The Veterans Health Administration: Taking Home Telehealth Services to Scale Nationally

Since the 1990s, the Veterans Health Administration (VHA) has used information and communications technologies to provide high-quality, coordinated, and comprehensive primary and specialist care services to its veteran population. Within the VHA, the Office of Telehealth Services offers veterans a program called Care Coordination/Home Telehealth (CCHT) to provide routine noninstitutional care and targeted care management and case management services to veterans with diabetes, congestive heart failure, hypertension, post-traumatic stress disorder, and other conditions. The program uses remote monitoring devices in veterans' homes to communicate health status and to capture and transmit biometric data that are monitored remotely by care coordinators. CCHT has shown promising results: fewer bed days of care, reduced hospital admissions, and high rates of patient satisfaction. This issue brief highlights factors critical to the VHA's success -- like the organization's leadership, culture, and existing information technology infrastructure -- as well as opportunities and challenges

Telehealthcare for chronic obstructive pulmonary disease

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a disease of irreversible airways obstruction in which patients often suffer exacerbations. Sometimes these exacerbations need hospital care: telehealthcare has the potential to reduce admission to hospital when used to administer care to the pateint from within their own home. OBJECTIVES: To review the effectiveness of telehealthcare for COPD compared with usual face‐to‐face care. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, which is derived from systematic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; last searched January 2010. SELECTION CRITERIA: We selected randomised controlled trials which assessed telehealthcare, defined as follows: healthcare at a distance, involving the communication of data from the patient to the health carer, usually a doctor or nurse, who then processes the information and responds with feedback regarding the management of the illness. The primary outcomes considered were: number of exacerbations, quality of life as recorded by the St George's Respiratory Questionnaire, hospitalisations, emergency department visits and deaths. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data. We combined data into forest plots using fixed‐effects modelling as heterogeneity was low (I(2) < 40%). MAIN RESULTS: Ten trials met the inclusion criteria. Telehealthcare was assessed as part of a complex intervention, including nurse case management and other interventions. Telehealthcare was associated with a clinically significant increase in quality of life in two trials with 253 participants (mean difference ‐6.57 (95% confidence interval (CI) ‐13.62 to 0.48); minimum clinically significant difference is a change of ‐4.0), but the confidence interval was wide. Telehealthcare showed a significant reduction in the number of patients with one or more emergency department attendances over 12 months; odds ratio (OR) 0.27 (95% CI 0.11 to 0.66) in three trials with 449 participants, and the OR of having one or more admissions to hospital over 12 months was 0.46 (95% CI 0.33 to 0.65) in six trials with 604 participants. There was no significant difference in the OR for deaths over 12 months for the telehealthcare group as compared to the usual care group in three trials with 503 participants; OR 1.05 (95% CI 0.63 to 1.75). AUTHORS' CONCLUSIONS: Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. However, further research is needed to clarify precisely its role since the trials included telehealthcare as part of more complex packages

Not all systematic reviews are systematic: A meta-review of the quality of systematic reviews for non-invasive remote monitoring in heart failure

We carried out a critical appraisal and synthesis of the systematic reviews and meta-analyses of remote monitoring for heart failure. A comprehensive literature search identified 65 relevant publications from 3333 citations. Seventeen studies fulfilled the inclusion and exclusion criteria. Seven (41%) systematic reviews pooled results for meta-analysis. Eight (47%) considered all non-invasive remote monitoring strategies. Five (29%) focused on telemonitoring. Four (24%) included both non-invasive and invasive technologies. The reviews were appraised by two independent reviewers for their quality and risk of bias using the AMSTAR tool. According to the AMSTAR criteria, ten (58%) systematic reviews were of poor methodological quality. In the high quality reviews, the relative risk of mortality in patients who received remote monitoring ranged from 0.53 to 0.88. The high quality reviews also reported that remote monitoring reduced the relative risk of all-cause (0.52 to 0.96) and heart failure-related hospitalizations (0.72 to 0.79) and, as a consequence, healthcare costs. However, further research is required before considering widespread implementation of remote monitoring. The subset of the heart failure population that derives the most benefit from intensive monitoring, the best technology, and the optimum duration of monitoring, all need to be identified. © The Author(s) 2013

