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5120_a07_p170-183TELEMEDICINE JOURNAL AND e-HEALTH
Volume 10, Number 2, 2004
Mary Ann Liebert, Inc.
HELEN C. NOEL, Ph.D., A.N.P., DONNA C. VOGEL, M.S.N., C.C.M., JOSEPH J. ERDOS, M.D., Ph.D., DAVID CORNWALL, R.N., M.B.A., ABSTRACT
The aim of this study was to determine whether home telehealth, when integrated with the
health facility’s electronic medical record system, reduces healthcare costs and improves qual-
ity-of-life outcomes relative to usual home healthcare services for elderly high resource users
with complex co-morbidities. Study patients were identified through the medical center’s
database. Intervention patients received home telehealth units that used standard phone lines
to communicate with the hospital. FDA-approved peripheral devices monitored vital signs
and valid questionnaires were used to evaluate quality-of-life outcomes. Out-of-range data
triggered electronic alerts to nurse case managers. (No live video or audio was incorporated
in either direction.) Templated progress notes facilitated seamless data entry into the patient’s
electronic medical record. Participants (n ؍ 104) with complex heart failure, chronic lung dis-
ease, and/or diabetes mellitus were randomly assigned to an intervention or control group for
6–12 months. Parametric and nonparametric analyses were performed to compare outcomes
for (1) subjective and objective quality-of-life measures, (2) health resource use, and (3) costs.
In contrast to the control group, scores for home telehealth subjects showed a statistically sig-
nificant decrease at 6 months for bed-days-of-care (p Ͻ 0.0001), urgent clinic/emergency room
visits (p ؍ 0.023), and A1C levels (p Ͻ 0.0001); at 12 months for cognitive status (p Ͻ 0.028);
and at 3 months for patient satisfaction (p Ͻ 0.001). Functional levels and patient-rated health
status did not show a significant difference for either group. Integrating home telehealth with
the healthcare institution’s electronic database significantly reduces resource use and im-
proves cognitive status, treatment compliance, and stability of chronic disease for homebound
elderly with common complex co-morbidities.
vism.2 This study examines the effect on a high-resource-use veteran population of imple- THE ELDERLY WITH COMPLEX CO-MORBIDITIES menting these strategies by means of telemed-
who receive traditional healthcare services icine. In 2001, the three most active sources for fail to show long-term compliance with pre- veteran home care were general hospitals (70% scribed regimens, medications, and dietary re- of all such referrals), community sources strictions.1 It has been shown, however, that (19.5%), and nursing homes (5.5%). Of the 23 strategies that include extrinsic motivators pro- listed major diagnoses, those with the highest mote long-term compliance and reduce recidi- percentage were diabetes mellitus (DM) (12%), VA Connecticut Healthcare Systems, West Haven, Connecticut.
HOME TELEHEALTH REDUCES COSTS
heart disease and circulatory system disease and decreased clinic and emergency room vis- (24%), stroke (Ͼ9%), and chronic obstructive its. Long-term disease-specific patient educa- tion is incrementally effective in sustaining ing dependency in activities-of-daily-living long-term compliance for patients with chronic (ADLs), diabetes (6%), heart and circulatory Telemedicine’s role as a technological com- counted for 22% out of a total of 41% not in- munication tool has evolved beyond early dependent in ADLs. Stroke is associated with experimental applications into a real-world dependency in six ADLs (3.2%), whereas dia- cost-saving strategy. For example, a 4-year tele- betes, heart and circulatory system diseases, health Medicare- and Medicaid-funded project and COPD are associated with dependency in will examine healthcare and resource use out- one ADL (Ͼ1.5%), two ADLs (Ͻ1.4%), and six comes for elderly diabetics in underserved ar- ADLs (Ͻ1%), respectively. Of the 5449 veter- eas in New York State. End points will include ans transferred from HBPC, three major desti- A1C and lipid levels, blood pressure (BP), pa- nations accounted for 89% of the total: general tient satisfaction, and healthcare resource costs hospital (43%), other community-based service and use.8 National healthcare systems beyond Home telemedicine (telehealth) transports telemedicine to provide clinical healthcare ser- data rather than people. Telemedicine is a vices in remote regions. In Ankara, Turkey,globally expanding technology,4–7 poised par- combining fields of medicine, telecommunica- ticularly to benefit homebound elderly with tion, and informatics enables clinical healthcare chronic complex co-morbidities. Elderly