During the 1990s, the Veterans Health Administration (VHA) underwent a major transformation, balancing inpatient care with outpatient 

services, ensuring Veterans had access to standardized benefits, and improving population 

health. Since those years, VHA has continued to 

make many incremental improvements. Faced 

with enormous changes within health care, future financial constraints on government, and 

evolving Veteran expectations, VHA must move 

beyond problem-based disease care to patientcentered health care, based on relationships 

between the patient, his or her family, and the 

health care team. This new system must also be 

safe, of high quality, and efficient. 

Today, VHA is embarking on our next major 

transformation, one that places the Veteran 

and his or her family at the center. This means 

focusing holistically on optimizing health and 

not just the treatment of disease; designing 

the delivery system around the needs of our 

Veterans and not around a medical model; and 

being responsive to the desires of our patients 

rather than designed for our convenience. 

A Vision for Continuing to Deliver 

‘The Best Care Anywhere’

Veterans have told us that they want a system that they can trust to reliably provide 

all necessary services to restore health and 

functionality, but that is well coordinated 

and conveniently available—both in terms of 

being timely and close to home. They want a 

relationship with a personal clinician, some 

choice in their options for care, and above 

all else, they want to be treated with respect 

and dignity. Yes, VHA has made enormous 

improvements over the last couple of decades; 

but if we are to continue to deliver “The Best 

Care Anywhere,” we must be bold in our vision of the future.1

 

Patient Aligned Care Teams (PACT) will be the 

patient-centered medical home for enrolled Veterans—the hub that helps patients develop and 

meet personal health goals, coordinates services 

and hand-offs, and ensures that patients have access to the right care, at the right time, in the right 

place, and by the right provider. We know that 

systems that have implemented similar models, 

particularly for patients with chronic disease, have 

been able to improve outcomes while reducing 

costs.2 While they did not call it PACT or medical home, VISN 23 implemented similar changes 

six years ago. Over the next five years, their admissions for ambulatory sensitive conditions fell 

14 percent while the rest of the country increased 

5 percent. But PACT will not succeed without 

new strategies to fully engage Veterans in the 

management of their own health.

The VHA system must develop processes to 

better help patients manage their chronic conditions. Telehealth, secure messaging, and mobile communication strategies can better link 

clinicians and patients through a web of support. Deployment of new technologies, such 

as the PTSD applet for the iPhone, will help 

improve the lives of VHA patients. The applet allows Veterans to track PTSD symptom 

severity and offers resources to those in need. 

Additional applications are being developed as 

part of VHA’s iPad-based “clinic in a hand,” 

which will be piloted next year.

FORUM

Translating research into quality health care for Veterans

Commentary

VHA: Designing Tomorrow’s 

Veteran-Centered Model of Care

James Tuchschmidt, M.D., M.M., VHA Office of Health Care Transformation

 November 2011

Contents

Director’s Letter 2

VHA Transformation Challenges 

and Lessons 3

Relational Coordination: 

Harnessing the Transformative 

Power of Relationships to 

Improve VA Health Care 4

The Critical Role of Caregivers 

Providing Care to Veterans 

with Dementia 5

Peer-Support Care Models for 

Patients With Diabetes 6 

Home Telehealth: Looking 

Under the Hood 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 
From Medical Home to a PatientCentered Community

To ensure seamlessness, VHA must design 

the rest of the health care neighborhood 

around that medical home. Specialty services 

must be available in real-time, and be designed to better serve the needs of patients 

and primary care clinicians. Several innovative ways of providing better subspecialty 

support for patients and primary care teams 

are currently being piloted. The first, Specialty Care Access Networks (SCAN), modeled after the University of New Mexico’s 

ECHO project, provides virtual specialty 

consultation for non-urgent issues, which 

improves access and enhances the ability of 

primary care teams to manage complex conditions, especially for those patients living in 

rural areas. Second, eConsult pilots provide 

specialty help to primary care clinicians without requiring a patient visit. These pilots are 

modeled after innovative work done by the 

Mayo Clinic, which estimated that 30 percent 

of their consults could be done with a virtual 

visit. Finally, specialists are providing justin-time support to primary care clinicians 

through phone consults.

