# Enhancing Elder Chronic Care Through Technology and Care Coordination

Rita Kobb MS, MN, ARNP, BC-address all correspondence and reprint
requests

Lead Care Coordinator

Rural Home Care Project (08)

North Florida/South Georgia Veterans Health System

801 South Marion Street

Lake City, Florida 32025

386-754-6412

Fax 386-754-6416

rita.kobb@med.va.gov

Nannette Hoffman MD

Chief, Geriatrics & Extended Care Service

North Florida/South Georgia Veterans Health System (11F)

1611 SW Archer Road

Gainesville, Florida 32608

Robert Lodge MSW

Care Coordinator

North Florida/South Georgia Veterans Health System

Lake City, Florida

Sheri Kline MSN, ARNP, BC

Care Coordinator

North Florida/South Georgia Veterans Health System

Gainesville, Florida

Abstract

The Rural Home Care Project is one of eight clinical demonstration
pilots in an expansive technology initiative implemented in the Veterans
Health Administration (VHA) Sunshine Network in Florida and Puerto Rico.
Three care coordinators consisting of two nurse practitioners and a
social worker collaborate with primary care providers in the management
of high-risk, high-cost veterans with multiple chronic diseases such as
diabetes and heart failure. The project staff uses home telehealth
devices to proactively monitor and educate patients to prevent
healthcare crises. The evaluation methodology is a quasi-experimental
design that uses a group of usual care veterans for comparison. The
methodology includes interviews with surveys, and statistical analysis
through a series of repeated-measure of covariance modeling designed by
a Health Economist and his research team from the University of
Maryland. Results for 281 patients show that care coordination enhanced
by technology reduced hospital admissions, bed days of care, emergency
room visits, and pharmacy prescriptions while showing high patient and
provider satisfaction. Veterans also had improved perception of physical
health as evidenced by a standardized functional status measure.

Over the past century, medical and technological advances have
dramatically altered healthcare delivery and improved longevity.
Concordantly, the prevalence of chronic diseases in our aging population
has grown in part due to this increased longevity. Today, chronic
illnesses such as heart disease and diabetes are among the most
predominant and costly. More than 1.7 million Americans die annually
from chronic disease. The frail and elderly are particularly at risk.
When calculating the burden of chronic disease, we significantly
underestimate the severity of this national health problem if we fail to
consider the additional strain of accompanying disability.^1,2^ One of
ten people in the United States has a chronic disabling condition that
has significantly limited activity and the ability to enjoy life.^2,3^
In the year 2000, 17% of the population was over age 65. In twenty
years, that percentage will rise to 25%.^1^ These demographics are very
germane to the Veterans Health Administration (VHA). The VHA is one of
three major branches of the Department of Veterans Affairs and the VHA
provides a comprehensive healthcare system for the nation's veterans.
The VHA has about 1,300 care facilities, including 163 hospitals, 850
ambulatory care and community-based outpatient clinics, 206 counseling
centers, 137 nursing homes, and 43 domiciliary facilities. Due to
technology and changes in national and VA health care trends, the VHA
has evolved from a hospital-based system to a primary outpatient-focused
system over the past five years.^4^

Within the VHA, the numbers of veterans seeking care from the system has
doubled since 1995. Currently, there are over 6 million enrolled
veterans consuming \$23 billion in healthcare resources. Many of these
are over age 65 and the total veteran population continues to age
rapidly.^5^ In an effort to manage chronic disease, healthcare
organizations frequently try harder to make current mechanisms of care
delivery work instead of putting efforts toward changing the manner in
which care is provided.^6^ Given the importance of preventive care and
coordinating services to enhance access to primary care, finding
cost-effective methods for managing chronic conditions becomes a
healthcare challenge we must confront.