usu- to reach rural areas.4 In Italy, seven 3-year ally require high levels of monitoring and are research projects served a dual goal: To im- more likely than younger people to have bar- prove healthcare, management, and perfor- riers in ambulation, geographic distance, and mance and to encourage large-scale imple- transportation to their healthcare providers.8 mentation for actual reduction in healthcare costs.6 The goal of Bhutan’s Health Telematics show improved health outcomes for complex- Project is to decrease time and distance barri- ill elderly.9,10 Telehealth is achieving integra- ers and optimize use of limited available health tion with home-based primary care services us- services.7 Telemedicine in Norway enhances ing a patient-centered approach. Innovative the working environment in psychiatry, der- strategies for patient education focus on long- matology, pathology, and otolaryngology by term patient compliance and disease-specific decreasing provider travel, increasing time for education and alert systems for rapid detection other work, and by promoting professional se- and treatment of early signs and symptoms of curity through integrated support systems.16 In instability.2,11 Decreasing the cost of healthcare Ecuador, a telemedicine project achieved sig- is a product of preventing unnecessary clinic nificant positive clinical outcomes and eco- visits, hospitalizations, and trips to the emer- nomic value for pre-surgical and post-surgical consultations; the project reached people in re- A positive perception of provider support- mote rural regions outside of Cuenca and the iveness (patient centeredness) is the key to achieving improved, sustained, and effective coping mechanisms, motivation, self-determi- traditional in-person clinic visits showed nation, self-management of chronic diseases, shorter waiting times for scheduling patients, and enhanced sense of well-being.1 A positive increased efficiency and productivity for clini- perception of provider supportiveness en- cians, and less operational costs for the clinic.
hances objective health outcomes for hyper- For patients, time and cost reductions resulted tension, DM, COPD, and congestive heart from reduced travel to clinic and fewer unnec-failure (CHF). In addition, positive patient per- essary clinic visits.9 Teledermatology facilitates ceptions and positive objective outcomes cor- transmission of dermatologic images, accurate relate with decreased bed-days-of-care (BDOC) diagnoses, and provider satisfaction, although NOEL ET AL.
one-way video is not patient-centered and re- (7) ongoing community nurse visits. Large- duces patient satisfaction by weakening the pa- sample, long-term studies (rather than small- tient–provider relationship.10 A multination scale pilot studies) can more accurately simu- late real-world healthcare challenges and can broadband with video-conferencing and eight more closely determine whether telemedicine telehealth services. Positive outcomes included strategies influence access to care and reduce user satisfaction with video and audio com- munication as well as confidentiality for three Quality-of-life questionnaires require objec- levels of participants—medical staff, patients, tive and subjective measures to accurately as- and supporters. Medical staff trusted some re- sess individualized patient-centered healthcare mote assessments, although not assessment or approaches. Elderly patients in declining life- treatment for critical situations.18 Video-tele- stages with chronic co-morbidities may show phone and regular telephone reminders each divergent responses to subjective and objective improve medication compliance in elderly pa- questionnaires. Elderly with chronic complex tients with CHF more than usual healthcare diseases may react differently from young peo- services or prepoured pillboxes. Long-term re- ple with reversible conditions to the functional inforcement methods and patient centeredness effects of illness and therapy. Satisfaction and instill positive perceptions of provider sup- happiness each characterize a particular time- portiveness and increase the likelihood of suc- frame between present experience and expec- tations. Among chronically-ill elderly, satis- approved peripheral devices and supported by depending on perceptions of well-being. The patient education enables transmission of valid domains affecting perceptions of health and and reliable data to healthcare providers and disease are level of physical functioning, psy- eliminates the need for frequent and costly pre- chological state, socioeconomic status, envi- ventive community nurse visits.19 Comparing ronment, social relationships, and somatic sen- the cost–benefit ratio of traditional healthcare management in a clinic setting to home tele-health healthcare management is vital to shift-ing telemedicine from an under-utilized health- MATERIALS AND METHODS
