Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients.

OBJECTIVE: This retrospective analysis of 2009-2012 Veterans Health Administration (VHA) administrative data assessed the efficacy of care coordination home telehealth (CCHT), a model of care designed to reduce institutional care. MATERIALS AND METHODS: Outcomes for 4,999 CCHT-non-institutional care (NIC) patients were compared with usual (non-CCHT) care in a matched cohort group (MCG) of 183,872 Veterans. Both cohorts were comprised of patients with complex chronic conditions with statistically similar baseline (pre-CCHT enrollment) healthcare costs, when adjusted for age, sex, chronic disease, emergency room (ER) visits, hospital admissions, hospital lengths of stay, and pharmacy costs. RESULTS: Subsequent analyses after 12 months of CCHT-NIC enrollment showed mean annual healthcare costs for CCHT-NIC patients fell 4%, from $21,071 to $20,206, whereas the corresponding costs for MCG patients increased 48%, from $20,937 to $31,055. Higher mean annual pharmacy expenditure of 22% ($470 over baseline) for CCHT-NIC patients versus 15% for MCG patients ($326 over baseline) was attributable to the medication compliance effect of better care coordination. Several healthcare cost drivers (e.g., ER visits and admissions) had sizable declines in the CCHT-NIC group. Medicare usage review in both cohorts excluded this as a confounding factor in cost analyses. Prefinal case selection criteria analysis of both cohorts yielded a 9.8% mortality rate in CCHT patients versus 16.58% in non-CCHT patients. CONCLUSIONS: This study corroborates previous positive VHA analyses of CCHT but contradicts results from recent non-VHA studies, highlighting the efficacy of the VHA's standardized CCHT model, which incorporates a biopsychosocial approach to care that emphasizes patient self-management.

The design, implementation, and operational management of a comprehensive quality management program to support national telehealth networks.

The Veterans Health Administration (VHA) is a large integrated healthcare system with a mission to care for over 5.6 million Veteran patients annually. VHA, like other healthcare organizations, is challenged with providing access to care to those it serves when they live at a distance from a physical site of care. VHA has embraced telehealth as a way of delivering care at a distance and increase access to specialty care services. Since 2003 VHA has developed large national telehealth networks that provided care to 497,342 patients in fiscal year 2012, who received 1,429,424 episodes of care, and is recognized as a national leader in this field. To ensure the safety and effectiveness of its telehealth networks in their delivery of care VHA has implemented a dedicated quality management (QM) program for telehealth. QM data for telehealth are reviewed at 3-month intervals, and the procedures and processes in place to support telehealth in VHA are assessed biannually in an internal accreditation process called "Telehealth Conditions of Participation." This collegial, nonadversarial process has ensured that all designated telehealth programs meet minimal standards and disseminate best practice. As a result of VHA's QM program, telehealth services in VHA meet consistently high clinical outcomes and have received no adverse Joint Commission citations. The Joint Commission regularly assesses patients managed via telehealth under its tracer methodology reviews.

E-patient connectivity and the near term future.

The healthcare system is challenged by growth in demand for services that is disproportionate to the volume of service providers. New care models must be created. The revolution in communications and monitoring technologies (connected health) allows for a care model that emphasizes patient self-management and just-in-time provider interventions. Challenges to realizing this vision exist, including maturity of the technology, privacy and security and the ability of providers to customize solutions to maximize patient engagement and behavior change. In addition, provider work-flow and reimbursement must be changed to enable new care models that are focused on patient self-care and just-in-time provider interventions.

Defining core issues in utilizing information technology to improve access: evaluation and research agenda.

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions.

Let There Be PEACE: Improving Continuous Symptom Monitoring in Hospice Patients.

