1118 TELEMEDICINE and e-HEALTH DECEMBER 2008 DOI: 10.1089/tmj.2008.0021

C A S E R E P O R T

Adam Darkins, M.D., Patricia Ryan, R.N., M.S., Rita Kobb, M.N., A.P.R.N., Linda Foster, M.S.N., R.N., Ellen Edmonson, R.N., M.P.H., Bonnie Wakefield, Ph.D., R.N., and Anne E. Lancaster, B.Sc.

Department of Veterans Affairs, Office of Care Coordination Services, Washington, D.C.

AbstractBetween July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth pro-gram, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHAs anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs

meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrollment into the pro-gram. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHAs experi-ence is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

Key words: home telehealth, chronic care, outcomes, patient satis-faction, veterans

Introduction he Veterans Health Administration (VHA) within the U.S. Department of Veterans Affairs is a large integrated health-care system. VHA currently delivers healthcare services1 that serve 5.6 million unique veteran patients annually. A total

of 7.6 million veterans are enrolled to receive VHA care.1 The number of veteran patients aged 85 years or more that VHA treats is set to triple by 2011 compared to 2000 (Fig. 1).

As the U.S. population ages, people are living longer,2 stay-ing healthier,35 and choosing to live independently at home.6,7

Responding to these same societal changes has heightened the emphasis Congress8 and VHA place upon developing noninstitutional

Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions

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VHA CARE COORDINATION/HOME TELEHEALTH

care (NIC) services since 1999 for the rising number of aging veterans with chronic care needs (Fig. 2).

Between July 2003 and December 2007, the Veterans Health Administration (VHA) implemented a national home telehealth program, Care Coordination/Home Telehealth (CCHT). CCHT is now a routine NIC service that supports the care for veterans with chronic conditions in their homes as they age. It involves the use of home telehealth and disease management technolo-gies in care management as adjuncts to VHAs existing health information technology (HIT) infrastructure. Since 1995, VHAs enterprise-wide implementation of HIT helped transform the organization from a predominantly hospital-based provider of care to one with a primary and ambulatory care focus. In 1995, 2.9 million unique veteran patients received VHA care at a time when VHAs complement of hospital inpatient beds was 53,200 and 30 million patient encounters were outpatient visits.1 By 2005, 5.3 million unique veteran patients received care. The complement of VHA inpatient beds had reduced to 18,199 and the number of outpatient encounters rose to 50 million.1 VHAs computerized patient record system (CPRS) supported the transi-tion of care from hospital inpatient to outpatient settings. CCHT builds on VHAs routine use of CPRS by extending the reach of HIT supported services directly into the home. VHAs develop-ment of its HIT platform for CCHT was based upon CCHTs ability to meet predefined patient needs.

An internal VHA needs assessment9 in 2002 outlined the scope for CCHT imple-mentation and recommended its initial focus on managing the care of between 21,000 and 32,000 NIC and chronic care management patients. Additional oppor-tunities were identified to expand CCHT to cover acute care management and health promotion/disease prevention. Thirty-two percent of the veteran population VHA treats lives in rural areas.1 This poses challenges in providing them with timely access to specialty care. Therefore, VHAs CCHT program was charged with ensur-ing it offered support to care for veterans needing NIC in rural areas.10

This case report outlines VHAs ratio-nale for adopting CCHT, traces its evolu-tion between July 2003 and October 2007, provides outcomes information from rou-

tine quality/performance management data, assesses how well CCHT meets the needs of the veteran patients VHA serves, and comments on the applicability of CCHT to other healthcare systems.

Materials and MethodsVHA commenced implementation of its national CCHT program

in July 2003. The programs primary mission was to provide routine NIC and chronic care management services to veteran patients with

Fig. 1. VHA veteran population for treatment age 85 or over in 20002028.

Fig. 2. Projected noninstitutional care provision FY20172011. ADC, Average Daily Census.

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The veteran population age 85 or over will increase by 124% between 2000 and 2020. The veteran population age 85 or over will peak in 2012 at 1.4 million, representing an increase

of 167% over the total of 510,000 veterans age 85 or over in 2000.Source: Vet Pop 2001 Adj

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DARKINS ET AL.

diabetes mellitus (DM), congestive heart failure (CHF), hypertension (HTN), posttraumatic stress disorder (PTSD), chronic obstructive pulmonary disease (COPD), and depression. CCHT was designed as a flexible and cost-effective way to augment VHAs preexisting tradi-tional NIC9 programs and support patient care in the least restrictive setting possible. VHAs design for its CCHT model of care refined the Community Care Coordination Service (CCCS), a precursor program9 piloted by VHA between 2000 and 2003, and combined this with elements of other exemplary VA home telehealth pilot programs.11,12 This model incorporated the necessary clinical, information technolo-gy (IT), business, and logistic elements required to project-manage the enterprise implementation of CCHT and sustain it thereafter. A core component in the design of CCHT was to define CCHT. In 2004, an expert group of care and case managers was convened within VHA to arrive at a definition. Their consensus definition of CCHT was:

The use of health informatics, disease management, and home telehealth technologies to enhance and extend care and case management to facilitate access to care and improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time.

VHAs definition of CCHT embraced the role of HIT in support-ing the coordination of patient care across the continuum from the hospital to the home. With VHAs CCHT model, care is actively coor-dinated across this continuum by a dedicated cadre of care coordina-tors. Care coordinators are healthcare professionals, usually nurses or social workers. Every CCHT patient is formally assessed by their care coordinator upon enrollment in the program. Explicit enrollment cri-teria determine whether the purpose of CCHT-supported care for any individual patient is for NIC, acute care management, or chronic care management services. After a patient is enrolled into the program, his or her care coordinator selects the appropriate home telehealth technology, gives the required training to the patient and caregiver, reviews telehealth monitoring data, and provides active care or case management (including communication with the patients physician). Typically, an individual care coordinator manages a panel of between 100 and 150 general medical patients or 90 patients with mental healthrelated conditions. Dependent upon a patients underlying chronic condition and guided by the enrollment assessment, their care coordinator selects the appropriate vital signs, other objective parameters (e.g., blood glucose), or disease management data to acquire from the home for ongoing monitoring and disease manage-ment purp