Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, 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 VHA's 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 enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience 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.
The Rural Home Care Project is one of eight clinical demonstration pilots in an initiative of the Veterans Health Administration (VHA) Sunshine Network in Florida and Puerto Rico. In this project three care coordinators consisting of two nurse practitioners and a social worker collaborate with primary care providers in the management of high-risk, high-cost veterans with multiple chronic diseases such as diabetes and heart failure. The project staff uses home telehealth devices to monitor and educate patients to prevent health crises. The evaluation methodology is a quasiexperimental design that uses a nonequivalent control group of usual care veterans. Data were gathered through personal interviews with patients and providers, and statistical analysis was based on a series of repeated-measure of covariance modeling designed by a research team from the University of Maryland. Findings demonstrate that care coordination enhanced by technology reduces hospital admissions, bed days of care, emergency room visits, and prescriptions as well as providing high patient and provider satisfaction. Veterans also had improved perception of physical health as evidenced by a standardized functional status measure.
We evaluated a Veterans Health Administration (VHA) care coordination/ home-telehealth (CC/HT) program on the utilization of health care services and health-related quality of life (HRQL) in veterans with diabetes. Administrative records of 445 veterans with diabetes were reviewed to compare health care service utilization in the 1-year period before and 1-year period post-enrollment and also examined self-reported HRQL at enrollment and 1 year later. Multivariate analyses indicated a statistically significant reduction in the proportion of patients who were hospitalized (50% reduction), emergency room use (11% reduction), reduction in the average number of bed days of care (decreased an average of 3.0 days), and improvement in the HRQL role-physical functioning, bodily pain, and social functioning. The results need to be interpreted with caution because we used a single-group study design that may be influenced by regression to the mean. Ideally, future research should use a randomized controlled trial design.
This study examined the effectiveness of a veterans affairs (VA) patient-centered care coordination/home-telehealth (CC/HT) program as an adjunct to treatment for veterans with diabetes. Using an adapted version of the Chronic Care Model, we analyzed the differences in healthcare service use between a cohort of 400 veterans with diabetes who were enrolled in a VA CC/HT program and a matched comparison cohort of 400 veterans with diabetes who received no CC/HT intervention. Propensity scores were used to improve the balance between the treatment and comparison groups. Service use outcomes were assessed at 12 months before and after enrollment. A difference-in-differences approach was used in the multivariate models to assess the treatment effect for patients in the CC/HT programs. Twelve months after enrollment, there was a significant difference between the treatment and comparison groups in terms of need-based primary care visits (newly scheduled visits that enable the veteran to be seen "just in time," where the health status is monitored and met before health deteriorates), increasing in the treatment group and decreasing in the comparison group (P < .01). In a subgroup analysis, where we were able to control for the patients' Hb A1c values, we found that the treatment group had a lower likelihood of having 1 or more hospitalizations than patients in the comparison group. Our findings have implications for management in that the CC/HT program appears to improve the ability of older veterans with diabetes to receive appropriate, timely care, thereby improving the quality of care for them and making more efficient use of VA healthcare resources.
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