care model to a pragmatic operational methodof providing healthcare services. Retrospective Our current telehealth project was preceded reviews of telemedicine studies show little at- by a pilot project. Results of the 90-day pilot tention to sustained real-world viability. Too study (n ϭ 20), conducted at VA Connecticut few studies have focused on (1) cost benefit analysis, (2) long-term outcome data, (3) confi- mote patient monitoring decreases healthcare dentiality issues, and (4) access to care.20,21 costs and improves well-being of frail elderly Cost-effectiveness analysis of telemedicine veterans with complex co-morbidities residing for real-world application requires examining at home. Although the pilot study differed healthcare costs and the broad spectrum of fac- from the present study in that it included a tors that influence them. A comprehensive costly central station for collecting and trans- multivariable approach is necessary to identify mitting patient data, findings showed that and measure direct and indirect healthcare costs. Fundamental variables that determine mented highest healthcare resource use at costs of alternate healthcare models include (1) transportation between remote site and clinic, nisms and patient satisfaction with a first-gen- (2) clinic timeframe and support personnel, (3) eration bulky home telehealth unit. A key les- target population such as elderly with complex chronic co-morbidities, (4) specialist consulta- importance of uploading data from the pa- tion, (5) type of telemedicine device and pe- tient’s telehealth unit into the healthcare facil- ripherals, (6) telephone connection costs, and ity’s electronic database. The design of the HOME TELEHEALTH REDUCES COSTS
large-sample project reported here focused on lated to disease-specific education modules achieving improved healthcare for homebound were acquired via the home-based telehealth elderly through integration with the healthcare units. These user-friendly devices feature a touch screen interface with 16-bit color, and The current project was conducted in real- step-by-step instructions using graphics, large world settings at an operational scale. It incor- text, and audio. FDA-approved peripheral de- porated: (1) an active working relationship vices plug into the telehealth unit and collect with a corporate partner, (2) home telehealth data for temperature, blood pressure, pulse, units placed in 47 homes, (3) use of the WEB (VA Intranet) and database server at VACT for stethoscope for heart and lung sounds, pulse data access and VISTA (VACT’s electronic oximetry, and weight. Pain level (0–9) is self- database) integration, (4) physiologic data in- reported using a simple questionnaire. Data are tegrated with VISTA, and (5) outcome data transmitted over POTS (plain old telephone from educational resources also integrated system) lines to VACT’s Web-based Intranet system and directly into the facility’s electronic This single-blind, single-site, randomized, database (VISTA). A patient-specific intake large-sample project was conducted at VACT.
form was completed before deployment of the The target population comprised frail elderly healthcare unit. The intake form addresses de- mographics and needs assessment for periph- ticipation duration for each subject was at least eral devices and safe range settings. Out-of- 6 months. Inclusion criteria included docu- range patient data trigger VA alerts via the mented high use of healthcare resources and Web to nurse case managers. The device sup- barriers to accessing healthcare services due ports on-screen hospital-to-home messaging,to geographic, economic, physical, linguistic, scheduling, and advice from providers to pa- technologic, and/or cultural factors. Candi- tients. Incoming data were automatically writ- dates who qualified for participation met these ten into the VA’s electronic patient record to inclusion criteria and had been actively receiv- templated progress notes or the vital sign record. A digital camera (Nikon Coolpix 880) months preceding the study and throughout was used to monitor wound care with images study participation. A needs assessment, de- transmitted to the Web server. Disease-specific patient education modules included pass/fail nursing care protocols, determined whether tests to demonstrate learning achieved. Pa- patients qualified for nurse case management.
tients completed on-screen assessment surveys The control group (n ϭ 57) received usual for pain, well-being, and patient satisfaction.