VHA must also design care around the specific 

needs of patients instead of organ systems. 

Bohmer and Lawrence suggested we should 

be designing “clinical production” around the 

unique needs of patient cohorts in ways that improve integration, predictability, and reliability.3

Oncology services are often arranged this way. 

We know that most patients with cancer need 

certain services over the course of their illness. 

Interdisciplinary teams have clinic together and 

coordinate services through a common treatment plan. Why not build similar care models 

for other unique patient populations? 

Duke University cardiologists have developed 

such a program for patients with advanced 

congestive heart failure.4 Highly integrated 

with primary care, these multidisciplinary 

teams have improved clinical outcomes 

and reduced costs by more than $8,000 per 

patient-year. They have successfully incorporated registries, protocols, and telehealth into 

their model. 

I can see a very different VA health care 

system 10 years from now, one that is truly 

designed around the Veteran. Places that 

excel at patient-centered care, such as Griffin Hospital in Connecticut, engage patients 

in ways that we find hard to imagine. In the 

ICU at Griffin, there are no visiting hours. 

Even the family dog is welcome. Families 

stay overnight in a “hotel room” immediately 

adjacent the patient’s ICU bed. Common 

family rooms and kitchenettes bring families 

together to support one another. They are 

invited to be present during invasive procedures and even at codes. The hospital’s 

approach reflects a fundamental belief about 

the primacy of the patient. For the past 10 

years, Griffin Hospital has been on Fortune 

Magazine’s list of Top 100 Employers of Choice. 

Although many may wonder if VHA can 

make this journey, or even if we should, I 

am confident that in the future we will fulfill 

Lincoln’s promise to America’s Veterans in 

powerful new ways.

References

1. Longman, P. 2007. Best Care Anywhere: Why VA Healthcare is Better Than Yours. Sausalito: Polipoint Press.

2. Grumbach, K. et al. The Outcomes of Implementing Patient 

Centered Medical Home Interventions: A Review of the Evidence on Quality, Access, and Costs from Recent Prospective 

Evaluation Studies, UCSF Center For Excellence in Primary Care, August 2009.

3. Bohmer, R.M.J. and D.M. Lawrence, “Care Platforms: 

A Basic Building Block for Care Delivery,” Health Affairs 2008; 27(5):1336-40.

4. Whellan D.J. et al. “The Benefits of Implementing a 

Heart Failure Disease Management Program,” Archives 

of Internal Medicine 2001; 61:2223-8.

FORUM — Translating research into quality health care for Veterans 2

Directors Letter: The Impact of Health Care Reform 

on VA Research

The VA health care system has many advantages for Veterans—quality care that equals or exceeds care in the civilian 

environment; a broad range of health care services; expertise 

in managing the health consequences of war; and an electronic 

health care record that improves access and continuity of care—

all provided at low cost to Veteran patients. 

However, the cost advantages to Veterans of obtaining health care from the VA 

may change in the next few years with the full implementation of the Patient 

Protection and Affordable Care Act of 2010 (i.e., health care reform). Increasing 

numbers of Veterans may seek care outside the VA health care system, and VA enrollment may decline. 

To continue to thrive in an increasingly competitive health care environment, the VA 

will need to emphasize quality health care and service even further. VA investigators 

will have an important role in helping to ensure the VA’s success. As investigators 

develop their individual research projects, it is imperative that system impact be considered. It is no longer sufficient to think only of the issues addressed in individual 

research projects. Rather, investigators must design their projects with a vision as to 

what additional research efforts may be required to improve the VA health care system. Innovative and inspired ideas will be needed. 

The Veterans Health Administration (VHA) has an appropriately proud history 

of care. Health services research will remain an important component of 

continuing success.