Home telehealth in older patients with heart failure – costs, adherence, and outcomes

Susanna Spinsante Dipartimento di Ingegneria dell'Informazione, Università Politecnica delle Marche, Ancona, Italy Abstract: This short review discusses the role of telehealth technologies in the management of older patients with heart failure, from different perspectives. Instead of providing a systematic overview of existing literature in the field, this paper provides evidence for a simple, but effective, paradigm upon which a telehealth system may be built, and highlights how such a model may successfully apply to heart failure management, to improve patients' quality of life after discharge, increase independency, and reduce readmissions and costs for the public health institutions. A few examples are discussed, to show the real applicability of the proposed model and further confirm the effectiveness of telehealth, when properly designed and tailored to users' needs. Keywords: remote health care, workflow, requirement

Remote Patient Monitoring: Decrease Rehospitalization for Spinal Cord Injury Patients

Practice Problem: The lengthy distance required to access specialty care, the overall higher cost of SCI/D care, complications associated with SCI, and the potential negative impact of shortened hospital stays are all compelling reasons to use telehealth technologies to deliver specialty services for medical issues. PICOT: The PICOT question that guided this project was in adult spinal cord injury patients with chronic disease receiving primary care at a spinal cord injury center (P), how does the implementation of a remote patient monitoring home telehealth for SCI patients recently discharged from acute-care setting (I) compared to the usual practice of one post-discharge follow up phone call at 7 days (C), improve early recognition of patient deterioration to prevent acute care rehospitalization (O) within 30 days of discharge (T). Evidence: Spinal Cord injury patients are at risk for developing complications after injury. Paststudies have demonstrated the effectiveness of telehealth to prevent rehospitalization, which suggests the potential of telehealth on post-discharge follow-up care. Intervention: Implement remote patient monitoring home telehealth for SCI patients meeting the criteria for high-risk rehospitalization. Outcome: The pilot project results have a positive correlation with the reduction of 30-day hospital readmission rates for SCI patients participating in the RPM. During the pilot period, no readmissions occurred for the RPM participants, whereas those who declined participation were readmitted at a rate of 22%. Clinical significant findings of improved outcomes and reduced 30-day readmissions are supported through this pilot project. Conclusion: The project utilized the Johns Hopkins evidence-based model’s three-step PET framework and Roger’s diffusion of innovation change theory to support reduced rehospitalization for SCI patients through RPM

Nurses' and community support workers' experience of telehealth: A longitudinal case study

Copyright © 2014 Sharma and Clarke; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.This article has been made available through the Brunel Open Access Publishing Fund.Background - Introduction of telehealth into the healthcare setting has been recognised as a service that might be experienced as disruptive. This paper explores how this disruption is experienced. Methods - In a longitudinal qualitative study, we conducted focus group discussions prior to and semi structured interviews post introduction of a telehealth service in Nottingham, U.K. with the community matrons, congestive heart failure nurses, chronic obstructive pulmonary disease nurses and community support workers that would be involved in order to elicit their preconceptions and reactions to the implementation. Results - Users experienced disruption due to the implementation of telehealth as threatening. Three main factors add to the experience of threat and affect the decision to use the technology: change in clinical routines and increased workload; change in interactions with patients and fundamentals of face-to-face nursing work; and change in skills required with marginalisation of clinical expertise. Conclusion - Since the introduction of telehealth can be experienced as threatening, managers and service providers should aim at minimising the disruption caused by taking the above factors on board. This can be achieved by employing simple yet effective measures such as: providing timely, appropriate and context specific training; provision of adequate technical support; and procedures that allow a balance between the use of telehealth and personal visit by nurses delivering care to their patients

Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial

Rationale: Early detection of COPD exacerbations using tele-monitoring of physiological variables might reduce the frequency of hospitalisation. Objectives: To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique (FOT) and cardiac parameters in older COPD patients with co-morbidities. Methods: This multicentre, randomized clinical trial recruited 312 GOLD grade II-IV COPD patients (median age 71 years [IQR:66-76], 49.6% grade II, 50.4% grade III-IV), with a history of exacerbation in the previous year and at least one non-pulmonary co-morbidity. Patients were randomised to usual care (n=158) or tele-monitoring (n=154) and followed for 9 months. All tele-monitoring patients self-assessed lung mechanics daily and in a subgroup with congestive heart failure (n=37) cardiac parameters were also monitored. An algorithm identified deterioration, triggering a telephone contact to determine appropriate interventions. Measurements and Main results: Primary outcomes were time to first hospitalisation (TTFH) and change in EQ-5D utility index score. Secondary outcomes included: rate of antibiotic/corticosteroid prescriptions, hospitalisation, CAT, PHQ-9 and MLHF questionnaire scores, quality-adjusted life years and healthcare costs. Tele-monitoring did not affect TTFH, EQ-5D utility index score, antibiotic prescriptions, hospitalization rate and questionnaire scores. In an exploratory analysis, tele-medicine was associated with fewer repeat hospitalizations (-54%, p=0.017). Conclusions: In older COPD patients with co-morbidities remote monitoring of lung function by FOT and cardiac parameters did not change TTFH and EQ-5D. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01960907

Clinical Effectiveness, Access to, and Satisfaction with Care Using a Telehomecare Substitution Intervention: A Randomized Controlled Trial

Background. Hospitalization accounts for 70% of heart failure (HF) costs; readmission rates at 30 days are 24% and rise to 50% by 90 days. Agencies anticipate that telehomecare will provide the close monitoring necessary to prevent HF readmissions. Methods and Results. Randomized controlled trial to compare a telehomecare intervention for patients 55 and older following hospital discharge for HF to usual skilled home care. Primary endpoints were 30- and 60-day all-cause and HF readmission, hospital days, and time to readmission or death. Secondary outcomes were access to care, emergency department (ED) use, and satisfaction with care. All-cause readmissions at 30 days (16% versus 19%) and over six months (46% versus 52%) were lower in the telehomecare group but were not statistically significant. Access to care and satisfaction were significantly higher for the telehomecare patients, including the number of in-person visits and days in home care. Conclusions. Patient acceptance of the technology and current home care policies and processes of care were barriers to gaining clinical effectiveness and efficiency

Development and Evaluation of a Heart Failure Tool for Homebound Patients

With more than 700,000 new diagnoses annually, congestive heart failure (CHF) is a chronic condition that affects the chambers of the heart. When not managed correctly, the disease rapidly progresses to substantial fluid volume overload that impacts activities of daily living and the overall quality of life. The financial implications for poor CHF management cost a mean annual medical expenditure of $33,427 per patient per year. The need for a diagnostic and prognostic at-home protocol is needed in the medical community, as there is currently no such tool on the market. Donabedian\u27s framework was used to guide the formulation and interpretation of this research. The purpose of this project was to design a CHF protocol using evidence-based research for clinicians making home visits to homebound patients with a primary diagnosis of CHF with an individualized protocol focusing on disease management, in home support system, knowledge base and financial factors for homebound patients. The protocol was released through a snowballing campaign to clinicians who work with CHF, transitional care, or homecare who then evaluated the protocol on its perceived efficacy if integrated into practice. Findings were analyzed using simple descriptive statistics by 32 nurses and other health care professionals who responded work in home care, cardiology, medical surgical nursing hospitalists, or skilled nursing facilities. Thirty-one of the 32 respondents deemed the protocol useful and stated a clinical need of protocol as evidenced by completed the AGREE II Questionnaire. The findings demonstrate that the CHF Practice Protocol provides clinicians with an evidence-based guidance to manage homebound patients with CHF on a small scale