home healthcare services plus nurse case man- This project involved multiple issues relating agement. The intervention group (n ϭ 47) re- to information security. The system’s design ceived home telehealth plus nurse case man- was examined and approved by computer sys- agement. Informed consent was obtained from tem security professionals (Corbett Technolo- all participants. Approval to conduct the study gies, Inc.). A comprehensive security plan was was granted by VACT’s institutional review implemented to ensure viability, confidential- board. Participants were instructed to call 911 ity, and security of the system. The system’s for emergencies because the home telehealth unit was not a life-saving device.18 Subjectiveand objective quality-of-life measures were • The Telewall server allowing only preregis- taken at baseline and quarterly. Cost data were tered phone numbers to connect to the sys- collected for 6 months preceding study entry and 6 months during participation in the study.
• An isolated network segment for the main Data analysis included parametric and non- system servers. These servers are protected parametric tests and made use of the SPSS 10.0 from VACT’s Intranet by a firewall.
• Virus protection software with scheduled Vital sign data and answers to quizzes re- NOEL ET AL.
• A software maintenance program to ensure vices Program. The 4-construct tool uses a 5- that all system security software is fully point Likert scale with 5 ϭ excellent and 1 ϭ poor responses, yes/no responses, and re- • User authentication scheme whereby pa- sponses based on current events. A sample tients must log on to their home units with question from the 10-item cognitive assessment asks: “Who is the president of the U.S. now?” • Machine authentication scheme that requires A typical question from the 15-item functional a unique log on from the patient’s terminal level questionnaire asks: “Can patient take care of perineum/clothing at toilet?” A 28-item pa-tient satisfaction question asks the patient to Maintaining a complete electronic patient rate “thoroughness of treatment.” A sample 37- record (EPR) was a fundamental goal of the item self-rated health status question asks: telemedicine design team. The developers at “During the past four weeks, have you accom- VACT wrote a suite of applications that sup- port data sharing between VISTA and the home Each study participant was assigned to the telehealth unit. All vital sign data collected in intervention (home telehealth unit) or control the home are written to VISTA and available (usual healthcare services) group. Due to ethi- for clinicians within 10 minutes of being re- cal concerns for this high-risk frail popula- ceived. Results of disease management surveys tion, all subjects continued receiving nurse and education assessments trigger the creation case management during study participation.
of VISTA progress notes and become part of VACT’s electronic database was used to deter- the permanent record. This VISTA Integration mine selection of qualified candidates. Partici- Process uses the same software technology pants who met inclusion criteria were highest used for the VA Healthcare System’s CPRS users of healthcare services with complex (Computerized Patient Record System). Data chronic co-morbidities—CHF, COPD, and/or are passed from an SQL Server using the VISTA Integration software and written to VISTA with standard RPC (Remote Procedure Call) func- Participation was skewed toward males be- tions. This automated approach eliminates un- cause too few female veterans met inclusion necessary documentation workloads, improves criteria for study participation. Regression data accuracy, and helps make VA Telemedi- techniques were performed to establish a rela- cine a fully supported extension of the VA tionship between co-morbid conditions and Healthcare System’s EPR. Patient confidential- healthcare use. Limitations were related to the ity was maintained throughout the study. In- small sample size in each group and diminish- struments were coded for data entry. Demo- ing participation in the study beyond 6 months.
graphic data were completed at baseline.