**Background**

The Veterans Health Administration (VHA) in Florida and Puerto Rico
examined some concerning trends. Among its users of services, it found
that 4% of the population consumed 41% of the total available
resources.^7^ This four percent was comprised of chronically ill and
disabled veterans. Based upon the above resource utilization traditional
care may have been inadequately addressing the older chronically ill
population's complex medical needs in a cost efficient manner. To
address this issue a task force was formed to develop a novel care
delivery system for chronically ill and disabled veterans in Florida and
Puerto Rico. From this task force, the Community Care Coordination
Service (CCCS) evolved in October 1999. The CCCS received funding from
the VHA for eight clinical demonstration pilots. These demonstration
projects used innovative technology to enhance the care coordination for
chronically ill veterans that were considered high-risk, high-use, and
high-cost. This article is about one of these successful pilots, the
Rural Home Care Project (RHCP).

The RHCP began April of 2000 as a population management initiative
combining expert care coordination with home telehealth technology to
proactively manage complex chronically ill older veterans. The RHCP is
based in the North Florida/South Georgia Veterans Health System (NF/SG
VHS) that is part of the VHA in Florida and Puerto Rico. The service
area of the system includes nineteen counties in southern Georgia and
thirty-seven counties in north Florida. The project staff members' main
goal was to work collaboratively with primary care providers to reduce
veterans' hospitalizations, unscheduled clinic and emergency room
visits, and prescription medication costs. The RHCP has two geriatric
nurse practitioners, a social worker, and a program support assistant.

For technology use, the RHCP team selected home telehealth equipment to
meet the specific needs of project patients and to enhance the care
coordinator's effectiveness. They did this after reviewing the home
telehealth literature.^8^ This equipment included an in-home messaging
device, the Health Buddy from Health Hero Network, American Telecare's
audio-video units, the Aviva 1010SLX with peripheral vital sign
monitoring, Wind Currents TeleVyou 500 videophone, and the telephone.
All equipment used plain old telephone service (POTS) and was
consistently reliable in the rural environment. All veterans had to have
telephone service for enrollment.

## Methods

The evaluation methodology was a prospective, quasi-experimental design
with periodic data collection at 6-month intervals. A series of
repeated-measure analysis of covariance modeling was used. A Health
Economist and his research team from the University of Maryland
developed a database, with an Intranet interface for staff to enter
survey and demographic data. Veterans were identified as potential
project enrollees due to their high-cost (\> \$25,000) and high-use (two
or more hospital admissions, frequent emergency room visits, many
unscheduled walk-in visits, and 10 or more prescriptions) in the year
preceding enrollment. In this group the most common chronic disease
diagnoses were hypertension, heart failure, emphysema, coronary artery
disease, and diabetes.

Veterans were risk-stratified into three levels based upon their disease
severity, functional and cognitive status, caregiver presence in the
home, and type of residence. RHCP staff members developed a technology
decision tree to help appropriately match the technology to the patient.
(Figure 1) This decision tree was largely based upon the literature
review as no veterans in the NF/SG VHS had ever used home telehealth
technology and staff did not know if this technology would work or be
accepted by the patients. It was understood that this decision tree
would be modified as needed based upon the data collected over the pilot
demonstration.

A group of usual care veterans (n=1120) with similar diagnoses, clinical
outcomes, health care resource consumption, and health care expenses,
were compared to those enrolled in the RHCP. The usual care group was
randomly selected through one of the VHA data sources, the decision
support system (DSS) and was enrolled in the NF/SG VHS. The decision
support system is the VHA's large computerized cost allocation system
that merges clinical, utilization, and cost information for individual
as well as groups of patients.^9^ Veterans in the RHCP also were
compared to themselves pre and post enrollment. The sample included in
this article (n=281) represents those veterans with 12 months pre and
post enrollment data. Twelve percent of the total number of veterans
contacted for enrollment declined participation. More than 90% of those
who declined did so due to discomfort with the technology. Patient and
provider satisfaction surveys were conducted at 6-month intervals.
Functional status data were also collected using the SF 36V, a validated
tool for assessing function and perceived health in the veteran
population.^10^ Patients completed the tool at baseline during
face-to-face interviews. After baseline, all interviews were conducted
by phone follow-up that provided an efficient cost-effective approach
for feedback of results to project team members. In addition, cost and
resource utilization data was reviewed from several VHA sources
including (DSS) and the computerized patient record system (CPRS). CPRS
is the VA's comprehensive computerized patient record that employs a
graphical interface mimicking the sections of a paper medical record
allowing clinicians anywhere in the VHA system to access patient-related
information and disseminate findings. Project team members can send
progress notes to any clinician for co-signature. This improves
communication and information management efficiency.