OBJECTIVE: To ensure that a standardized method of continuous symptom monitoring was available to hospice patients enrolled at our institution. PATIENTS AND METHODS: The Palliative/End-of-Life/Assessment/Care Coordination/Evidence-Based Program (PEACE) seeks to enhance the provision of hospice care through symptom control and patient support. We conducted a quality improvement initiative between November 1, 2015, and March 31, 2017, following Define-Measure-Analyze-Improve-Control methodology to improve hospice care at a rural hospice. The gap in our current hospice model was a standardized method of continuous symptom monitoring. We aimed to explore ways in which technology-assisted care coordination could enhance end-of-life and hospice care. We measured continuous symptom assessments through co-developed condition management protocols (CMPs), technology-assisted care pathways (TACPs), nursing visits, length of stay, respite days, and satisfaction survey data from patients, caregivers, and hospice staff. At baseline, no continuous symptom monitoring was being performed. Baseline data for our enrolled population was compared with data from patients who were eligible, but opted out. RESULTS: We monitored 50 patients using CMP and TACP. The mean ± SD number of skilled nursing visits per patient in the enrolled population compared with those who were eligible but opted out was 13.7±7.6 vs 14.2±10.5, respectively. In response to the survey question, "Because of the overall program, I felt supported and confident at home," 74% (37 of 50) of patients and caregivers answered, "always." CONCLUSION: PEACE enhanced hospice care through symptom control and patient support through CMP and TACP. PEACE is a unique and feasible care platform for hospice patients, with high patient and caregiver satisfaction.

Enhancing access of combat-wounded veterans to specialist rehabilitation services: the VA Polytrauma Telehealth Network.

Operations Iraqi Freedom and Enduring Freedom have resulted in U.S. military personnel sustaining combat wounds of unprecedented severity and complexity that necessitate long-term rehabilitation. To meet what are often conflicting requirements in providing severely wounded veterans with timely and convenient access to specialist rehabilitation care, and to enable them to return to their local communities, the Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network that enhances access to such services by linking Veterans Administration rehabilitation facilities. This article describes the clinical, technical, and business process issues involved in the development of this network.

VA telemental health: suicide assessment.

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.

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.

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.

Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program.

The 2001 Institute of Medicine report indicted that the US healthcare system fails to provide high-quality care, and offered 6 aims of improvement that would redesign the delivery of care for the 21st century. This study compared the use of Department of Veterans Affairs (VA) inpatient and outpatient services of cancer patients enrolled in a Cancer Care Coordination/Home-Telehealth (CCHT) program that involved remote management of symptoms (eg, emotional distress, pain) via home-telehealth technologies to a control group of cancer patients receiving standard VA care. Using a matched case-control design, 2 control patients per case were selected, matched by tumor type and cancer stage. There were 43 Cancer CCHT patients and 82 control group patients. Based on a medical record review of each patient, the total number of cancer-related services (defined as visits that were expected given the patients' cancer diagnosis and treatment protocol) and preventable services (defined as visits needed outside of those expected given the cancer diagnosis and planned treatment) were calculated over a 6-month period. Poisson multivariate regression models were used to estimate the adjusted relative risks (RRs) for the effects of the Cancer CCHT program on the service use outcomes. Cancer CCHT patients had significantly fewer preventable services (clinic visits: RR = 0.03, 95% confidence interval [CI] = 0.00-0.24; bed days of care (BDOC) for hospitalization [all-cause]: RR = 0.50, 95% CI = 0.37-0.67; hospitalizations [chemotherapy related]: RR = 0.43, 95% CI = 0.21-0.91; and BDOC for hospitalizations [chemotherapy related]: RR = 0.49, 95% CI = 0.34-0.71) than the control group. This study offered some preliminary evidence that patients enrolled in a Cancer CCHT program can successfully manage multiple complex symptoms without utilizing inpatient and outpatient services.

Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010.

OBJECTIVE: The study assessed clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services of the U.S. Department of Veterans Affairs between 2006 and 2010. METHODS: The study compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the telemental health services. RESULTS: Between 2006 and 2010, psychiatric admissions of telemental health patients decreased by an average of 24.2% (annual range 16.3%-38.7%), and the patients' days of hospitalization decreased by an average of 26.6% (annual range 16.5%-43.5%). The number of admissions and the days of hospitalization decreased for both men and women and in 83.3% of the age groups. CONCLUSIONS: This four-year study, the first large-scale assessment of telemental health services, found that after initiation of such services, patients' hospitalization utilization decreased by an average of approximately 25%.