Means and standard deviations showed broad A research nurse administered quality-of-life fluctuations. Therefore, statistical tests were se- questionnaires at baseline and quarterly. Qual- lected on the assumption that data were distri- ity-of-life was assessed with a valid and reli- bution free. Parametric and nonparametric able published instrument comprising two ob- tests for independent groups and for paired jective tools that measure cognitive status and groups were performed to compare length in functional level and two subjective tools that study (baseline 3, 6, 9, and 12 months) with measure patient satisfaction with care and self- scores for healthcare resource use and scores rated health status (the OARS Multidimen- for quality-of-life measures. Regression and sional Functional Assessment).28 These instru- analysis of variance were performed to deter- ments were chosen because results of research mine whether a significant difference existed have shown a correlation between healthcare between intervention and control groups and costs in elderly patients with co-morbidities in according to disease conditions CHF, COPD, declining life and responses to subjective-ob- jective surveys.29 The OARS questionnaire de- Reliability of the difference in means among rives from the Americans Resources and Ser- dependent and independent variables was lim- HOME TELEHEALTH REDUCES COSTS
ited due to small sample sizes for each disease morbidities, CHF ϩ COPD ϭ 22, CHF ϩ DM ϭ condition and due to tapering effects of inter- 35, and COPD ϩ DM ϭ 13; and three, CHF ϩ vention and control group samples at 9 and 12 months. The t test, nonparametric tests, and lo- The VACT electronic database was used to col- gistic regression were performed to compare lect healthcare use for BDOC, total visits, urgent visits (unscheduled clinic and emergency scores for health resource variables BDOC, to- room), A1C levels for the diabetic sample, and tal visits, urgent visits (unscheduled clinic and coumadin visits for the anticoagulated sample.
emergency room visits), A1C levels for the di- Number of nurse home visits was collected from abetic sample, and RN home visits for 6 months community agencies and VACT’s home-based preceding study entry and 6 months of study program. Data are shown in Tables 2 and 3.
participation. The t test and nonparametric tests were performed to compare between- and the intervention group (p Ͻ 0.001) and the within-group differences for scores for quality control group (p ϭ 0.001). Urgent visits de- of life for four variables, at baseline, 3, 6, 9, and creased for the intervention group (p ϭ 0.023, 12 months of study participation. Data analy- z ϭ 0.003) and increased for the control group ses were performed for direct and indirect (p ϭ 0.902). Total visits also decreased for the healthcare costs using a standard average cost control group (z ϭ 0.042). The number of for each variable. The t test and nonparametric coumadin visits showed broad variability pre- ceding and during study participation; varia- tion was most likely related to varying risks of anticoagulation in this vulnerable population.
Table 4 shows results for A1C levels for 51 participants with active diabetes; seven partic- ipants were not included in the data analysisbecause diabetes was not active, no A1C levels Table 1 shows demographic data. Of the 104 were performed, and no hypoglycemic agent participants, 101 were males and 3 were fe- was prescribed. At baseline, A1C levels were males. Average age was 71 years old (range higher for the intervention group (M ϭ 8.30) 54–90 years). Distribution of the participants’ and lower for the control group (M ϭ 7.03). At morbidities was as follows: one morbidity, 6 months in study, the intervention group CHF ϭ 59, COPD ϭ 35, and DM ϭ 58; two co- showed a strong statistically significant decrease TABLE 1. DEMOGRAPHIC DATA FOR THE TOTAL SAMPLE cCOPD, Chronic obstructive pulmonary disease.
NOEL ET AL.
dScheduled specialty and primary care clinic visits.
eUnscheduled clinic and emergency room visits.
in A1C levels (M ϭ 7.30; p Ͻ 0.001), whereas the Results for self-rated health status showed no control group showed a strong statistically sig- between-group difference and no within-group nificant increase in A1C levels (M ϭ 7.83; p ϭ difference from baseline to 12 months. The in- 0.002). Results for logistic regression for each cost tervention group showed a higher average mean variable showed p values Ͼ 0.05; change in R2 and standard deviation from baseline (M ϭ 81.32 and SD ϭ 13.07) at 12 months (M ϭ 88.00; SD ϭ Findings for quality-of-life scores are shown in 22.16). In contrast, the control group at 12 months Tables 5–8. Results for cognitive level showed no showed a lower average mean and standard de- differences at 6 months in the study for either viation (M ϭ 82.21; SD ϭ 10.81) than at baseline group. The standard deviation decreased for each group from baseline to 12 months. Between- Healthcare costs of participants were re- group analysis showed a statistically significant trieved from VACT’s electronic database for re- difference at 12 months (p Ͻ 0.001) with the 8 re- source utilization. Healthcare costs were com- maining participants in the intervention group pared between groups and within groups for 6 achieving perfect cognitive scores. Mean average months preceding study and for 6 months en- score for the control group did not change at 12 rolled in study as shown in Table 9. Current months (M ϭ 19.43) compared to baseline (M ϭ year 2002 was used to compute cost for each 19.43). Results for functional level showed no be- variable: Round-trip transportation cost be- tween-group difference and no within-group tween the patient’s home and VACT, $69.00; difference from baseline to 12 months.
