He didn’t have health insurance or much trust in the healthcare system that had let him down so many times before.

Karen did show up — the first step in creating trust and a foundation toward Bill’s future health.

“That’s why I do this job,” said Fernandez. “It’s rewarding. If you can make an impact on a person’s life, they will never forget it.”

This is just one of hundreds of stories illustrating the impact that the four community health workers who comprise Healthy Neighbor are bringing to the Camden community.

They are equipped with a technology platform called SPICE from Medtronic LABS, which develops community-based, tech-supported healthcare solutions for underserved communities.

This digital tool streamlines their work by capturing basic healthcare needs, tracking blood pressure and glucose over time, and flagging elevated readings for follow-up. This helps link community and health system care, reduces paperwork, and allows the community health workers to focus on their patients.

Bringing a global program home

Camden, a city of about 70,000 people across the Delaware River from Philadelphia, has a life expectancy gap of as much as 16 years compared to neighborhoods just 6.5 miles away.^[i] The rates of diabetes and high blood pressure are dramatically higher than in nearby communities.

Virtua Health is South Jersey's largest healthcare provider, and many of its patients live in Camden. When leadership at Virtua saw these staggering health statistics, they felt compelled to do something.

“Our mission is to help our community be well, get well, and stay well. We take it very seriously,” said Dan Master, the director of community health and impact at Virtua. “And there is a lot of alignment with Medtronic LABS and Medtronic in this.”

For over a decade, Medtronic LABS has built community-based, tech-enabled solutions to address healthcare disparities around the world. But they had never built a program in the United States. Until Virtua called.

“When we first met with Virtua, we knew this was a great opportunity to bring our learnings from community-based care models in Asia and Africa to the U.S. and continue to innovate,” said Lauren Leccese, head of U.S. programs at Medtronic LABS. “The shared values and commitment to health equity across our organizations created a strong foundation as we started to build the program.”

From pilot to expansion

In August 2023, Medtronic LABS and Virtua launched Healthy Neighbor. The goal was to improve health outcomes through a home visiting program where community health workers provide integrated health and social care for patients living with high blood pressure and/or type 2 diabetes. And it’s working.

The data from the first two years of the program is in — and it’s remarkable:

• 74% of patients with uncontrolled hypertension achieved meaningful improvement (15-point mean drop in systolic blood pressure)
• 69% of patients with uncontrolled diabetes achieved meaningful improvements (1.2% mean drop in A1C)

These numbers are so impressive that the program is expanding. Virtua received a grant from the city of Camden to grow the community health worker team and reach more patients.

“We all had high standards and high hopes for the program when it started, and it's been living up to them,” said Alexis Nieves, a Healthy Neighbor community health worker who has been with the program from the beginning. “And these results are not just because of us, but because the patients are willing to make changes as well.”

More than the numbers

The impact of Healthy Neighbor goes beyond data. Patients are enrolled in the program because of either uncontrolled high blood pressure or diabetes (or both), but the care they receive goes far beyond treating those conditions.

“It’s not normal for a medical team to go out of their way to help you,” said Greg Ashton*, a Healthy Neighbor patient. “They're going above and beyond their duty, for someone that they don't even know.”

There are many factors that influence a person’s health, and community health workers are skilled at addressing all of them. They help their patients secure housing, healthy food, heat, and mental-health support. They provide education on nutrition, teach patients to monitor their blood pressure and glucose levels, remind them about upcoming appointments, and help them find transportation to the appointments.

“La Shawn is a positive influence on my life, she motivates me,” said Denise Manlius, a Healthy Neighbor patient, of her community health worker. “She makes sure that I take my medications. She calls to remind me of appointments. She helped me change my eating habits. Since she’s been in my life, my A1C (blood sugar) went down. And it’s not just a paycheck to her; she really cares about her people.”

‘Someone cared enough’ 

“A lot of patients just need to know someone cared enough,” said La Shawn Dutton-Spruill. “To show them how to fill up their pillbox until they understand how to do it themselves. To help them understand that their meds will be green this month and white next month, but that it’s still the same medication.”

Due to the program's success and a desire to replicate it to help more patients across the country, Virtua and Medtronic LABS created a toolkit that other health systems can use to establish Healthy Neighbor programs in their communities. The goal is to help more healthcare systems address health disparities and make a meaningful difference in the health of their patients and communities.

As Fanny Ochoa, a community health worker with Healthy Neighbor, explained, “It's not just what you do when you’re with the patient. The reward is seeing your patients continue to make changes after you leave. The goal of our work is to create a better lifestyle and a better outcome for our patients, beyond the time that we are with them.”

*Names changed to protect patient privacy 

Learn more about how Medtronic LABS develops community-based, tech-enabled solutions for underserved patients, families, and communities across the world.