**Virtually Healthy: Chronic Disease Management\
in the Home**

MARLIS MEYER, M.A.,^1^ RITA KOBB, M.N., ARNP,^2^ and PATRICIA RYAN,
R.N., M.S.^3^

**ABSTRACT**

**Beginning in April 2000, eight clinical demonstration projects were
funded for 2 years within the Sunshine Network of the Veterans Health
Administration (VHA) to test disease management principles, the care
coordinator role, and the effective use of technology to maintain
veterans in their homes. Five of these projects focused on complex
medical/chronic disease populations. Seven hundred and ninety-one
veterans were recruited in these five projects and enrolled in the
Community Care Coordination Service (CCCS). The program was
conceptualized around and designed by network field staff as an \" aging
in place\" model. The purpose behind the integration of the care
coordinator role with technology was to improve health status, increase
program efficiency, and decrease resource utilization. Evaluation
results to date have shown a 40% reduction in emergency room visits, 63%
reduction in hospital admissions, 60% reduction in hospital bed days of
care, 64% reduction in VHA nursing home admissions, and 88% reduction in
nursing home bed days of \'care. All Performance Improvement outcomes
reached or exceeded the targeted goals, and a functional assessment
revealed five significant improvements out of 10 domains of the SF
36V.**

INTRODUCTION

Two OUT OF 1HREE Americans-at least 150 million people-have one or more
chronic health conditions that reduce the quality of their lives.[^1]
These conditions may account for two-thirds of the annual \$1 trillion
in health care costs.[^2] It is no wonder that healthcare systems
allover the country are looking for solutions to the burgeoning costs of
chronic care. Obstacles like upfront costs continue to confound health
care organizations in their search for ways to incorporate disease
management in the care of their chronically ill adults.[^3] Private
sector managed-care programs control costs and cap services. Stories of
the treatments they withhold or deny continue to make headlines. The
Veterans Health Administration (VHA) in Florida also faces these cost
and treatment issues, made even more of a challenge by increased
enrollment of older veterans with very complex health problems due to
expanded veteran entitlement. Funding has not kept pace with the rate of
enrollment. Community Care Coordination Service (CCCS) leaders sought a
different solution to bridge this gap-a solution that is a break from
traditional VHA care.

Background

The VA Florida-Puerto Rico Veterans Integrated Service Network (VISN 8)
is an integrated system of seven hospitals, 10 multi-specialty
outpatient clinics, and 28 community-based primary care clinics. The
defined service area for VISN 8 includes 60 of 67 Florida counties, 19
rural counties of southern Georgia, Puerto Rico, and the Virgin Islands.
Currently, over a million and a half veterans reside in the VISN 8
service area, and, of those, 45% are age 65 and older.[^4]

In 1998, VISN 8 was moving in a number of new directions. These included
implementation of new technologies that would drive improvements in
business practices, patient safety, noninstitutional care, expansion
into the home health sector, and development of new alliances with the
community to jointly expand healthcare delivery. These new directions
were implemented to help the VISN 8 meet key strategic priorities such
as improving access to care, reducing costs, increasing the number of
home care programs, increasing partnerships with the community, and
utilizing noninstitutional alternatives for long-term care.

In looking at populations that might benefit from care coordination and
technology across the continuum of care, it was noted that 4% of all
veterans in the VISN 8 service area, a group defined as high risk, high
use, high cost, were consuming over 40% of the network\'s resources.^4^
To better care for these patients and utilize resources more
efficiently, a new care model was developed. From this strategic model,
the CCCS was formed. The CCCS developed both clinical and business
models, and structured a care coordination system that combines the
professional role of the care coordinator with innovative technologies.

To stimulate innovation in delivering care and to meet identified
strategic priorities, especially the "aging in place" concept, a
network-wide call for proposals resulted in the funding of eight
clinical demonstration projects. Five of these projects focused on
complex medical / chronic disease populations. CCCS leaders charged
these projects with testing disease management principles, through the
role of care coordinator, using innovative technology effectively in the
home. The goal was to ensure patients were treated in the most
appropriate care setting and given the right amount of care at the right
time. High-risk, high-use, high-cost veterans were targeted. Several
common chronic conditions such as hypertension (HTN), heart failure
(CHF), lung disease (COPD), and diabetes (DM) were managed in the
population.

