Early Outcomes of a Care Coordination-Enhanced Telehome Care Program for Elderly Veterans with Chronic Heart Failure

Abstract

Veterans with chronic heart failure (HF) are frequently elderly, have numerous comorbid chronic medical illnesses, frequent hospitalizations, and have high rates of cardiovascular events. Within the Veterans Health Administration (VHA), primary care providers are required to manage the majority of HF patients because access to cardiac specialty care within the VHA may be limited. We designed and implemented a care-coordinated, nurse-directed home telehealth management program for veterans with difficult-to-manage or new onset chronic systolic HF. An in-home telehealth message device was provided to the patient at enrollment, and patients received daily HF-specific education via the nurse coordinator and/or the device throughout their continuum of care. We collected demographic characteristics, clinical characteristics, and outcome data at the time of enrollment and at nearly 6 months after enrollment. A total of 92 patients were enrolled, with complete data available on 73. The mean patient age was 67 years, the mean left ventricular ejection fraction (LVEF) was 23%, and nearly all patients (99%) were men. After enrollment, significant improvements were found in blood pressure (129/73 to 119/69 mm Hg, p < 0.05), weight (196 to 192 pounds, p < 0.01), and shortness of breath rating (0-10 scale, 4.0 to 2.7, p = 0.02). Average daily doses of fosinopril (24 to 35 mg/d, p < 0.01) and metoprolol (84 to 94 mg/d, p = 0.05) were also improved. The total number of inpatient hospital days were reduced while on the home telehealth program (from 630 for the previous year to 122 for the duration of the program) with only 31% of the hospitalizations related to HF while on the program. Our nurse-directed, care coordinated home telehealth management program was associated with improved early outcomes in a group of elderly male veterans with chronic HF.

Impact of a Telehealth and Care Management Program on All-Cause Mortality and Healthcare Utilization in Patients with Heart Failure

“…Prior studies have found that use of the HBP was associated with greater compliance with prescription medications, 13 titration of medications, 14 and compliance with nonpharmacologic recommendations, 15 suggesting the HBP likely improved both care delivery and patient self-management, which may have contributed to reductions in mortality and hospitalization observed in the present study. In addition, secondary analyses of multiple randomized trials have shown improved outcomes in patients who demonstrate high pharmacologic adherence in the placebo arm comparable to those receiving the study drug, supporting the possibility that patient engagement may be a marker for other beneficial characteristics.…”

Telemedicine Experience for Chronic Care in COPD

“…This finding is consistent with other reports in 1) cardiac rehabilitation in the home [10], suggesting that ECG telemonitoring was only useful to enroll higher risk patients, whereas all others could obtain the same results with a simple telephone connection during the training session and 2) a randomized trial for home telecare in congestive heart failure [11] where the reduction of readmissions was similar for a group with telephone care and other with televisits and telemonitoring. A recently reported elderly telemonitoring program based on a simple question and answer device [12] also supports this view. In COPD, according to our study team's opinion, a telephonic-, internet-, or WAP-based symptoms questionnaire, as also reported by some researchers [13], [14], might be more useful than spirometry and pulse-oximetry telemonitoring, or may complement the information they provide, that is, similar to what is done in the field of diabetes, which is a pioneer in telemedicine for chronic care.…”

“…All these professionals share the WPMM and use it as a collaborative working tool (schedule specialist or home visits, send messages to other professionals, view visit agenda). Other home telemedicine systems are either directed only to primary care and case managers [12], integrate specialists in a marginal way (faxing occasional reports) [3], or are addressed only to specialists [4], [15]. Care coordination is understood to have a crucial role in chronic patient care and allows adapting the level of care received by each patient to his/her needs at each moment and a smooth transfer among levels when required (exacerbations).…”

Implementing the Chronic Disease Self Management Model in Vulnerable Patient Populations: Bridging the Chasm through Telemedicine

“…Home-based case management directed by a nurse in conjunction with TM-case managed telemedicine (CMTM) is an effective intervention for enhancing the continuum of care (Speedie et al, 2008). It has been shown to improve outcomes in those patients classified as high risk, in elderly veterans (Schofield, 2005), patients with chronic atrial fibrillation (Inglis et al, 2004), and diabetics (Chumbler et al, 2005). CMTM has also shown reduce cost of care, improve compliance, self-efficacy and patient education.…”