**Results**

Over 425 veterans have been enrolled in the project since
implementation. Outcome data presented is for the 281 patients with
12-months of pre-and-post enrollment data. The usual care group
consisted of 1120 veterans, a comparison of demographics with project
patients is provided. (See table 1) Project patients showed a greater
improvement in healthcare resource consumption as compared to the usual
care group. (See table 2) Patient and provider satisfaction surveys
about the technology and the project were completed every 6 months.
Patients reported high levels of satisfaction with both project team
members and technology. They reported the technology was easy to use and
helpful in managing their chronic conditions. (See Figure 2) Providers
also responded very positively in the surveys. (See Figure 3)
Satisfaction data related to technology usage and care coordination was
only collected on project patients' as the usual care group did not have
these interventions. Because hypertension was the number one diagnosis
noted in the target population, medication compliance in this group was
tracked. Medication compliance was monitored every quarter this included
reviewing prescription refill patterns, CPRS for notes related to
medication issues, and talking directly with veterans and caregivers.
Project patients started out with 68% compliance in the first quarter of
enrollment and rates steadily rose to maintain themselves consistently
over the target goal of 78%. Current compliance rates are 93%.
Compliance data on immunization administration was also collected.
Target goals were set by CCCS staff to reflect VA performance measure
standards for project patients, for hypertensive medication compliance,
influenza, and pneumoccacal vaccines. Panel patients' compliance rates
were 83% for flu and 84% for pneumovax. Usage compliance was collected
for one of the technologies used-the Health Buddy. Veterans answered
questions daily and compliance was based upon how many sessions they
received and how many they actually answered. Compliance rates for
project patients have been between 90-92%. This was considered to be a
positive outcome because the population has been labeled as
non-compliant and some non-compliance with the technology was
anticipated. The authors believe the high compliance rates were due in
part to the diligent monitoring by the care coordinators and the
unexpected high acceptance of the technology.

Functional status data collected by the SF 36V also showed improvement
from baseline. At one year from enrollment, patients demonstrated a
positive change in their perceptions of physical health, social
functioning, and mental health with no decline in perception about
bodily pain, vitality, or emotional status. (See Figure 4) Veterans
selected for enrollment had multiple chronic health conditions that
negatively impacted their quality of life. Reporting no decline
represented the perception of maintaining current functional ability.
Therefore having no decline was also seen as a positive outcome by the
project team.

## Discussion

Chronic disease imposes a heavy financial and emotional burden on
patients and the healthcare system. The Rural Home Care project used a
novel approach that blended expert care coordination with home
telehealth technology to promote independence, compliance, and to
maintain the chronic disease patient in the least restrictive
environment-the home. Rural Home Care staff strongly relied upon primary
care provider collaboration with the new role of care coordinator.
Technology was employed to enhance the achievement of project goals and
needed to be user friendly for both patient and care coordinator. We
believe the project results demonstrate the success of partnering
technology with skilled professional intervention.

In addition veterans readily responded to the technology. An example of
this was a 78-year old WW II veteran who had 5 admissions, 15 bed days
of care, 3 emergency room visits, and 18 clinic visits in the

6 months prior to enrollment. He was using the Health Buddy disease
management tool for monitoring his heart failure. He was compliant with
answering his daily questions. He reported that the device gave him back
stability in his life. He had no healthcare consumption in the 6 months
after enrollment.

