TELEMEDICINE JOURNAL AND e-HEALTH
`Volume 9, Number 3, 2003
`© Mary Ann Liebert, Inc.
`
`Case Study
`
`Opening a Window of Opportunity through Technology
`and Coordination: A Multisite Case Study
`
`JULIE CHEITLIN CHERRY, R.N., M.S.N.,1 KIRSTEN DRYDEN,1
`RITA KOBB, M.S., M.N., A.R.N.P., B.C.,2 PATRICIA HILSEN, R.N., B.S.N.,2
`and NICOLE NEDD, M.S.N., A.R.N.P., B.C.2
`
`AB STRACT
`
`The Community Care Coordination Service (CCCS) program was implemented in April, 2000,
`at the Veterans Integrated Service Network (VISN 8). The goals of the CCCS were to improve
`the coordination of care for clinically complex patients, referred to as veterans, and to increase
`their access to care while reducing complications, hospital admissions, and emergency room
`(ER) visits. This program used a coordinated care approach, a process whereby veterans were
`followed throughout the continuum of care. The information presented in this case study is
`specific to three medical centers that implemented the CCCS: Ft. Myers, Lake City, and Mi-
`ami. Analysis of utilization and clinical impact were conducted after 18 months. Inpatient ad-
`missions were reduced by 46% at Ft. Myers, 68% at Lake City, and 13% at Miami. ER en-
`counters were reduced by 19% at Ft. Myers, 70% at Lake City, and 15% at Miami. Reductions
`in bed days were demonstrated at Ft. Myers (29%) and Lake City (71%). In Miami, there was
`a 13% increase in the number of bed days of care for the patients after 1 year in the program.
`In addition to these changes in health-care utilization, quality of life was significantly im-
`proved as evidenced by increases in the four of the eight components scores of the Medical
`Outcomes Study 36-item Short Form health survey for veterans (SF36V) at Lake City and Ft.
`Myers. In the CCCS model of care using home telehealth technology, the Care Coordinators
`bridged the gap between office visits by providing a daily connection between the coordi-
`nators and the patients. This daily communication made it possible for problems to be iden-
`tified early and interventions implemented before problems escalated.
`
`INTRODUCTION
`
`THE VETERANS HEALTH ADMINISTRATION
`(VHA) is recognized as a leader in devel—
`oping home telehealth care services. Home
`telehealth combined with expert care coordi—
`
`
`nation holds great promise in increasing access
`to high-quality health care, improving chronic
`care management, enhancing patient satisfac-
`tion, and managing resource utilization.1 To
`meet the challenges of providing services to
`chronically ill veterans in Florida and Puerto
`
`1Health Hero Network, Inc., Mountain View, California.
`2VISN 8 Community Care Coordination Service, VA Medical Center, Bay Pines, Florida.
`
`265
`
`1
`
`Bosch Ex. 2054
`Bosch EX. 2054
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`266
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`CHERRY ET AL.
`
`Rico, the Network Director established a task
`
`force to develop a new model of care delivery
`that would marry coordination with technol-
`ogy. From this group's efforts the Community
`Care Coordination Service (CCCS) was created.
`The increasing incidence of chronic conditions
`such as diabetes, depression, and heart and lung
`disease have a tremendous impact on the qual—
`ity of life and health—care cost issues for many
`Americans.2 In Florida, where veterans are older
`and more frail, this is a greater problem and has
`become a challenge for VHA in meeting the
`health-care needs of this population.3 It is well
`documented that the management of chronic
`diseases responds well to carefully coordinated
`efforts.4'5 The mission of the CCCS was to pro-
`vide the right care, at the right place, at the right
`time, where the place of residence is the site of
`care. The health-care professional providing
`care coordination for the veteran is the key to
`the success of this program; however, it is the
`technology as a tool that enables the clinical
`model to be effective and efficient.
`
`In the CCCS program, five different tech-
`nologies were implemented. Each veteran’s
`needs were assessed and the appropriate tech-
`nology was chosen to help coordinate care. The
`Health Hero® Health Buddy® appliance was
`one of the five technologies used and is the one
`specifically evaluated in this case study.
