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Mary Ann Liebert, Inc.
Virtually Healthy: Chronic Disease Management
in the Home
MARLIS MEYER, M.A.,' RITA KOBB, M.N., ARNP, and PATRICIA RYAN, R.N., M.S.
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
services. Stories of the treatments they TWO OUT OF THREE Americans at least 150 withhold or deny continue to make headlines.
The Veterans Health Administration (VHA) health conditions that reduce the quality of in Florida also faces these cost and treatment their lives. These conditions may account for issues, made even more of a challenge by intwo-thirds of the annual $1 trilliori in health creased enrollment of older veterans with care costs.? It is no wonder that healthcare sys- very complex health problems due to extems all over the country are looking for solu- panded veteran entitlement. Funding has not tions to the burgeoning costs of chronic care. kept pace with the rate of enrollment. ComObstacles like upfront costs continue to con- munity Care Coordination Service (CCCS) found health care organizations in their search leaders sought a different solution to bridge for ways to incorporate disease management in this gap a solution that is a break from trathe care of their chronically ill adults. Private ditional VHA care.
Community Care Coordination Service, Department of Veterans Affairs, Lake City, Florida.
MEYER ET AL.
ensure patients were treated in the most ap
propriate care setting and given the right The VA Florida-Puerto Rico Veterans Inte- amount of care at the right time. High-risk, grated Service Network (VISN 8) is an inte high-use, high-cost veterans were targeted. grated system of seven hospitals, 10 multi- Several common chronic con tions such as hyspecialty outpatient clinics, and 28 community- pertension (HTN), heart failure (CHF), lung based primary care clinics. The defined service disease (COPD), and diabetes (DM) were manarea for VISN 8 includes 60 of 67 Florida coun- aged in the population. ties, 19 rural counties of southern Georgia, Puerto Rico, and the Virgin Islands. Currently, Care coordination over a million and a half veterans reside in the
When CCCS leaders first presented the con VISN 8 service area, and, of those, 45% are age cept of care coordination to staff members, care 65 and older."
was taken to clearly define key concepts and In 1998, VISN 8 was moving in a number of
identify variations from the current practice of new directions. These included implementa
case management. In VHA, case management tion of new technologies that would drive im. usually pertains to one episode of care and takes provements in business practices, patient safety, noninstitutional care, expansion into the place within a hospital setting. Veterans are ashome health sector, and development of new
signed a case manager upon admission. This in
dividual follows the patient's progress and alliances with the community to jointly expand works with
family and healthcare team members healthcare delivery. These new directions were
to establish a discharge plan. Once the patient implemented to help the VISN 8 meet key has been discharged, the contact is discontinued strategic priorities such as improving access to care, reducing costs, increasing the number of unless the patient returns for another admission.
In the CCCS model, disease management is home care programs, increasing partnerships conducted throughout the continuum of care. with the community, and utilizing noninstitu- Care coordinators monitor patient problems tional alternatives for long-term care. In looking at populations that might benefit and help resolve them whenever and wherever
they arise. The current healthcare system in from care coordination and technology across
America is fragmented, and VHA is similar to the continuum of care, it was noted that 4% of all veterans in the VISN 8 service area, a group
the private sector in this regard. The role of the
care coordinator is a key factor in ensuring apdefined as high risk, high use, high cost, were
propriate, timely patient datam-which consticonsuming over 40% of the network's resources.“ To better care for these patients and making—is communicated to the healthcare
tutes the most vital part of clinical decisionutilize resources more efficiently, a new care model was developed. From this strategic provider. The professional backgrounds of the
care coordinators vary and include social workmodel, the CCCS was formed. The CCCS de
ers, nurse practitioners, and registered nurses. veloped both clinical and business models, and
All of these individuals are empowered to asstructured a care coordination system that
sess and make decisions across departments to combines the professional role of the care co
enhance access to care and to eliminate bureauordinator with innovative technologies.
