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While older adults may be less technologically
savvy relative to younger individuals,
they are nonetheless interested in and willing
to use technology to improve their quality
of life and ability to "age-in-place."
Three areas of particular importance and
interest to older adults include:
- health
and well-being, including remote sensing
and monitoring;
- personal safety, including
personal emergency alarms and motion sensors;
and
- social connectivity. 1
Telehealth technologies are being used to
provide convenient access to these services
in patients' homes. While much attention
has been paid to technology and development
of innovative equipment, less effort
has focused on systematically evaluating the
efficiency and effectiveness of these applications.
A notable exception is the use of
the telephone for follow-up care and patient
reminders. Telephone care can improve
outcomes through more frequent contact
between patients and health professionals,
but it requires real-time interaction. With
the increasing introduction of low-cost
remote monitoring devices that allow asynchronous
contact, studies are increasingly
being implemented to address the value of
home monitoring.
The Department of Veterans Affairs has
been a leader in the use of home monitoring.
Since 2003, more than 43,000 veterans
have enrolled in the Care Coordination/
Home Telehealth Program (CCHT). Technology
is assigned based on patient needs
and includes a range of devices such as
videophones, messaging devices, biometric
devices, digital cameras, and telemonitoring
devices. Each enrolled veteran has an assigned
care coordinator to help them manage
their condition and coordinate care.
Since 1997, we have been evaluating how
telehealth technologies improve veterans’
access to services in their home setting. Our
earliest studies evaluated the provision of
specialty services between a state veterans
home and VA Medical Center. We evaluated
the feasibility of providing nursing-based
wound consultation services and the provision
of specialist physician consultation via
real-time interactive video. In both studies,
clinicians were able to diagnose and treat the
health problem using the technology while
the patient was able to remain at the nursing
home (their home). This eliminated a four
hour round-trip for the patient and saved
transportation costs. Furthermore, both clinicians
and patients expressed satisfaction
with the use of telehealth; in fact, most patients
felt it was easier to get medical care.
In a second study, we compared the effectiveness
of two home telehealth communication
modes (telephone or videophone)
to traditional care provided for recently
discharged outpatients with heart failure.
Patients discharged from the hospital
following treatment for heart failure exacerbation
were randomized to a 90-day, nursemanaged,
telephone- or interactive videofacilitated
heart failure disease management
program or control condition. The intervention
resulted in significantly longer time
to readmission but had no effect on mortality,
hospital days, or urgent care clinic visits.
Intervention patients reported higher diseasespecific
quality of life scores at one year.
We found no substantive differences in
communication patterns between the telephone
and videophone group, thus both approaches
worked equally well.
In a third study, we evaluated varying doses
of remote monitoring in veterans with comorbid
hypertension and diabetes. To date,
most projects have focused on single disease
populations, e.g., heart failure or mental illnesses.
Furthermore, few controlled clinical
trials have investigated varying the intervention
dose. Subjects were randomized to three
groups: low-intensity monitoring plus nurse
care management intervention, high-intensity
monitoring plus nurse care management intervention,
and usual care. In both intervention
groups, patients transmitted vital signs daily.
In addition, the low-intensity group answered
two general health questions, while
the high-intensity group responded to a
complete range of questions focused on
diabetes and hypertension, and received
educational tips. The intervention groups
participated in the protocol for six months
following enrollment. Preliminary results
indicate that the intervention was effective
in improving HbA1c and this effect was
more pronounced in the high-intensity group.
Only the high-intensity group showed an
improvement in systolic blood pressure.
Because family members frequently assist
with disease management in the home, a
study currently under way is evaluating how
informal caregivers support veterans enrolled
in the VA CCHT program.
Through optimal use, telehealth technologies
can be used to leverage limited health care
resources to better meet the needs of older
adults. The wide array of telehealth technologies
has created many new and promising
ways to increase access, availability, and
quality while reducing costs. Rigorous evaluation
is needed to determine which patients
may benefit most from telehealth and which
technologies are most cost-effective.
-
"Aging and Technology: Landscapes and Attitudes
Toward Adoption." Blue Shield of California Foundation
Issue Brief, March 2008.
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