`
`MATERIALS AND METHODS
`
`Featured sites and programs
`
`Three sites are featured in this case study:
`The Telehealth Care Program in Ft. Myers,
`Florida; The Rural Home Care Project in Lake
`City, Florida; and, The T-Care Program in Mi-
`ami, Florida. Patients were selected from a net—
`work pool of 8,704 veterans who were identi-
`fied as high cost in the prior year (Z$25,000)
`and diagnosed with congestive heart failure
`(CHF), coronary artery disease (CAD), dia-
`betes , mellitus
`(DM), hypertension (HTN),
`and chronic obstructive pulmonary disease
`(COPD). Then, the veterans were stratified by
`location, and a care coordinator from each pro-
`gram site contacted the identified veterans in
`their respective area to explain the program
`and assess the veteran’s willingness to partici-
`
`pate. A total of 345 veterans were enrolled in
`the Health Buddy arm of the study. The fol-
`lowing is a description of each of the three pro-
`grams.
`The Ft. Myers Telehealth Care Program mon-
`itored 98 veterans with chronic diseases includ—
`
`ing CHF, DM, HTN, and COPD along with three
`co-morbid disease programs. The service area
`covered Lee, Collier, Charlotte, Hendry, and
`parts of Glades and Sarasota Counties. The av~
`erage age of the patients was 72.5 years. The care
`coordination team was comprised of a registered
`nurse (RN), a nurse practitioner (ARNP), and a
`program assistant. The focus of the Ft. Myers
`program was patient education, compliance, and
`early intervention, thereby decreasing emergent
`care visits and hospitalizations.
`In Lake City, The Rural Home Care Project
`team consisted of two nurse practitioners, a so-
`cial worker, and a program assistant who coor-
`dinated care for 183 veterans from 19 counties
`
`in South Georgia and 34 counties in Florida. The
`average age of the veterans was 72 years and the
`target population included veterans with multi-
`ple co-morbidities such as CHF, COPD, CAD,
`HTN, and DM. The team used home telehealth
`
`technology to maximize the care coordinators’
`work efficiency and proactively to prevent acute
`problems in a remote population.
`The T-Care Program in Miami served 64 vet-
`erans in the counties of Miami-Dade and
`
`Broward with an average age of 71.9 years. The
`care coordination team was interdisciplinary
`and included a physician, advanced registered
`nurse practitioner, clinical social worker, and
`health technician. Patients diagnosed with
`CHF, COPD, DM, HTN, and CAD were candi-
`dates for the program. Patients resided at home
`or in an assisted living facility. Care was coor-
`dinated with the primary care team with the
`goal of decreasing emergency room visits and
`hospitalizations.
`
`Technology overview
`
`The Care Coordinators used an Internet-
`
`based care management tool, the Health Hero®
`iCare Desktop”, and a patient communication
`appliance, the Health Buddy® to monitor vet-
`erans on a daily basis. The Health Hero iCare
`Desktop provided an integrated set of patient
`enrollment, scheduling, and monitoring tools
`
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`TECHNOLOGY AND COORDINATION
`
`267
`
`that enabled the care coordinators to stay
`abreast of their patients’ day-to-day conditions.
`It monitors through a multitiered approach,
`consisting of signs and symptoms reporting,
`targeted education around the disease(s), pro-
`viding positive reinforcement for appropriate
`understanding of the disease(s), and compli-
`ance to recommended regimens. The Health
`Buddy also prompted the patient to action if
`indicated by daily signs and symptoms values.
`The appliance connected to any existing ”plain
`old telephone system” (POTS) line, much like
`an answering machine. It has a large, easy-to—
`read screen and four large blue buttons for re~
`sponses. Patients’ responses were sent over an
`800 toll-free telephone number to Health Hero’s
`data center in San Jose, California. Patients
`were not required to have Internet access to use
`this system. Daily responses sent by patients
`were categorized and risk-prioritized to alert
`the care coordinators to the most serious out-
`
`comes (signs and symptoms) first.
`
`Program implementation
`
`The CCCS Program primarily served an
`older population that was generally frail and
`that had multiple chronic conditions, includ-
`ing diabetes, high blood pressure, heart fail-
`ure, and lung disease. There were 345 veterans
`using the Health Buddy at the time of this eval-
`uation. All programs in the CCCS had Inter-
`nal Review Board (IRB) approval. After a po-
`tential candidate was identified,
`the care
`coordinator then discussed the program and
`technology with the patients, and asked the
`veteran for his or her willingness to partici-
`pate. Once the patient had agreed to partici-
`pate in the program, a home visit was set up
`to obtain a signed informed consent and per-
`form a complete assessment to determine the
`veteran’s need for the equipment. During the
`home visit, an algorithm, developed by the
`researchers, was used to determine the appro—
`priateness of this technology for the veteran.
