DISEASE MANAGEMENT Virtually Healthy: Chronic Disease Management MARLIS MEYER, M.A.,1 RITA KOBB, M.N., ARNP,2 and PATRICIA RYAN, R.N., M.S.3 ABSTRACT Beginning in April 2000, eight clinical demonstration projects were funded for 2 years within the Sunshine Network of the Veterans Health Administration (VHA) to test disease management principles, the care coordinator role, and the effective use of technology to maintain veterans in their homes. Five of these projects focused on complex medical/chronic disease populations. Seven hundred and ninety-one veterans were recruited in these five projects and enrolled in the Community Care Coordination Service (CCCS). The program was conceptualized around and designed by network field staff as an "aging in place” model. The purpose behind the integration of the care coordinator role with technology was to improve health status, increase program efficiency, and decrease resource utilization. Evaluation results to date have shown a 40% reduction in emergency room visits, 63% reduction in hospital admissions, 60% reduction in hospital bed days of care, 64% reduction in VHA nursing home admissions, and 88% reduction in nursing home bed days of care. All Performance Improvement outcomes reached or exceeded the targeted goals, and a functional assessment revealed five significant improvements out of 10 domains of the SF 36V. sector managed-care programs control costs and cap services. Stories of the treatments they withhold or deny continue to make headlines. The Veterans Health Administration (VHA) in Florida also faces these cost and treatment issues, made even more of a challenge by increased enrollment of older veterans with very complex health problems due to expanded veteran entitlement. Funding has not kept pace with the rate of enrollment. Community Care Coordination Service (CCCS) leaders sought a different solution to bridge this gap a solution that is a break from traditional VHA care. 'Community Care Coordination Service, Department of Veterans Affairs, Lake City, Florida. Background The VA Florida-Puerto Rico Veterans Integrated Service Network (VISN 8) is an integrated system of seven hospitals, 10 multispecialty outpatient clinics, and 28 communitybased primary care clinics. The defined service area for VISN 8 includes 60 of 67 Florida counties, 19 rural counties of southern Georgia, Puerto Rico, and the Virgin Islands. Currently, over a million and a half veterans reside in the VISN 8 service area, and, of those, 45% are age 65 and older.4 In 1998, VISN 8 was moving in a number of new directions. These included implementation of new technologies that would drive improvements in business practices, patient safety, noninstitutional care, expansion into the home health sector, and development of new alliances with the community to jointly expand healthcare delivery. These new directions were implemented to help the VISN 8 meet key strategic priorities such as improving access to care, reducing costs, increasing the number of home care programs, increasing partnerships with the community, and utilizing noninstitutional alternatives for long-term care. In looking at populations that might benefit from care coordination and technology across the continuum of care, it was noted that 4% of all veterans in the VISN 8 service area, a group defined as high risk, high use, high cost, were consuming over 40% of the network's resources. To better care for these patients and utilize resources more efficiently, a new care model was developed. From this strategic model, the CCCS was formed. The CCCS developed both clinical and business models, and structured a care coordination system that combines the professional role of the care coordinator with innovative technologies. To stimulate innovation in delivering care and to meet identified strategic priorities, especially the "aging in place" concept, a network-wide call for proposals resulted in the funding of eight clinical demonstration projects. Five of these projects focused on complex medical/chronic disease populations. CCCS leaders charged these projects with testing disease management principles, through the role of care coordinator, using innovative technology effectively in the home. The goal was to MEYER ET AL. ensure patients were treated in the most appropriate care setting and given the right amount of care at the right time. High-risk, high-use, high-cost veterans were targeted. Several common chronic conditions such as hypertension (HTN), heart failure (CHF), lung disease (COPD), and diabetes (DM) were managed in the population. Care coordination When CCCS leaders first presented the concept of care coordination to staff members, care identify variations from the current practice of was taken to clearly define key concepts and usually pertains to one episode of care and takes case management. In VHA, case management place within a hospital setting. Veterans are assigned a case manager upon admission. This inworks with family and healthcare team members dividual follows the patient's progress and has been discharged, the contact is discontinued to establish a discharge plan. Once the patient unless the patient returns for another admission. In the CCCS model, disease management is conducted throughout the continuum of care. Care coordinators monitor patient problems they arise. The current healthcare system in and help resolve them whenever and wherever America is fragmented, and VHA is similar to the private sector in this regard. The role of the care coordinator is a key factor in ensuring appropriate, timely patient data-which constitutes the most vital part of clinical decisionmaking-is communicated to the healthcare provider. The professional backgrounds of the care coordinators vary and include social workers, nurse practitioners, and registered nurses. All of these individuals are empowered to assess and make decisions across departments to enhance access to care and to eliminate bureaucratic barriers that sometimes prevent timely symptom management. The technology serves as a tool to help the care coordinator stay efficient and productive in meeting the needs of many patients. MATERIALS AND METHODS Technology Choosing appropriate technology to enhance the care coordinator role was paramount to the VIRTUALLY HEALTHY success of the care coordination model. At the start of the program, equipment fairs were conducted to familiarize staff with the technology. Care coordinators from each project selected technology to meet the needs of their own patient populations. Multiple technologies were reviewed for use in the home or other residential settings and those selected included traditional telehealth (telemonitors and videophones) with and without peripheral attachments, an in-home messaging device with chronic disease management dialogues, and instamatic cameras for diabetic wound care management. These technologies were chosen with residential use in mind, and often were placed in areas where the phone infrastructure was limited. Both telehealth