RN home visit, $93.00; BDOC, $1286 (average Findings for patient satisfaction showed wide admission and discharge days plus integral variability in average mean and standard devia- days as inpatient); ER, $50.00; Specialty Clinic, tion for each group throughout the 12-month $50.00; Primary Care, $15.00; Coumadin Clinic, study period. Scores for the control group $15.00; use of telehealth unit for 36 months, showed a statistically significant improvement at $10,000.00 (6-month/participant, $1666.00).
3 months (p ϭ 0.001) and 6 months (p ϭ 0.020) Costs shown are for fiscal year 2002 VA defined compared to the intervention group. At 12 costs for services listed. These values were used months, a significant improvement was shown to calculate the cost for each cost item in Table within the control group (p ϭ 0.004).
9 for both patient groups pre- and post-study.
HOME TELEHEALTH REDUCES COSTS
TABLE 3. RESULTS OF TWO-TAILED t TESTS AND WILCOXON SIGNED RANK TESTS FOR TWO INDEPENDENT GROUPS AND PAIRED SAMPLES WITHIN-GROUP AT 6 MONTHS IN STUDY: EFFECT SIZE ON VA AND NON-VA BDOC, TOTAL CLINIC VISITS, URGENT VISITS, AND COUMADIN VISITS SHOWING SIGNIFICANT AND NON-SIGNIFICANT FINDINGS Total sample, n ϭ 104; intervention group, n ϭ 47; control group, n ϭ 57.
Results of two-tailed t tests and Wilcoxon signed rank tests for two independent groups and paired samples for within-group at baseline and 6 months in study. Effect size on A1C levels showing a statistical significant differencewithin each group and no significant difference between groups.
NOEL ET AL.
TABLE 5. QUALITY-OF-LIFE MEASURE: COGNITIVE STATUS Results of two-tailed t tests and Wilcoxon signed rank tests for two independent groups and paired samples for within-group at 3, 6, 9, and 12 months in study. Effect size on cognitive status showing significant and nonsignifi-cant findings.
creasing elderly population with shortened lifespans and with complex, chronic co-morbidi- Combining home telehealth, nurse case man- ties.29 A primary goal of our project was to agement, and patient-centered care has the po- implement a coordinated telecommunication tential to control healthcare costs effectively monitoring system for detecting early signs of and optimize wellness, especially for an in- instability and implement early intervention TABLE 6. QUALITY-OF-LIFE MEASURE: FUNCTIONAL LEVEL Results of two-tailed t tests and Wilcoxon signed rank tests for two independent groups and paired samples for within-group at 3, 6, 9, and 12 months in study. Effect size on functional level showing nonsignificant findings.
HOME TELEHEALTH REDUCES COSTS
TABLE 7. QUALITY-OF-LIFE MEASURE: PATIENT SATISFACTION Results of two-tailed t tests and Wilcoxon signed rank tests for two independent groups and paired samples for within-group at 3, 6, 9, and 12 months in study. Effect size on patient satisfaction showing significant and non-significant findings.
measures to prevent costly and unnecessary re- functional level, patient satisfaction with care, and self-rated health status. We expected that were coupled to VACT’s VA alert system, outcome quality-of-life data would not neces- which triggered patient feedback for out-of- sarily correlate with healthcare costs for range data. We used subjective and objective BDOC, total clinic visits, urgent visits, and A1C quality-of-life tools to measure cognitive status, levels in an aging high-risk population, with TABLE 8. QUALITY-OF-LIFE MEASURE: SELF-RATED HEALTH STATUS Results of two-tailed t tests and Wilcoxon signed rank tests for two independent groups and paired samples for within-group at 3, 6, 9, and 12 months in study. Effect size on self-rated health status showing nonsignificant findings.