Remote patient-provider communication and quality of life: empirical test of a dialogic model of cancer care.

We examined the feasibility of a Cancer Care Dialogues Model, with daily telehealth interactions between patients at home and their care coordinator, who acted as an adjunct to the oncologist. The patient and the care coordinator used a home messaging device, connected via the ordinary telephone network. Thirty-four patients with a new diagnosis of cancer and whose treatment plan included chemotherapy taken at a single clinic were enrolled and followed for six months. The home messaging device collected information daily on common symptoms associated with chemotherapy. On average, the patients had the home messaging device for 120 days (range 30-180). The mean cooperation rate was 84% (range 4-100). No variables were significantly associated with patient cooperation in the dialogues over time. The health-related quality of life (HRQL) mean score at baseline was 73.9 (SD 15.4), and the mean score at six months was 78.4 (SD 14.5). After adjusting for demographic and clinical factors, there was a 6.5-point increase in HRQL score between the baseline and end of treatment, which represented an important clinical difference. Management of nervousness/worry over time through cancer care dialogues is important in maintaining HRQL and can be assisted by remote home messaging.

Framework for a national teleretinal imaging program to screen for diabetic retinopathy in Veterans Health Administration patients.

Digital retinal imaging with remote image interpretation (teleretinal imaging) is an emerging healthcare technology for screening patients for diabetic retinopathy (DR). The Veterans Health Administration (VHA) convened an expert panel in 2001 to determine and resolve the requisite clinical, quality and training, information technology, and healthcare infrastructure issues associated with deploying a teleretinal imaging system. The panel formulated consensus recommendations based on available literature and identified areas of uncertainty that merited further clarification or research. Subsequent VHA experience with teleretinal imaging and accumulated scientific evidence support nationwide regionalized deployment of teleretinal imaging to screen for DR. The goal is to screen approximately 75,000 patients in the first year of the program, which commenced in 2006. This program will increase patients' access to screening for DR, provide outcomes data, and offer a unique platform for systematically evaluating the role of this technology in the care of diabetic eye disease and routine eye-care practice.

A modeled economic analysis of a digital tele-ophthalmology system as used by three federal health care agencies for detecting proliferative diabetic retinopathy.

The objective of this study was to compare, using a 12-month time frame, the cost-effectiveness of a non-mydriatic digital tele-ophthalmology system (Joslin Vision Network) versus traditional clinic-based ophthalmoscopy examinations with pupil dilation to detect proliferative diabetic retinopathy and its consequences. Decision analysis techniques, including Monte Carlo simulation, were used to model the use of the Joslin Vision Network versus conventional clinic-based ophthalmoscopy among the entire diabetic populations served by the Indian Health Service, the Department of Veterans Affairs, and the active duty Department of Defense. The economic perspective analyzed was that of each federal agency. Data sources for costs and outcomes included the published literature, epidemiologic data, administrative data, market prices, and expert opinion. Outcome measures included the number of true positive cases of proliferative diabetic retinopathy detected, the number of patients treated with panretinal laser photocoagulation, and the number of cases of severe vision loss averted. In the base-case analyses, the Joslin Vision Network was the dominant strategy in all but two of the nine modeled scenarios, meaning that it was both less costly and more effective. In the active duty Department of Defense population, the Joslin Vision Network would be more effective but cost an extra 1,618 dollars per additional patient treated with panretinal laser photo-coagulation and an additional 13,748 dollars per severe vision loss event averted. Based on our economic model, the Joslin Vision Network has the potential to be more effective than clinic-based ophthalmoscopy for detecting proliferative diabetic retinopathy and averting cases of severe vision loss, and may do so at lower cost.

Telehealth practice recommendations for diabetic retinopathy.

Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.