Seth Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service November 2011
VA Office of Research & Development, Health Services Research & Development Service November 2011

As Dr. Tuchschmidt affirmed, VHA is undertaking a major transformation aimed at 

creating a comprehensive array of interlinked, 

technologically advanced services centered on 

Veteran needs and preferences, with VHA’s 

infrastructure of primary care practices serving as the hub. Termed Patient Aligned Care 

Teams (PACT) and initiated in early 2010, 

this reorganization envisions both a higher 

quality of primary care and integration of specialized care into the primary care setting. To 

accomplish these goals, PACT aims to push 

VHA’s already advanced technologies and 

staff training capabilities to new levels. 

The magnitude of the PACT reorganization 

is staggering. Unlike non-VHA examples of 

primary care redesign, PACT engages an entire 

highly developed national system, with participants located in hundreds of local primary care 

practices, in over a hundred different medical 

systems, and in more than twenty administrative regions. PACT changes are occurring in 

sites that are reluctant or enthusiastic, urban 

or rural, academic or non-academic. These diverse participants must build PACT into established and sometimes rigid clinical, information 

system, financial, and human resource functions. In this context, VHA’s highly developed 

technological and human infrastructure is both 

a resource and a barrier to change. 

The Power of Disruptive 

Innovation

Changes of the magnitude being undertaken 

in VHA PACT have been termed disruptive innovations by Clayton Christensen and 

other organizational theorists.1 Provision 

of self-serve gasoline or ATM technology, 

for example, increased customer access, decreased costs, and drove major reorganization 

of the respective industries. Disruptions such 

as these occur when gaps between needs or 

preferences and offered services or products 

are too large to allow linear change. In health 

care, successful disruptive innovation would 

reduce costs, increase access, and place a 

greater share of health care tools and technology in the hands of patients. In accomplishing these goals, the innovation would also 

reduce morbidity and mortality disparities; 

focus medical workforce training and evaluation on competency and performance; make 

waste reduction a core cultural value; and 

clearly define and articulate rights and responsibilities of providers and patients.2

 PACT 

goals are thus in-line with disruptive innovation principles.

The motivations in VHA for undertaking disruptive innovation are compelling. First, VHA 

exists in order to be “the best care anywhere” 

for Veterans. As Dr. Tuchschmidt points out, 

we have yet to fully exploit the enormous 

VHA system capabilities, especially in terms 

of optimal responsiveness to Veteran needs 

and preferences. Another is flattening or slight 

deterioration in VHA primary care quality and 

satisfaction in recent years. Most care provided 

to most patients is either primary care or accessed through primary care—unsatisfactory 

primary care is a major threat to the system’s 

viability. Finally, the opportunities for improving VHA’s primary care models and the threats 

from not achieving it are occurring within a 

broader context of upcoming increases in both 

affordable insurance choices for Veterans and 

in federal budget constraints. 

Lessons from Prior 

Reorganizations

VHA’s ability to undertake disruptive innovation has already been demonstrated. Prior to 

1994, the VHA system was a natural experiment in providing access to specialty and 

hospital care, but not to primary care, because 

federal regulations prohibited the system 

from delivering primary care. This hospitalcentric care configuration was typical of 

safety net systems of the time. While specialty 

care was often high quality, access to general 

care, even for serious symptoms, was a major 

problem. The rapid bottom-up and top-down 

reorganization of the VHA system to correct these problems (beginning around 1990 

prior to legalization of VHA primary care and 

extending through the next decade) was both 

disruptive and highly productive.3, 4

PACT implementation shares some, but not 

all, features of the 1990’s reorganization. 

First, in the earlier reorganization, the large 

resources freed up by reducing preventable 

hospital admissions were available for building primary care. Currently, VHA rates of 

preventable hospitalization, such as for ambulatory care sensitive conditions, are low. 

Second, the models of the 1990s were preliminarily built and tested from the bottom up 

prior to full system implementation; PACT 

lacks this level of prior bottom up development. Third, the prior reorganization could 

achieve improvements even when it did not 

deliver full biopsychosocial care to vulnerable patients. For PACT, these patients may 

provide the largest remaining opportunities 

for improvement. Overcoming these challenges will require ongoing bottom-up local 

innovation, as well as top-down guidance, but 

can lead the way to better, more efficient, and 

more patient-centered health care models for 

the 21st century.