Care coordination

When CCCS leaders first presented the concept of care coordination to
staff members, care was taken to clearly define key concepts and
identify variations from the current practice of case management. In
VHA, case management usually pertains to one episode of care and takes
place within a hospital setting. Veterans are assigned a case manager
upon admission. This individual follows the patient\'s progress and
works with family and healthcare team members to establish a discharge
plan. Once the patient has been discharged, the contact is discontinued
unless the patient returns for another admission.

In the CCCS model, disease management is conducted throughout the
continuum of care. Care coordinators monitor patient problems and help
resolve them whenever and wherever they arise. The current healthcare
system in America is fragmented, and VHA is similar to the private
sector in this regard. The role of the care coordinator is a key factor
in ensuring appropriate, timely patient data-which constitutes the most
vital part of clinical decision-making is communicated to the healthcare
provider. The professional backgrounds of the care coordinators vary and
include social workers, nurse practitioners, and registered nurses. All
of these individuals are empowered to assess and make decisions across
departments to enhance access to care and to eliminate bureaucratic
barriers that sometimes prevent timely symptom management. The
technology serves as a tool to help the care coordinator stay efficient
and productive in meeting the needs of many patients.

MATERIALS AND METHODS

Technology

Choosing appropriate technology to enhance the care coordinator role was
paramount to the success of the care coordination model. At the start of
the program, equipment fairs were conducted to familiarize staff with
the technology. Care coordinators from each project selected technology
to meet the needs of their own patient populations. Multiple
technologies were reviewed for use in the home or other residential
settings and those selected included traditional telehealth
(telemonitors and videophones) with and without peripheral attachments,
an in-home messaging device with chronic disease management dialogues,
and instamatic cameras for diabetic wound care management.

These technologies were chosen with residential use in mind, and often
were placed in areas where the phone infrastructure was limited. Both
telehealth units used POTS (plain old telephone service) instead of the
higher speed ISDN (integrated services digital network) technology .The
in-home messaging device is a web-based, store-and-forward application
that connects to the Internet from the patient\'s home daily via a
toll-free number. Dialogues were developed for this device in
collaboration with care coordinators and included DM, HTN, COPD, CHF,
coronary artery disease, and angina, and dual dialogues such as DM/HTN,
CHF/DM, and COPD/HTN. The dialogues, a series of questions and answers,
include symptom management, self-management behaviors, and disease
knowledge areas. Symptom parameters were adjusted to comply with VHA
clinical guidelines. Care coordinators were able to access the answers
over a secured website on a daily basis. Finally, an Instamatic camera
was selected for diabetic patients to use for weekly photographs of
their diabetic wounds. The camera was extremely easy to operate and to
train patients and caregivers on. The camera has two lights that come
together at the picture perfect distance. It uses special grid-lined
film that aids the care coordinator in assessing the healing process.

The CCCS Clinical Program Director and care coordinators developed a
technology algorithm to guide in the selection of technology for all
patients. Some of the factors the algorithm looked at in determining the
technology used was the clinical stability of the patient, their
functional ability to manage the technology, and place of residence
(private versus congregate). The algorithm continues to be honed for
best practices. All technology used complied with the Joint Commission
on Accreditation of Hospital Organizations (JCAHO) for durable medical
equipment and infection control standards. Most of the equipment was
purchased outright with only one device in a leasing arrangement.

Performance improvement

A standardized performance improvement (PI) plan was implemented across
all projects in the CCCS. The PI plan was based upon VHA national
clinical guidelines. It addressed H1N medication compliance. Many of the
diabetics enrolled had HTN as a comorbidity, and blood pressure control
plays an important role in the diabetic patient\'s risk for heart attack
and stroke. Influenza and pneumococcal pneumonia vaccination rates also
were targeted. A provider communication survey was done to determine the
adequacy and appropriateness of communication between the primary care
provider and the care coordinator.

Methodology

The evaluation methodology is a prospective, quasi experimental design.
It was theorized that, when compared to themselves as well as to
non-intervened veterans with similar comorbidities, clinical outcomes
and VHA health care resource consumption would show improvement over
time. Quarterly intervals were the unit of measure. A database with an
Intranet interface was developed so that project staff could input
demographic and survey tool data for each patient enrolled. The SF 36V,
a standardized, scientifically validated questionnaire specifically
designed for veterans, was administered to patients at baseline and
6-month intervals from enrollment in the program. This instrument is
generally regarded as a reliable measure of quality of life and
functional ability. In addition to this, data was extracted from several
other VHA sources, including VISTA (a VHA computerized information
system) and the computerized patient record system (CPRS). An odds ratio
(OR) was used as a measure of association to approximate the likelihood
for nursing home admissions.