units used POTS (plain old telephone service) instead of the higher speed ISDN (integrated services digital network) technology. The in-home messaging device is a web-based, store-and-forward application that connects to the Internet from the patient's home daily via a toll-free number. Dialogues were developed for this device in collaboration with care coordinators and included DM, HTN, COPD, CHF, coronary artery disease, and angina, and dual dialogues such as DM/HTN, CHF/DM, and COPD/HTN. The dialogues, a series of questions and answers, include symptom management, self-management behaviors, and disease knowledge areas. Symptom parameters were adjusted to comply with VHA clinical guidelines. Care coordinators were able to access the answers over a secured website on a daily basis. Finally, an Instamatic camera was selected for diabetic patients to use for weekly photographs of their diabetic wounds. The camera was extremely easy to operate and to train patients and caregivers on. The camera has two lights that come together at the picture perfect distance. It uses special grid-lined film that aids the care coordinator in assessing the healing process. The CCCS Clinical Program Director and care coordinators developed a technology algorithm to guide in the selection of technology for all patients. Some of the factors the algo rithm looked at in determining the technology used was the clinical stability of the patient, their functional ability to manage the technology, and place of residence (private versus con gregate). The algorithm continues to be honed for best practices. All technology used complied with the Joint Commission on Accreditation of Hospital Organizations (JCAHO) for durable medical equipment and infection control standards. Most of the equipment was purchased outright with only one device in a leasing arrangement. Performance improvement A standardized performance improvement (PI) plan was implemented across all projects in the CCCS. The PI plan was based upon VHA national clinical guidelines. It addressed HTN medication compliance. Many of the diabetics enrolled had HTN as a comorbidity, and blood pressure control plays an important role in the diabetic patient's risk for heart attack and stroke. Influenza and pneumoccocal pneumonia vaccination rates also were targeted. A provider communication survey was done to determine the adequacy and appropriateness of communication between the primary care provider and the care coordinator. Methodology The evaluation methodology is a prospective, quasiexperimental design. It was theorized that, when compared to themselves as well as to nonintervened veterans with similar comorbidities, clinical outcomes and VHA health care resource consumption would show improvement over time. Quarterly intervals were the unit of measure. A database with an Intranet interface was developed so that project staff could input demographic and survey tool data for each patient enrolled. The SF 36V, a standardized, scientifically validated questionnaire specifically designed for veterans, was administered to patients at baseline and 6-month intervals from enrollment in the program. This instrument is generally regarded as a reliable measure of quality of life and functional ability. In addition to this, data was extracted from several other VHA sources, including VISTA (a VHA computerized information system) and the computerized patient record system (CPRS). An odds ratio (OR) was used as a measure of association to approximate the likelihood for nursing home admissions. Population selection was from a network pool of 8,704 veterans identified as high cost in the prior year (≥$25,000), stratified by VA medical centers, and identified with chronic conditions such as CHF, COPD, HTN, and DM. Each care coordinator reviewed the list for appropriateness, made contact to establish willingness of veterans to participate and enrolled those who were willing and appropriate candidates. Seven hundred and ninety-one veterans were enrolled. The drop-out rate was very low (<10%); however, the lists used for enrollment had many exclusions due to death, inability to make contact, or institutionalization. A comparison population with clinically similar but nonenrolled veterans was also assembled. This group was randomly selected from a stratified sample similar in diagnosis, age, and gender. A comparison of their 1-year average health care utilization rate compared to the intervened group is attached (Table 1). It is important to remember, however, that the in TABLE 2. INTERVENED GROUP: FIRST-YEAR COMMUNITY CARE COORDINATION SERVICE EVALUATION VIRTUALLY HEALTHY Months TABLE 3. COMPARISON GROUP: DATA ON RESOURCE Utilization FOR SAME TIME FRAME AS INTERVENED GROUP Clinic visits ER stops Hospital admission Hospital BDOC NH admission NH BDOC The intervened group comprised 791 veterans enrolled in the CCCS program for 1 year. A comparison group of veterans were also analyzed (Table 3). The comparison group received usual care with no care coordination or technology. Results for the intervened group from the change in first year to second year data analysis showed a reduction in ER visits by 40%, hospital admissions by 63%, and hospital BDOC by 60% (Table 4). Clinic visits went up 14% in the first quarter postenrollment for the intervened group (Fig. 1). This trend was reviewed, and it was noted that care coordinators who had been empowered to make assessments had scheduled clinic appointments during the first few months of enrollment to ensure all clinical needs were met in a timely fashion. After the first 3 months, the number of clinic visits steadily declined. It is also noted that, although this group went up in clinic visits overall, the comparison group went up even more (40%). In addition to these outcomes, nursing home admissions and bed days of care were evaluated. It was believed by CCCS program lead ers that the veteran population targeted by the program was at high-risk for premature institutionalization and thus could be impacted by the care coordination process. Nursing home admissions declined by 64% and nursing home BDOC were reduced by 88%. In the comparison group, nursing home admissions increased by 106% (Table 4). An Odds Ratio analysis revealed that patients enrolled in the program were 77.7% less likely to be admitted to a nursing home care unit than those not enrolled in the program (Table 5). Quality of life and functional ability as measured by the SF 36V indicated significant improvements in the Role Physical (p < 0.003), Bodily Pain (p<0.000), Social Functioning (p < 0.004), Role Emotional (p < 0.000), and the Mental Composite (p < 0.011) scores. The other five domains remained the same, which is also significant in a frail elderly population with complex medical/chronic disease condi tions. Overall, when comparing the intervened group findings to the comparison group, it was found that the intervened group showed con TABLE 4. INTERVENED AND COMPARISON GROUPS: PERCENT CHANGE FROM YEAR 1 TO YEAR 2 |