`Some of the factors assessed were the clinical
`
`stability of the patient, the functional ability to
`use the technology, and the place of residence
`(private versus congregate). Every patient
`completed a return demonstration on the use
`and maintenance of the equipment
`in the
`home. Once a veteran was selected to use this
`
`system, the care coordinator used a tutorial to
`teach the veteran the proper use of the equip-
`ment. During the visit, the care coordinator
`had the veteran sign the informed consent,
`spoke with the veteran about the program, and
`assessed the home for safety. The SF 36V, a
`standardized,
`scientifically validated ques-
`tionnaire was used to measure the veteran’s
`
`quality of life and functional ability upon en-
`rollment in the program.6 When the care co-
`ordinator had completed the patient’s in—home
`assessment and equipment
`installation,
`the
`care coordinator returned to the office where
`
`the patient was entered into the Health Hero
`iCare Desktop. This patient management soft-
`ware allowed the coordination team to moni-
`
`tor each veteran daily.
`
`ANALYSIS
`
`Data were extracted from several internal
`
`VHA sources including VISTA (a VHA com-
`puterized information system), the computer-
`ized patient record system (CPRS), and the
`browser-based care management
`tool,
`the
`Health Hero® iCare DesktopTM. The Health
`Buddy intervention group of patients was com-
`pared to themselves both pre- and post—enroll-
`ments in the program. All patients that started
`in the program after April, 2000, and had com-
`pleted 12 months by May, 2002, were included
`in the evaluation.
`
`Clinical and performance improvement data,
`such as patient satisfaction, was obtained by
`face-to-face and phone interviews using survey
`tools. Provider
`satisfaction was obtained
`
`through anonymous surveys that were mailed
`back to project staff.
`Quality of life was measured at baseline and
`6 months using the Medical Outcomes Study
`36-item Short Form health survey designed for
`veterans (SF—36V). A paired t—test was used to
`test whether the change made from baseline to
`6 months was statistically significant.
`
`RESULTS
`
`Patient satisfaction
`
`Results showed that patients were satisfied
`with the technology and the CCCS project staff.
`
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`

`268
`
`CHERRY ET AL.
`
`Patients in each program were asked three
`questions at the end of the first 12 months in
`the program. The questions were: (1) Do you
`think that the technology has helped you stay
`healthy? (2) Has having staff monitor you
`made you feel more comfortable? (3) Would
`you recommend this project to other veterans?
`For all three of these questions, 96% of Ft.
`Myers patients answered yes, 98% of Lake City
`patients answered yes, and 96% of Miami’s vet-
`erans answered yes.
`
`Provider satisfaction
`
`As part of CCCS’s performance improve—
`ment plan, providers were asked three ques—
`tions about the technology used in the CCCS
`programs at the end of the first year. These
`questions were designed to provide both the
`patient and the provider with better service
`from the project team. Physicians and nurse
`practitioners were supportive of the project and
`perceived it as a benefit to their patients. See
`Table 1 for the results of the provider satisfac-
`tion surveys by program site.
`
`Quality of life
`
`Quality of life was assessed using the Med-
`ical Outcomes Study 36—item Short Form health
`survey designed for veterans (SF—36V). At Lake
`City, six domain change scores and one com-
`
`posite change score were significantly different
`(p < 0.05) from baseline to 6 months in the pro—
`gram. Of these significant differences, four
`were positive changes in quality of life. The
`positive changes were in physical functioning
`(p = 0.005),
`role-physical
`(p = 0.018),
`sOcial
`functioning (p = 0.013), and the physical com-
`posite score (p = 0.014). At Fort Myers, 8 out of
`the 10 domain changes and composite scores
`changed in a positive direction, and of those
`four were statistically significant. The signifi-
`cant changes were in physical functioning (p =
`0.023), role-physical
`(p = 0.024), vitality (p =
`0.000), and the physical composite score (19 =
`0.008). The quality of life scores at the Miami
`program site showed no statistically significant
`differences from baseline to six months. Table
`
`2 presents all of the quality of life scores for the
`three programs at baseline and 6 months.