References 

1. Christensen C.M. “Disruptive Innovation: Can Health 

Care Learn from Other Industries? A Conversation 

with Clayton M. Christensen. Interview by Mark D. 

Smith.” Health Affairs 2007; 26(3):w288-95.

2. Brook R.H. “Disruption and Innovation in Health 

Care.” Journal of the American Medical Association, 

302(13):1465-6.

3. Yano E.M. et al. “The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health 

Administration’s Quality Transformation.” American 

Journal of Public Health 2007; 97(12):2151-9.

4. Rubenstein L.V. et al. “Evaluation of the VA’s Pilot 

Program in Institutional Reorganization Toward 

Primary and Ambulatory Care: Part II, A Study of Organizational Stresses and Dynamics.” Academic Medicine 

1996;71(7): 784-92.

Response to Commentary

VHA Transformation Challenges and Lessons

Lisa V. Rubenstein, M.D., M.S.P.H., F.A.C.P., VA HSRD Center of Excellence for the 

Study of Healthcare Provider Behavior, VA Greater Los Angeles and UCLA

FORUM — Translating research into quality health care for Veterans 3
It would be easy to conclude from this actual 

case that Mr. LW’s care is an isolated example 

of individual break-downs in communication. 

However, it is estimated that up to 20 percent 

of hospitalized patients like Mr. LW are readmitted for problems which could have been 

prevented had communication and coordination 

been more effective. Health services researchers, and others interested in quality and safety, 

have pinpointed the increasingly complex web 

of human/machine interactions that comprise 

health care delivery today. This web has expanded to the point where it makes less sense 

to blame single individuals and weed out “bad 

apples,” than it does to study the behavior of 

clinical “microsystems,” the smallest functional 

work unit in a hospital or clinic.1 Incorporating a 

systems approach extends our understanding of 

high reliability health care as a complex constellation of interrelated actions and activities rather 

than the addition or subtraction of a single individual’s performance. 

Recognizing the critical need for new care 

delivery models, the Institute of Medicine 

(IOM) in 2001 published a highly influential 

monograph entitled “Crossing the Quality Chasm: A New Health System for the 

21st Century.”2 In that document, the IOM

asserted that patient-centered care—i.e., 

care that establishes a continuous partnership among practitioners, patients, and their 

families to ensure high quality accessible services—was one of six indicators of quality. 

One response to the IOM report has been the 

rapid growth of the patient-centered medical 

home (PCMH), also known in the VA as the 

Patient Aligned Care Team (PACT). Rather 

than viewing a patient’s care as episodic and the 

responsibility of several to many unconnected 

individuals operating across time and space, the 

PACT views the care process as a continuum, 

from primary to specialty care, from hospital to 

home, and from the clinic to the community. 

The potential payoff from the PACT model is to 

provide patients with a seamless care experience 

whether it is in the hospital, clinic, or at home. 

Realizing this potential is a huge technological, 

logistical, and cultural challenge.

A Promising Approach

One promising research approach to transforming performance within and across settings is 

“relational coordination,” a term coined by Jody 

Gittell, a professor of management at Brandeis 

University. Relational coordination refers to, “a 

mutually reinforcing process of interaction between communication and relationships carried 

out for the purpose of task integration.” Gittell 

first applied the concept to studying Southwest 

Airlines and found that the company’s success 

lay primarily in its ability to encourage and support high levels of communication across multiple job classifications and management. Her 

latest work has been in health care where she has 

shown that organizations with high levels of relational coordination have better care outcomes 

and lower overall costs.3

Using the concept of relational coordination, 

we can return to Mr. LW’s discharge and ask 

whether improved relational coordination could 

have led to a different outcome. It is clear that 

the health professionals caring for Mr. LW had 

different information and ideas about the postdischarge plan. One improvement might have 

been to connect the health care professionals to 

one another sequentially, each briefly noting in 

VA’s Computerized Patient Record System what 

was discussed. Another approach might have 

been to start each conversation by asking Mr. 