Population selection was from a network pool of 8,704 veterans
identified as high cost in the prior year (\>=\$25,000), stratified by
VA medical centers, and identified with chronic conditions such as CHF,
COPD, HTN, and DM. Each care coordinator reviewed the list for
appropriateness, made contact to establish willingness of veterans to
participate and enrolled those who were willing and appropriate
candidates. Seven hundred and ninety-one veterans were enrolled. The
drop-out rate was very low (\<10%); however, the lists used for
enrollment had many exclusions due to death, inability to make contact,
or institutionalization.

A comparison population with clinically similar but nonenrolled veterans
was also assembled. This group was randomly selected from a stratified
sample similar in diagnosis, age, and gender. A comparison of their
1-year average health care utilization rate compared to the intervened
group is attached (Table 1). It is important to remember, however, that
the in\~ tent behind selection of the intervened group was to target a
high use, high risk, and high cost population. The intervened group is
therefore the group most likely to be biased towards having more adverse
events, which will make the comparison a conservative estimate.

RESULTS

Utilization outcomes

In an effort to determine the impact of the CCCS program on the targeted
population, the following utilization measures were analyzed (Table 2):

-   Clinic visits

-   Emergency room (ER) visits

-   Hospital admissions

-   Hospital bed days of care (BDOC)

-   Nursing home (NH) admissions

-   NH BDOC

The intervened group comprised 791 veterans enrolled in the CCCS program
for 1 year. A comparison group of veterans were also analyzed (Table 3).
The comparison group received usual care with no care coordination or
technology. Results for the intervened group from the change in first
year to second year data analysis showed a reduction in ER visits by
40%, hospital admissions by 63%, and hospital BDOC by 60% (Table 4).

Clinic visits went up 14% in the first quarter postenrollment for the
intervened group (Fig. 1). This trend was reviewed, and it was noted
that care coordinators who had been empowered to make assessments had
scheduled clinic appointments during the first few months of enrollment
to ensure all clinical needs were met in a timely fashion. After the
first 3 months, the number of clinic visits steadily declined. It is
also noted that, although this group went up in clinic visits overall,
the comparison group went up even more (40%).

In addition to these outcomes, nursing home admissions and bed days of
care were evaluated. It was believed by CCCS program leaders that the
veteran population targeted by the program was at high-risk for
premature institutionalization and thus could be impacted by the care
coordination process. Nursing home admissions declined by 64% and
nursing home BDOC were reduced by 88%. In the comparison group, nursing
home admissions increased by 106% (Table 4). An Odds Ratio analysis
revealed that patients enrolled in the program were 77.7% less likely to
be admitted to a nursing home care unit than those not enrolled in the
program (Table 5).

Quality of life and functional ability as measured by the SF 36V
indicated significant improvements in the Role Physical (*p* \< 0.003),
Bodily Pain (*p* \< 0.000), Social Functioning (*p* \< 0.004), Role
Emotional (*p* \< 0.000), and the Mental Composite (*p* \< 0.011)
scores. The other five domains remained the same, which is also
significant in a frail elderly population with complex medical / chronic
disease conditions.

Overall, when comparing the intervened group findings to the comparison
group, it was found that the intervened group showed considerably
greater improvements on all measures.

![](media/image1.png){width="5.809722222222222in"
height="3.8340277777777776in"}

Performance improvement

Performance improvement data was evaluated on the intervened group. All
eight clinical demonstration sites participated in the data collection.
Measures identified were immunization rates for influenza (flu) and
pneumococcal pneumonia, compliance with antihypertensive medication, and
appropriate, timely communication between the primary care provider and
the care coordinator.

Data for the five complex medical / chronic disease projects is included
here. The immunization measures were in line with VHA performance
standards. Other measures were developed by CCCS staff based on
identified problem areas. VHA immunizations target goals were 78% for
both influenza and pneumococcal measures. Eighty-three percent of the
CCCS veterans had a current flu shot, and 90% had a current pneumococcal
vaccine. Medication compliance, which was chosen as a measure because it
is often an issue with the chronically ill population, was 93%. The
target goal was also 78%. Primary care providers responded positively to
the role of the care coordinator, with an 85% outcome measure for
appropriate and timely communication. Eighty-five percent was also the
target goal for this measure.

DISCUSSION

Many aspects of chronic disease management must be carefully coordinated
and monitored. CCCS leaders therefore believe that the model does
improve clinical outcomes and reduces healthcare utilization. One of the
core principles behind successful chronic disease management is
effective self-management.[^5] The chronic disease dialogues used by the
in-home messaging device not only provided daily, repetitive education
on self-management principles, but also monitored a variety of symptom
parameters including blood sugar, weight, blood pressure, and chest
pain.