cratic barriers that sometimes prevent timely To stimulate innovation in delivering care and to meet identified strategic priorities, es
symptom management. The technology serves
as a tool to help the care coordinator stay effipecially the "aging in place” concept, a net
cient and productive in meeting the needs of work-wide call for proposals resulted in the
many patients. funding of eight clinical demonstration projects. Five of these projects focused on complex medical/chronic disease populations. CCCS MATERIALS AND METHODS leaders charged these projects with testing dis
Technology ease management principles, through the role of care coordinator, using innovative technol- Choosing appropriate technology to enhance ogy effectively in the home. The goal was to the care coordinator role was paramount to the
success of the care coordination model. At the gregate). The algorithm continues to be honed start of the program, equipment fairs were con- for best practices. All technology used comducted to familiarize staff with the technology. plied with the Joint Commission on AccreditaCare coordinators from each project selected tion of Hospital Organizations (CAHO) for technology to meet the needs of their own durable medical equipment and infection conpatient populations. Multiple technologies trol standards. Most of the equipment was purwere reviewed for use in the home or other res- chased outright with only one device in a leasidential settings and those selected included ing arrangement. traditional telehealth (telemonitors and videophones) with and without peripheral attachments, an in-home messaging device with
Performance improvement chronic disease management dialogues, and in- A standardized performance improvement stamatic cameras for diabetic wound care man- (PI) plan was implemented across all projects agement.
in the CCCS. The PI plan was based upon VHA These technologies were chosen with resi- national clinical guidelines. It addressed HTN dential use in mind, and often were placed in medication compliance. Many of the diabetics areas where the phone infrastructure was lim- enrolled had HTN as a comorbidity, and blood ited. Both telehealth units used POTS (plain old pressure control plays an important role in the telephone service) instead of the higher speed diabetic patient's risk for heart attack and ISDN (integrated services digital network) stroke. Influenza and pneumoccocal pneumo technology. The in-home messaging device is nia vaccination rates also were targeted. A a web-based, store-and-forward application provider communication survey was done to that connects to the Internet from the patient's determine the adequacy and appropriateness home daily via a toll-free number. Dialogues of communication between the primary care were developed for this device in collaboration provider and the care coordinator. with care coordinators and included DM, HTN, COPD, CHF, coronary artery disease, and
Methodology angina, and dual dialogues such as DM/HTN, CHF/DM, and COPD/HTN. The dialogues, a The evaluation methodology is a prospective, series of questions and answers, include symp- quasiexperimental design. It was theorized that, tom management, self-management behaviors, when compared to themselves as well as to nonand disease knowledge areas. Symptom pa- intervened veterans with similar comorbidities, rameters were adjusted to comply with VHA clinical outcomes and VHA health care resource clinical guidelines. Care coordinators were able consumption would show improvement over to access the answers over a secured website time. Quarterly intervals were the unit of meaon a daily basis. Finally, an Instamatic camera sure. A database with an Intranet interface was was selected for diabetic patients to use for developed so that project staff could input de weekly photographs of their diabetic wounds. mographic and survey tool data for each patient The camera was extremely easy to operate and enrolled. The SF 36V, a standardized, scientifito train patients and caregivers on. The camera cally validated questionnaire specifically de has two lights that come together at the picture signed for veterans, was administered to paperfect distance. It uses special grid-lined film tients at baseline and 6-month intervals from that aids the care coordinator in assessing the enrollment in the program. This instrument is healing process.
generally regarded as a reliable measure of qualThe CCCS Clinical Program Director and ity of life and functional ability. In addition to care coordinators developed a technology al- this, data was extracted from several other VHA gorithm to guide in the selection of technology sources, including VISTA (a VHA computerized for all patients. Some of the factors the algo information system) and the computerized parithm looked at in determining the technology tient record system (CPRS). An odds ratio (OR) used was the clinical stability of the patient, was used as a measure of association to aptheir functional ability to manage the technol- proximate the likelihood for nursing home adogy, and place of residence (private versus con- missions.