NOEL ET AL.
TABLE 9. TOTAL HEALTH-CARE COSTS AND AVERAGE/PARTICIPANT HEALTH CARE COSTS FOR INTERVENTION AND CONTROL GROUPS AT 6 MONTHS PRE-STUDY AND 6 MONTHS ENROLLED IN STUDY Total sample, n ϭ 104; intervention group, n ϭ 47; control group, n ϭ 57.
aCoumadin Clinic visits listed to demonstrate real-world costs without an approved, alternative safe, valid, and bTotal Clinic visits represent all scheduled visits.
cUrgent Clinic visits represent all unscheduled visits.
dCriteria for VA-paid transportation: Category C (low income), service-connected disability and unstable medically.
An average of 50% participants in each group met inclusive criteria and received VA-paid transportation. The remaining 50% of participants used private sources for transportation to the health-care facility.
chronic and complex co-morbidities, shortened intervention group, operating the telehealth life span, and fluctuating perceptions of well- unit functions provided mental stimulation but not intrinsic motivation. It required repetitive task completion and commitment regardless of for the intervention and control groups (an ex- the desire to perform the functions because pected effect of nurse case management), the noncompliance with prescribed telehealth unit telehealth group showed a significant addi- tasks triggered VA alerts and follow-up tele- tional drop in BDOC and a significant drop in phone calls to the patient. This kind of regular unscheduled (urgent) visits at 6 months.
reinforcement strategy is known to improve Health and quality of life are multidimen- compliance and health outcomes but does not sional constructs that are weighted differently by each individual during health and illness Similar reasoning applies to the significant and during end-of-life stages. Satisfaction with decrease in A1C levels observed in the inter- care and self-rated health status belong to a vention group but not for the control group.
particular moment in time and represent shift- Diabetics in both groups performed home fin- ing areas of life deemed important by the in- gerstick glucose monitoring, but compliance dividual.26 Psychological, social, and spiritual was more likely with telehealth participants be- cause glucose readings outside preset ranges being, functional level, and satisfaction with triggered VA alerts and follow-up phone call life.27 This complex, personal, and varying inquiries. Other studies have found that tele- character may explain why, in our study, qual- health works as an effective reinforcement tool ity of life outcomes did not correlate with each for promoting long-term compliance for dia- other or with outcomes for health resource use.
betics through human motivation, perceptions The intervention group showed improved cog- of diabetic patient centeredness, perceived au- nitive status at 12 months whereas three other tonomy self-determination, and perceptions of measures for quality of life showed no im- provement. In contrast, the control group showed improved patient satisfaction with care vention group and might have been expected whereas three other measures for quality of life to bias outcome data for quality of life and re- showed no improvement. It may be that for the source use. Nevertheless, no relationship was HOME TELEHEALTH REDUCES COSTS
shown between functional level, satisfaction which saves 90–120 minutes of RN time and with care, or self-perceived health status and eliminates unnecessary home visits for moni- the presence or absence of caregivers. Only toring vital signs. Home telehealth prevents cognitive status showed significant improve- unnecessary primary care clinic visits through ment at 12 months for the few remaining ac- early detection, diagnosis, and intervention, a tive participants in the intervention group.