Even though patients were readily accepting the technology, there were
some initial hurdles from providers in believing the technology could be
useful. Staff was able to change providers' perceptions about technology
building a strong foundation for collaboration. The Rural Home Care
Project proved that chronic disease veterans could benefit from a new
way of delivering care and that by coordinating services resource
utilization could be reduced without a subsequent loss of quality.

A healthcare system seeking to improve the management of chronic
diseases must accept the need for radical change. Focusing on keeping
people as healthy and active as possible in the context of chronic
illness will transform any system from reactive to proactive. Home
telehealth technology can be a tremendous asset in managing chronic
illness because it helps the clinician to be proactive. This requires
not only determining what care or service is needed but making sure the
patient gets it at the right time, and in the right place.

**Acknowledgements**

### Juanita Bradley

Program Assistant

Rural Home Care Project

Dr. Douglas Bradham DrPh

University of Maryland, Baltimore

**References**

> 1\. Centers For Disease Control. National Diabetes Facts and Figures,
> 2000.
>
> [www.cdc.gov](http://www.cdc.gov/).
>
> 2\. Robert Wood Johnson Foundation.
> [www.improvingchroniccare.org](http://www.improvingchroniccare.org/)
>
> 3\. Federal Interagency Forum on Aging Related Statistics.
> [www.agingstats.gov]{.underline}
>
> 4\. Veterans Health Administration Intranet.
> [vaww.va.gov/med]{.underline}.

5.  Roswell Sworn in as VA Under Secretary for Health April 2002.
    vaww.visn8.med.va.gov

6.  Institute of Medicine. [Crossing the quality chasm: a new health
    system for the 21^st^ century]{.underline}. Washington, DC: National
    Academy press, 2001.

7.  Florida-Puerto Rico Veterans Integrated Service Network. VISN 8
    Network Plan. April 2001.

8.  Hersh, W., Helfand, M., Wallace, J., Kraemer, D., Patterson, P.,
    Shapiro, S., & Greenlick, M. (2000). Clinical outcomes resulting
    from telemedicine interventions: a systematic review. [BMC Medical
    Informatics and Decision Making]{.underline}, [1]{.underline}(5).
    Available at <http://www.biomedcentral.com/1472-6947/1/5>

9.  Health Economist Research Center.
    [www.herc.research.med.va.gov](http://www.herc.research.med.va.gov/)

10. Kazis, L., et al. Health-Related Quality of Life in patients Served
    by the Department of Veterans Affairs. *Arch Intern Med.* Vol. 158.
    March 1998. Pp 82-88.

Figure 1 Rural Home Care Technology Decision Tree

### 

### Figure 2 Patient Satisfaction

![](media/image1.png)

*Graph above indicates: Customer Satisfaction Survey Results, Patients
(n=281). Survey conducted every six months. Question: Do you think
technology has helped you stay healthy? 270 respondents (96%) stated
"yes", 11 respondents (4%) stated "no". Question: Has having staff
monitor you made you feel more comfortable? 267 respondents (95%) said
"yes", while 14 (5%) said "no". Question: Would you recommend this
project o other veterans? 273 respondents(97%) replied "yes", while 8
respondents (3%) indicated "no".*

Figure 3 Provider Satisfaction

![](media/image2.png)

*Graph above indicates: Customer Satisfaction Survey Results, Providers
(n=57). Survey conducted every six months. Question: Is communication
between yourself and care coordinator time/appropriate? 56 respondents
(98%) indicated "yes", 1 (2%) indicated "no". Question: Is the project a
benefit to your patients? All 57 (100%) of the respondents indicated
"yes". Question: Would upi refer patients to this project? 57
respondents (100%) indicated "yes".*

Figure 4 SF 36V Results at Baseline and 12 months

![](media/image3.wmf)