`
`Utilization
`
`The CCCS program, coupled with Health
`Hero technology, decreased overall healthcare
`utilization through reduced hospitalizations,
`bed days of care (BDOC), and walk—in clinic
`and emergency room visits (ER).
`Hospitalization data were collected for each
`patient for the 12 months prior to enrollment
`in the program and during the first 12 months
`after admission into the program. Inpatient ad-
`missions were reduced by 68% at Lake City,
`
`TABLE 1.
`
`PROVIDER SATISFACTION BY PROGRAM SITE
`
`Number of
`respondents
`Yes
`No
`Percent satisfied
`
`15 the communication
`between you and the care
`coordinator timely and
`appropriate?
`Lake City
`Miami
`Fort Myers
`Is the program a benefit to
`your patients?
`Lake City
`Miami
`Fort Myers
`Would you refer patients to
`this program?
`100%
`0
`57
`57
`Lake City
`100%
`0
`11
`11
`Miami
`
`
`
`
`17 16 1Fort Myers 94%
`
`98%
`100%
`100%
`
`100%
`100%
`88%
`
`56
`11
`17
`
`57
`11
`15
`
`1
`0
`0
`
`0
`0
`2
`
`57
`11
`17
`
`57
`11
`17
`
`4
`
`

`

`TECHNOLOGY AND COORDINATION
`
`269
`
`TABLE 2. QUALITY OF LlFE SCORES
`
`SF-36V Domain scores
`
`Change in score after 6 months paired
`
`Domain
`
`Lake City
`Physical Functioning
`Role-Physical
`Bodily Pain
`General Health
`Vitality
`Social Functioning
`Role-Emotional
`Mental Health
`Physical Composite
`Mental Composite
`Fort Myers
`Physical Functioning
`Role-Physical
`Bodily Pain
`General Health
`Vitality
`Social Functioning
`Role—Emotional
`Mental Health
`Physical Composite
`Mental Composite
`Miami
`
`Mean
`Mean at 6
`
`n
`baseline
`months
`
`Mean
`
`185
`182
`183
`185
`183
`185
`183
`184
`177
`177
`
`113
`113
`113
`112
`113
`112
`112
`113
`110
`110
`
`26.0
`24.1
`60.1
`48.3
`42.6
`47.9
`59.0
`73.1
`29.5
`49.1 ~
`
`28.0
`27.6
`52.5
`44.9
`30.0
`60.4
`56.7
`66.8
`29.7
`47.6
`
`34.5
`32.4
`60.8
`41.7
`39.9
`56.4
`58.1
`64.2
`32.4
`46.3
`
`36.4
`38.4 .
`58.7
`46.3
`41.8
`58.7
`59.7
`67.8
`33.5
`47.4
`
`8.5
`8.3
`0.6
`—6.6
`—2.8
`8.5
`-0.9
`-8.9
`2.9
`~2.8
`
`8.4
`10.8
`6.2
`1.5
`11.8
`-1.7
`3.0
`1.0
`3.8
`—0.2
`
`Std.
`dev.