saving of 30 or more minutes of primary care Participants receiving home telehealth used fewer RN home visits, BDOC, unscheduled (ur- A reduction in number of home visits, clinic gent) visits, and transportation to the health- visits, and bed-days-of-care enhances produc- care facility. Telehealth added $1666.00 to tivity for healthcare team members by open-outcome costs during 6 months in study. Nev- ing time frames to enroll larger numbers of ertheless, healthcare costs decreased by 58% for the telehealth group. Participants in the control programs and expand caseloads for clinic- group with usual home healthcare services ians. Fewer hospitalized patients translates to fewer BDOC, scheduled (total) visits, and greater flexibility for hospital-based personnel transportation to the healthcare facility dur- to care for in-patients with the greatest health- ing 6 months in the study. Health-care costs dropped by 47% for the control group. Nurse We collected Coumadin cost data to demon- case management was the variable shared by strate high costs for traditional methods of per- the intervention and control groups and was forming anticogulation tests. Variation in total expected to alter healthcare costs for both number of Coumadin Clinic visits for each group pre-study and during the study reflected high risks associated with anticogulation and frequency rates for blood tests from weekly to ables homebound patients to participate ac- monthly depending on INR levels. All of the tively in their healthcare through feedback and three traditional methods are costly: (1) An RN healthcare provider collaboration. Unstable home visit for blood drawing, (2) blood tests in events are deemed preventable inasmuch as the healthcare facility, or (3) blood tests in a early symptoms and signs of instability are community laboratory. Each method signifi-targeted with early intervention measures cantly increases healthcare costs. Currently through automated, electronic, VA-alert sys- there is no approved safe, valid, and reliable tems. Reductions in healthcare costs showed a method for INR/PT to be performed at home direct relationship between home telehealth and elimination of unnecessary RN home vis-its, urgent visits, emergency room visits, andhospitalization.
Time-saving and cost-saving strategies im- prove efficiency and productivity in multiple This project targeted an elderly population interrelated ways: (1) data collection with pe- ripheral device in the home environment, (2) DM—three of the highest users of healthcare transmission of data over POTS lines, (3) auto- resources. Outcomes demonstrated that con- matic electronic medical entry of within-range data, (4) automatic VA alert and pager activa- healthcare facility’s electronic database pro- tion of nurse case manager for out-of-range vides mechanisms for early intervention, effi- data, (5) trigger of out-of-range data into elec- cient reinforcement strategies, increased pa- tronic templated progress notes with interven- tient compliance, and decreased unnecessary tion strategies and patient education, (6) pa- resource use. The home telehealth unit added tient/specific nurse case manager/provider an additional cost. Nevertheless, a significant collaboration, and (7) patient-specific disease decrease in healthcare costs was shown for the feedback. Time from data transmission to tem- plated progress note drops to 10 minutes, Home telehealth did not influence patient NOEL ET AL.
satisfaction. In our pilot study, the home tele- exercise regimens, and enhances patient satis- health unit was equipped with a video screen faction. Home telerehabilitation encourages for viewing by nurses at the central station. Pa- shortened rehabilitation hospital stays, less use tients communicated by voice with nurses in of expensive community rehabilitative practi- the central station. The pilot study telehealth tioners, and transparent teleconsultation by group showed higher satisfaction with care specialists. Concurrently, telehealth is used to than the control group. Videoconferencing monitor medical conditions and prevent signs adds a supportive link between patient and provider and supports the assumption thatvideoconferencing between patient and health-care provider directly influences patient sat ACKNOWLEDGMENTS
isfaction.10 Socioeconomic, technological, polit-ical, and professional barriers impede imple- This research was funded by VA Health Ser- mentation of high-quality, two-way, video-im- vices Research and Development (HSR&D).
age conferencing between remote patients and The authors deeply appreciate the assistance healthcare facility-based providers. The infra- and support of the following: Leo Calderone, structure at state and national levels lacks uni- form policies and standards for healthcare fa- ment; Margaret Veazey, M.S.N., A/D for Pa- cilities and for patient confidentiality issues. A tient/Nursing Services; Kathleen O’Neill and national licensing system could eliminate legal Nurse Case Managers Gail Barrows, Phyllis and regulatory inconsistencies that block the Carlson, Elaine DiCicco, Susan Dicker, Cather- current system. Corporate economic strategies ine Smith, and Lorraine Urquhart at VA Con- add additional barriers through competition, necticut Healthcare System. In addition, the arbitrary boundaries for services, and high authors deeply appreciate the in-depth com- costs to support broadband connectivity. Pub- mitment of Panasonic Corporation to this proj- lic and private payers’ reluctance to establish ect and for re-engineering and upgrading the reimbursement policy at lower levels adds an- home telehealth unit throughout the 2-year other obstacle to broader deployment of real- multiple-site, large-sample, home telehealth REFERENCES
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