Care co-ordination through home telehealth - a ‘potential’ new model of care for the UK?
A new report from the Veterans Health Administration (VHA: you can order an essay using https://order-essays.com to study the report in more detail)1 – a large integrated health care system serving 7.6 million veterans in the USA – has concluded that care co-ordination through home telehealth (CCHT) provides a solution to the complex problem of how to provide care for the rapidly rising numbers of patients with chronic care needs and ‘offers a potential model for other healthcare systems facing comparable challenges’.
The CCHT programme uses care co-ordinators to identify appropriate technology for selected patients with chronic conditions that – depending on the nature of the condition – might include videophones, messaging devices, biometric devices, digital cameras, and telemonitoring devices. Eligible patients are offered the choice of telehealth or other non-institutional care services and are free to withdraw from the programme if they wish.
Care co-ordinators work with the patient’s doctor, providing training where necessary, and retain access to data on their patients. They monitor risk against set thresholds (eg, blood pressure upper levels), and receive colour-coded alerts of significant changes allowing them to intervene – usually by telephone – when there is an elevated risk. Co-ordinators typically manage 100-150 patients with general medical conditions or 90 with mental health conditions. All steps of the process are carefully quality-assured and use identifiable standards for data exchange. Data on workload and cost are captured, and patient satisfaction is tested every three months.
From 42,460 patient surveys submitted during 2006 and 2007 there was an 86% mean satisfaction score. Information on routine outcomes was reported from a cohort of 17,025 patients over the same time period: the mean age at enrollment was 65 years, with 15.1% aged 80 years or older; 96% were male. The percentage of patients managed for various conditions was as follows:
congestive heart failure 24%
chronic obstructive pulmonary disease 11%
post-traumatic stress 1%
64% of patients were monitored for one condition and 36% for multiple conditions.
Hospital admission data for patients during the year prior to enrollment into CCHT was compared with the data for the six months after enrollment. This showed a 19.74% reduction in hospital admissions and 25.31% reduction in bed days of care (BDOC) following enrollment into the programme. During the same period, there was a reduction of 4.6% in BDOC for all patients enrolled within VHA that needs to be taken into account when interpreting this change.
The cost of CCHT was significantly lower than other forms of care – $1,600 per patient per annum (pppa,) compared to $13,121 pppa for the direct cost of VHA’s home-based primary care services and an average of $77,745 pppa for nursing home care rates.
Lessons for the NHS
The VHA case study provides a business case for home telehealth to be included as a care option for patients with a chronic illness requiring care co-ordination. However, it should be noted that the VHA targeted high-utilisation patients, mostly male, who were ‘amenable’ to telehealth and there was a significant ‘rural factor’ to selection which impacted on travel costs.
A key factor to the success of VHA’s approach is the extent of integrated working across the care continuum. Indeed, the VHA consider that a key to success of the initiative has been a ‘systems approach’ to its design including the ‘standardisation of the clinical, educational, technical, business, and organisational elements of CCHT based upon experience gained from piloting it prior to its widespread implementation’. The Chronic Care Model2 has also been used to support the case for making the patient’s home and for emphasizing that the self-management elements of CCHT represent a shared responsibility arrangement between patient and caregiver.
The availability of a computerised patient record appears to have been fundamental prerequisite. Workforce training was also important and was facilitated through an online programme of support.
The VHA consider that CCHT does not replace the need for nursing home care or for traditional non-institutional care programmes. However, they believe that it has the potential to improve self-management of chronic disease as well as to delay the need for institutional care. As long as home telehealth is targeted on selected patients with chronic care needs who have the necessary caregiver support, it appears to offer a way for people to remain living independently at home.
Mike Clark is co-project lead for WSDAN
Adam Darkins et al (2008). 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. Journal of Telemedicine and E-Health, December, 1118-1126.
For an introduction to the Chronic Care Model and improving chronic illness care visit www.improvingchroniccare.org