*Graph above indicates: Physical Function has increased from 28 to 40.
Role Physical has increased from 27 to 37. Bodily Pain has not changed.
General Health has increased from 47 to 49. Vitality has remain the
same. Social Function has increased from 49 to 60. Role Emotional
remains unchanged. Mental Health increased from 72 to 85.*

Table 1 Demographics Comparison Usual Care to Rural Home Care (RHCP)

+--------+------+-----+--------+-------+------+-------+------------+
|        | ##   | ##  | ###    | **Ma  | #    | ####  | #### Top 5 |
|        |  Avg | ##  | # War  | rital | ###  |  Insu |            |
|        |  Age | Gen | Period | Sta   | Race | rance | **DRGs**   |
|        |      | der |        | tus** |      |       |            |
|        |      |     |        |       |      | **    |            |
|        |      |     |        |       |      | Cover |            |
|        |      |     |        |       |      | age** |            |
+========+======+=====+========+=======+======+=======+============+
| #      | 70   | #   | #####  | ###   | ###  | ##### | ##### HTN  |
| # Usua |      | ### |  WW II | ## Ma | ## C |  None |            |
| l Care |      | # M |        | rried |      |       | ##### CHF  |
|        |      |     | (35%)  |       | (    | (60%) |            |
| #      |      | (9  |        | (53%) | 70%) |       | COPD       |
| ### N  |      | 8%) |        |       |      |       |            |
| = 1120 |      |     |        |       |      |       | Diabetes   |
|        |      |     |        |       |      |       |            |
|        |      |     |        |       |      |       | Atrial     |
|        |      |     |        |       |      |       | Fi         |
|        |      |     |        |       |      |       | brillation |
+--------+------+-----+--------+-------+------+-------+------------+
| #      | 72   | #   | #####  | ###   | ###  | ##### | ##### HTN  |
| # RHCP |      | ### |  WW II | ## Ma | ## C |  None |            |
|        |      | # M |        | rried |      |       | ##### CHF  |
| **N =  |      |     | (43%)  |       | (    | (55%) |            |
| 281**  |      | (9  |        | (52%) | 65%) |       | ####       |
|        |      | 8%) |        |       |      |       | # Diabetes |
|        |      |     |        |       |      |       |            |
|        |      |     |        |       |      |       | COPD       |
|        |      |     |        |       |      |       |            |
|        |      |     |        |       |      |       | Cardiac    |
|        |      |     |        |       |      |       | A          |
|        |      |     |        |       |      |       | rrhythmias |
+--------+------+-----+--------+-------+------+-------+------------+

Table 2 Resource Utilization Comparison Usual Care to Rural Home Care
(RHCP)

Percentage Change (- = decrease; + = increase)

+--------+---------+------+---------+------+-------+-------+--------+
|        | ## Adm  | #    | ####    | **   | ####  | **C   | **Phar |
|        | issions | ###  |  NH Adm | NH** |  ER v | linic | macy** |
|        |         | BDOC | issions |      | isits | vis   |        |
|        |         |      |         | **BD |       | its** |        |
|        |         |      |         | OC** |       |       |        |
+========+=========+======+=========+======+=======+=======+========+
| #      | +27%    | +32% | +11%    | +18% | +22%  | +19%  | #####  |
| # Usua |         |      |         |      |       |       |        |
| l Care |         |      |         |      |       |       | +37%   |
|        |         |      |         |      |       |       |        |
| #      |         |      |         |      |       |       |        |
| ### N  |         |      |         |      |       |       |        |
| = 1120 |         |      |         |      |       |       |        |
+--------+---------+------+---------+------+-------+-------+--------+
| #      | -60%    | -68% | -81%    | -94% | -66%  | -4%   | #####  |
| # RHCP |         |      |         |      |       |       |        |
|        |         |      |         |      |       |       | -59%   |
| **N =  |         |      |         |      |       |       |        |
| 281**  |         |      |         |      |       |       |        |
+--------+---------+------+---------+------+-------+-------+--------+