Population selection was from a network tent behind selection of the intervened group pool of 8,704 veterans identified as high cost in was to target a high use, high risk, and high the prior year ($25,000), stratified by VA cost population. The intervened group is there medical centers, and identified with chronic fore the group most likely to be biased towards conditions such as CHF, COPD, HTN, and DM. having more adverse events, which will make Each care coordinator reviewed the list for ap- the comparison a conservative estimate. propriateness, made contact to establish willingness of veterans to participate and enrolled those who were willing and appropriate car
RESULTS didates. Seven hundred and ninety-one veter
Utilization outcomes ans were enrolled. The drop-out rate was very low (<10%); however, the lists used for enroll- In an effort to determine the impact of the ment had many exclusions due to death, in- CCCS program on the targeted population, the ability to make contact, or institutionalization. following utilization measures were analyzed
A comparison population with clinically (Table 2); similar but nonenrolled veterans was also assembled. This group was randomly selected • Clinic visits from a stratified sample similar in diagnosis, • Emergency room (ER) visits age, and gender. A comparison of their l-year • Hospital admissions average health care utilization rate compared • Hospital bed days of care (BDOC) to the intervened group is attached (Table 1). It Nursing home (NH) admissions is important to remember, however, that the in- • NH BDOC
TABLE 2 INTERVENED GROUP: FIRST-YEAR COMMUNITY CARE COORDINATION SERVKE EVALUATION
OUTCOME DATA POR RESOURCE UTILIZATION OF * = 791 ENROLLED PATIENTS
ER stops Hospital admission Hospital BDOC NH admission
346 281 429 528
Pre 12 Pre 9 · Pre 6
930 1,028 880
5 3 i2
35 593 116
14 80 27 12
ER, emergency room; BDOC, bed days of care; NH, nursing home.
TABLE 3. COMPARISON GROUP: DATA ON RESOURCE UTIZATION FOR SAME TIME FRAME AS INTERVENED GROUP
The intervened group comprised 791 veterans ers that the veteran population targeted by the enrolled in the CCCS program for 1 year. A program was at high-risk for premature insticomparison group of veterans were also ana- tutionalization and thus could be impacted by lyzed (Table 3). The comparison group re- the care coordination process. Nursing home ceived usual care with no care coordination or admissions declined by 64% and nursing home technology. Results for the intervened group BDOC were reduced by 88%. In the comparifrom the change in first year to second year son group, nursing home admissions increased data analysis showed a reduction in ER visits by 106% (Table 4). An Odds Ratio analysis reby 40%, hospital admissions by 63%, and hos- vealed that patients enrolled in the program pital BDOC by 60% (Table 4).
were 77.7% less likely to be admitted to a nursClinic visits went up 14% in the first quarter ing home care unit than those not enrolled in postenrollment for the intervened group (Fig. the program (Table 5). 1). This trend was reviewed, and it was noted Quality of life and functional ability as meathat care coordinators who had been empow. sured by the SF 36V indicated significant imered to make assessments had scheduled clinic provements in the Role Physical (p < 0.003), appointments during the first few months of Bodily Pain (p<0.000), Social Functioning enrollment to ensure all clinical needs were met (p < 0.004), Role Emotional (p<0.000), and in a timely fashion. After the first 3 months, the the Mental Composite (p < 0.011) scores. The number of clinic visits steadily declined. It is other five domains remained the same, which also noted that, although this group went up is also significant in a frail elderly population in clinic visits overall, the comparison group with complex medical/ chronic disease condiwent up even more (40%).
tions. In addition to these outcomes, nursing home Overall, when comparing the intervened admissions and bed days of care were evalu- group findings to the comparison group, it was ated. was believed by CCCS program lead- found that the intervened group showed con
INTERVENED AND COMPARISON GROUPS: PERCENT CHANCE FROM YEAR 1 TO YEAR 2