LW who else had already talked with him about 

discharge and what the content of the discussion was. A third approach might have been to 

ask which family member he would prefer to be 

contacted with follow-up information and appointment reminders. Finally, asking Mr. LW to 

repeat back his understanding of the discharge 

plans (also known as a teach-back or a talk-back) 

might have uncovered discrepancies in the information he had been given and perhaps have prevented some of the confusion he experienced. 

Relational coordination is not about blaming 

individuals for poor performance, but rather 

encouraging us to recognize the immense complexity of creating coordinated experiences for 

the billion patient visits in the United States each 

year. Doing so requires everyone’s best collective efforts and creativity; to do less may put the 

future of patients like Mr. LW, and our current 

medical culture, at risk. 

 

References 

1. Nelson, E.C. et al., “Microsystems in Health Care: Part 

1. Learning from High-Performing Front-line Clinical 

Units,” Joint Commission Journal on Quality Improvement

2002; 28(9): p. 472-93.

2. Institute of Medicine 2001, Crossing the Quality Chasm: 

A New Health System for the 21st Century. Washington 

D.C.: National Academies Press.

3. Gittell, J.H. 2009, High Performance Healthcare: Using the 

Power of Relationships to Achieve Quality, Efficiency and Resilience, New York: McGraw-Hill.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service November 2011

Research Highlight

Relational Coordination: Harnessing the 

Transformative Power of Relationships to 

Improve VA Health Care

Richard M. Frankel, Ph.D., The Richard L. Roudebush VA HSR&D Center of Excellence on Implementing Evidence-Based Practice, Indianapolis, Indiana

Mr. LW, an 83-year-old WW II Veteran is about to be discharged from the VA hospital four 

days after presenting with a deep vein thrombosis (DVT), for which he has been treated with 

warfarin, an anticoagulant that requires close post-discharge monitoring. Past medical history 

includes a distant traumatic brain injury (TBI) that resulted in mild cognitive impairment. His 

discharge includes: a visit by a pharmacist who tells him to take his medication as prescribed 

in the hospital (10mg), and reminds him to have his blood levels checked next Thursday at 

the warfarin clinic. Ten minutes later, a nurse tells him that she will follow up with his daughter (although he lives with his wife who is his health care proxy). Finally, a second-year medical resident gives him a written discharge summary, and instructs him to break in half the 

10mg tablets he will receive. He reminds him to follow up at the warfarin clinic next Wednesday. Mr. LW is not seen again until four weeks later when he is again admitted, this time for a 

DVT in his left leg.
VA Office of Research & Development, Health Services Research & Development Service November 2011

FORUM — Translating research into quality health care for Veterans 5

Optimal care and outcomes for chronic 

medical illnesses often depend not only on 

the Veteran and medical provider but also 

on a caregiver who is responsible for much, 

if not most, of the Veteran’s daily care. 

Both members of the Veteran/caregiver 

unit, called a dyad, have needs that must be 

addressed. Without a foundation of family 

caregivers to provide long-term care and 

support, the VA would not be able to meet 

the care needs of these Veterans. To underscore the critical role of informal caregivers 

for Veterans, the VA has enacted several 

clinical and research initiatives. The research 

initiatives call for interventions that aim to 

improve the health of the Veteran and caregiver who are struggling with psychological 

and physical ailments, such as Alzheimer’s 

disease and other dementias.

Importance of Interventions for 

both the Veteran and Caregiver

The negative impacts of dementia can affect many facets of family life, including 

physical health, emotional health, social 

relationships, and legal and financial issues.1

Although not all caregivers experience these 

negative effects, most exhibit declines in 

their emotional and physical health, are 

unable to maintain work and family responsibilities, and experience social isolation. 