`
`40.3
`47.2
`43.7
`34.8
`32.0
`46.3
`54.8
`30.2
`15.4
`16.7
`
`38.8
`50.1
`40.5
`34.1
`32.7
`45.4
`52.6
`31.0
`14.7
`17.6
`
`t
`
`Sig (Z-tailed)
`
`2.9
`2.4
`0.2
`-2.6
`—1.2
`2.5
`—O.2
`—4.0
`2.5
`-2.2
`
`2.3
`2.3
`1.6
`0.5
`3.8
`—0.4
`0.6
`0.3
`2.7
`—O.1
`
`0.005
`0.018
`0.847
`0.010
`0.245
`0.013
`0.823
`0.000
`0.014
`0.027
`
`0.023
`0.024
`0.109
`0.653
`0.000
`0.697
`0.553
`0.732
`0.008
`0.900
`
`0.078
`0.3
`42.8
`1.5
`37.0
`35.6
`89
`Physical Functioning
`0.318
`1.0
`56.6
`6.1
`44.3
`38.2
`88
`Role-Physical
`0.357
`0.9
`43.6
`4.3
`62.5
`58.2
`89
`Bodily Pain
`0.487
`—0.7
`38.3
`—2.9
`47.6
`50.6
`83
`General Health
`0.503
`—0.7
`39.2
`—2.8
`43.8
`46.6
`89
`Vitality
`0.980
`0.0
`52.2
`0.1
`65.0
`64.9
`89
`Social Functioning
`0.108
`—1.6
`54.1
`-9.4
`63.8
`73.2
`87
`Role-Emotional
`0.068
`—1.8
`31.8
`‘63
`65.5
`71.8
`88
`Mental Health
`0.287
`1.1
`17.4
`2.1
`35.0
`32.9
`78
`Physical Composite
`
`Mental Composite 0.120 78 51.1 47.6 -3.5 19.8 —1.6
`
`
`
`
`
`
`
`46% at Ft. Myers, and 13% at Miami (see Table
`3). Emergency room encounters and Visits to the
`walk—in clinics were reduced by 70% at Lake
`City, 19% at Ft. Myers, and 15% at Miami (see
`Table 4). Bed days of care were reduced by 71%
`at Lake City and 29% at Ft. Myers. In Miami,
`there was an increase of 13% in bed days of care
`after one year in the program (see Table 5).
`
`Medication compliance
`
`One of the important areas of patient over-
`sight in the CCCS program was medication
`compliance. Veterans were asked on a regular
`basis about their medications, ensuring that the
`veterans remembered to take them and under-
`
`stood why it was important to do so. Patients
`
`TABLE 3 HOSPITALIZATION BY PROGRAM SITE BEFORE AND
`AFTER INTERVENTION
`
`
`EMERGENCY ROOM VISITS AND WALK-IN VISITS
`TABLE 4.
`BY PROGRAM SITE BEFORE AND AFTER PROGRAM
`IMPLEMENTATION
`
`
`Before program
`Percent
`
`implementation After 12 months
`change
`
`Before program
`implementation After 12 months
`
`Percent
`change
`
`-—70%
`62
`208
`Lake City
`—68%
`89
`279
`Lake City
`—19%
`515
`635
`-46% Fort Myers
`15
`28
`Fort Myers
`—15%
`77
`91
`—13% Miami
`48
`55
`Miami
`
`5
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`270
`
`CHERRY ET AL.
`
`TABLE 5. NUMBER OF BED DAYS BY PROGRAM SITE BEFORE
`AND AFTER PROGRAM IMPLEMENTATION
`
`Before program
`implementation
`
`After 12 months
`
`Lake City
`Fort Myers
`Miami
`
`637
`128
`335
`
`185
`91
`379
`
`Percent
`change
`
`—71%
`—29%
`+ 13%
`
`cluded days where it was not possible for the
`survey to be taken, for example, on days that
`the veteran was on vacation or hospitalized.
`Overall Health Buddy compliance at Lake City
`was 83%, Miami was 80%, and Ft. Myers was
`64% (see Fig. 2).
`
`were asked every 3 months about compliance
`with ordering refills and refill procedures, med—
`ication side effects, and missed doses and how
`to handle them. As part of the enrollment pro-
`cess patients were asked, ”Are you taking all of
`your medications as prescribed?” Then at one
`year, the question was repeated. At baseline, 68%
`of the patients reported they took their medica-
`tions as prescribed compared to 93% at the end
`of 12 months in the program (see Fig. 1).
`
`Compliance
`
`Compliance was calculated as the number of
`sessions taken by the patient divided by the to-
`tal number of sessions available for the patient
`to take starting on the first day the patient was
`enrolled in the program and ending on the
`360th day. The calculation was based on the as—
`sumption that a veteran was able to take a
`Health Buddy survey each day during their en-
`tire tenure in the program. The calculation ex-
`
`Medication Compliance
`
`93%
`
`100%
`
`
` 0%
`
`DISCUSSION
`
`The encouraging evidence from this study is
`that the CCCS program, powered by remote
`patient monitoring technology, reduces uti—
`lization and health-care costs in patients with
`multiple chronic conditions. Analysis of the fi-
`nancial, clinical, and patient satisfaction impact
`of the program after 12 months showed reduc-
`tions in utilization, as well as improvements in
`quality of life, and a highly satisfied patient
`population. Inpatient admissions were reduced
`by 46% at Ft. Myers, 68% at Lake City, and 13%
`at Miami; ER encounters were reduced by 19%
`at Ft. Myers, 70% at Lake City, and 15% at Mi-
`ami. Reductions in bed days of care was re—
`duced by 29% at Ft. Myers and 71% at Lake
`City, and increased by 13% at Miami. The re-
`duction in utilization is an important finding
`and suggests the CCCS program was effective
`in managing health—care resource utilization
`for the veteran population.
`In addition to the reduction in utilization,
`
`quality of life was significantly improved as ev—
`idenced by increases in the mental, physical,
`
`VISN 8 - Health Buddy® Compliance by Location
`Overall Patient Compliance, by Site
`
`1 00%
`
`
`
`Lake City
`
`Ft. Myers
`
`FIG. 2. Health Buddy compliance by location.
`
`6
`
`68%
`
`40%
`
`20%
`
`80%
`
`60%
`
`40%
`
`20%
`
`Before Health Buddy After Health Buddy
`
`FIG. 1. Medication compliance: percentage of patients
`who report taking their medications regularly before and
`after program implementation.
`
`
`
`Percentageofpatientswhotakemedicationsregularly
`
`

`

`r,13‘
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`TECHNOLOGY AND COORDINATION
`
`271
`
`the
`functional, and social components of
`SF36V. Without remote monitoring, patient
`care is based on episodic encounters between
`patients and their care providers. This episodic
`approach relies on the patient’s ability and will-
`ingness to collect, record, and act upon disease-
`related events over an extended period. The
`CCCS program’s use of Health Hero’s tele-
`health technology, bridged the gap between of-
`fice Visits by providing a platform for daily
`communication with the patient and making it
`possible for the care provider to identify prob~
`lerns and intervene before problems escalate.
`The CCCS program improved clinical out-
`comes and reduced health-care utilization. Pro-
`
`'
`
`gram patients experienced high levels of satis-
`faction with Health Buddy. Veterans who are
`often labeled as ”learned helpless” have taken
`a more active role in the self-management of
`their chronic diseases. Leider and Krizan7 men-
`
`tioned in their article, ”Disease management—
`a great concept but can you implement it?” that
`to have a successful disease management pro-
`gram, the veterans must be active participants;
`effectively self—managing chronic conditions
`through improved health behaviors. Clearly
`this program’s success can be attributed to the
`fact that it fostered self-management for a pop-
`ulation of veterans.
`
`Based on the program’s 2-year pilot, it is ev-
`ident that this program has benefited the frail
`elderly, medically complex veterans. We be-
`lieve this program has helped these veterans
`maintain their independence, thus reducing the
`possible risk of early institutionalization. It is
`clear that veterans enrolled in the CCCS Pro—
`
`gram throughout VISN 8 are more stable, sat-
`isfied, and able to manage and cope with their
`chronic health problems.
`
`REFERENCES
`
`1. Darkins A. The development and expansion of home
`telehealth in VHA. Internal report, Department of Vet-
`erans Affairs, 2002.
`2. Centers for Disease Control and Prevention. National
`
`diabetes facts and figures. Atlanta, GA: US. Depart—
`ment of Health and Human Services, Centers for Dis-
`ease Control and Prevention, 2000.
`3. Department of Veterans Affairs. VISN 8 network plan.
`Florida~Puerto Rico Veterans Integrated Service Net-
`work, 2001.
`4. Brooks D. Demo produces stunning results in care of
`complex patients. Disease Management Adviser 2001;7:
`113—117.
`
`5. Meyer M, Kobb R, Ryan P. Virtually health: chronic
`disease management in the home. Disease Management
`2002;5287—94.
`6. Kazis L, Miller D, Clark J, Skinner K, Lee A, Rogers W,
`Siro A, Payne 5, Finche G, Selim A, Linzer M. Health-
`related quality of life in patients served by the De-
`partment of Veterans Affairs. Arch Inter Med 1998;
`158:82—88.
`
`7. Leider HL, Krizan K. Disease management—a great
`concept but can you implement it? Disease Management
`2001;4:111—1 19.
`
`Address reprint requests to:
`Kirsten Dryden
`Health Hero Network, Inc.
`2570 W. El Camino Real, Suite 111
`Mountain View, CA 94040
`
`E-mail: kdryden@healthhero.com
`
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