Leider and Krizan postulated that, for a disease management model to be
effective, it must employ three basic strategies: improving patient
compliance and self-management behaviors, strong physician leadership,
and rigorous monitoring of patients so that clinical outcomes can be
improved.[^6] The CCCS model embodied these strategies, and staff
members were able to effectively operationalize them in practice.
Technologies were chosen that supported patient compliance and provided
educational opportunities to enhance self-management. Special emphasis
was put on keeping the technology simple and user friendly to allow for
the broadest use regardless of the patient\'s technological expertise.
The CCCS leaders strongly relied upon the collaboration of physician
providers with care coordinators. Physician champions were sought to
provide leadership at local project sites and to work directly with CCCS
leaders to promote acceptance of the care coordinator role. Care
coordinators themselves were chosen for their judgment skills and their
effectiveness in managing patient needs across the healthcare continuum.

CONCLUSION

Based on the first-year findings, it is evident that the CCCS model has
benefited many frail elderly, medically complex patients. It has helped
them to maintain their independence, improved their functional status
and deterred from costly hospitalizations and institutionalizations. It
is strongly believed that the key to this success has been the carefully
constructed role of the care coordinator, with clinical expertise to
properly assess patient needs. This role in tandem with the right tools
and the technology most adaptable to the needs of the patient and
clinician have provided the means for early detection of patients at
risk for further deterioration. Through the use of technology,
efficiencies in process and practice, previously not possible, are
achieved. This approach has given the patients a safer and more secure
environment in their most preferred setting, the home.

The first step in the process of inventing a proactive healthcare model
that facilitates patient-oriented and cost-effective delivery of
services is improving health and information access. The primary concept
of integrating technology into care coordination has gone beyond that
first step. The model has successfully evolved into an effective
approach for managing patients with multiple chronic diseases. The CCCS
is in the initial phase of identifying best practices for the strategic
model. The intent is to draw upon the lessons learned and develop
standards that can serve as the basic foundation for any population
management program.

The early successes have warranted expansion of the program to other
populations. In 2001, two new demonstration programs were added. There
will be a second request for proposals in 2002 to explore the effect of
the concepts on other populations and new technologies not yet tested in
this environment. In addition, VISN 8 is exploring accreditation
opportunities in disease management to further validate and strengthen
both the clinical and business applications of the concepts. The aging
in place model has been the most notable success of this program. It is
readily apparent that more veterans are stable, satisfied and able to
manage their chronic health problems in their home environment.

ACKNOWLEDGMENTS

We would like to thank the following individuals: (1) Project staff from
the following clinical demonstration medical program sites: Lake City ,
Gainesville, Ft. Myers, Miami, and San Juan. (2) Douglas D. Bradham,
Dr.P.H., Associate Professor, Division of Healthcare Outcomes Research,
Department of Epidemiology and Preventive Medicine, School of Medicine,
University of Maryland. (3) Neale R. Chumbler, Ph.D., Associate
Professor, Department of Health Policy and Epidemiology, University of
Florida.

[^1]: REFERENCES

    ^?^ Centers for Disease Control. National diabetes fact sheet 2000
    \[On-line\]. Available: www.cdc.gov/needphp/ddr/pubs/facts/98.htm.

[^2]: American Diabetes Association. Diabetes facts and figures 2000
    \[On-line\]. Available:
    [www.diabetes.org](http://www.diabetes.org/).

[^3]: Piette JD. Satisfaction with care among patients with diabetes in
    two public health care systems. Med Care 1999;37:538.

[^4]: Veterans Integrated Service Network (VISN 8). Strategic plan.
    Department of Veterans Affairs, Bay Pines, FL: 2001.

[^5]: Blonde B. Optimizing therapy in type 2 diabetes. Patient care for
    the nurse practitioner. Diabetes: Fall 2001, 8-14.

[^6]: ^?^ Demo produces stunning results in care of complex patients.
    Dis Management Advisor 2001;7:113-117.

    ^7^ Leider HL, Krizan K. Disease management-a great concept but can
    you implement it? Dis Management 2001;4:111-119.

    Address reprint requests to:

    *Marlis Meyer, M.A.*

    *Community Care Coordination Service (08)*

    *801 South Marion St.*

    *Lake City, FL 32025*

    *E-mail:* marlis.meyer@med.va.gov