These “role and intra-psychic strains” can 

be attributed to burdens associated with the 

Veteran’s symptoms and care. Caregivers 

may not perceive a relationship between 

these consequences and the Veteran’s 

symptoms and care, though negative impacts on general well-being may be evident. 

Examples of such negative outcomes are 

increased depression, deterioration in health 

status, increased health care service use, and 

increased risk for illness and death.

Caregivers are not well-positioned to provide 

optimal care for a Veteran if their well-being is 

impacted by a large number of these negative effects or by any number of them to a debilitating 

degree. In fact, high levels of caregiver burden 

have been associated with hospitalization and 

death among community-dwelling elders. Accessing the variety of services necessary to address 

the care needs of a Veteran with dementia as 

well as his or her own needs is particularly challenging, but important, for a family caregiver. 

Interventions targeting both members of the care 

dyad are the ideal approach to address well-being 

for both the Veteran and his or her caregiver. 

Dyadic interventions that address the negative 

effects of caregiving through greater access to 

support services are imperative to help caregivers have improved mental health, provide quality 

care to Veterans, and continue to provide care 

for Veterans in the community rather than in 

high-cost institutions and facilities. 

Partners in Dementia Care 

Intervention

The Partners in Dementia Care (PDC), carecoordination intervention is an innovative, 

telephone-based coaching program originating 

from the Chronic Care Model.2 The goal of PDC 

is to address the unmet care needs of Veterans 

with dementia and their family caregivers across all 

dementia stages. PDC provides information and 

assistance to facilitate access to formal services, 

mobilizes family members and friends, and offers 

emotional support and coaching. PDC was implemented through formal partnerships between a 

dementia care coordinator at a VA medical center 

and a care consultant from a local Alzheimer’s Association chapter. 

A total of 508 Veterans age 60 and over with Alzheimer’s disease and other dementias and 486 of 

their informal family caregivers participated in the 

PDC intervention. Preliminary analysis of data 

collected at enrollment for the intervention, and 

six and 12 months after enrollment, has focused 

on psychosocial well-being outcomes for both 

Veterans and their caregivers. Overall, Veterans 

and their caregivers have significantly improved 

across all domains measured: most important 

subjective stressor; factors affecting stress level; 

role and intra-psychic strain; and general wellbeing. Most of these benefits were observed 

after 6 months in PDC and maintained at the 

12-month follow-up. Of note, after 6 months 

in PDC, Veterans exhibited a 25 percent reduction in scores on the measure of embarrassment about memory problems, and caregivers 

experienced a 15 percent decrease in depression 

symptoms. Furthermore, caregivers in the intervention group had an average of five fewer 

unmet dementia-related needs than caregivers in 

the comparison group after six months. 

Meeting the needs of informal family caregivers providing care for Veterans with dementia 

represents an important challenge for the VA. 

For the coming years, the VA has prioritized the 

development of larger-scale feasibility studies 

and broader implementation of caregiver support services. Effective dyadic interventions that 

treat both the Veteran and his/her caregiver can 

overcome barriers to bridge the gap between 

caregivers and supportive services available to 

them. Preliminary findings suggest that PDC 

is effective at reducing unmet dementia-related 

needs and improving outcomes for caregivers 

and Veterans with Alzheimer’s disease and other 

dementias. Access to and utilization of these 

services are essential to minimize the negative 

effects of caregiving, ensure well-being of both 

members of the dyad, and promote continued 

care at home.

References

1. Bass, D.M, et al. “Negative Caregiving Effects Among 

Caregivers of Veterans with Dementia,” American Journal of Geriatric Psychiatry (in press).

2. Judge, K.S. et al. “Partners in Dementia Care: A 

Care Coordination Intervention for Individuals with 

Dementia and Their Family Caregivers,” Gerontologist

2011; 51(2): 261-72.

Research Highlight

The Critical Role of Caregivers Providing 

Care to Veterans with Dementia

Whitney L. Mills, Ph.D., and Mark E. Kunik, M.D., M.P.H., 

HSR&D’s Houston Center for Quality of Care and Utilization Studies, Houston, