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Telehealth Technologies: Improving Veterans' Access to Care

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:

1. health and well-being, including remote sensing and monitoring;
2. personal safety, including personal emergency alarms and motion sensors; and
3. 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.

VA's Care Coordination/Home Telehealth Program

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.

Rigorous Evaluation Needed

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.

References

1. "Aging and Technology: Landscapes and Attitudes Toward Adoption." Blue Shield of California Foundation Issue Brief, March 2008.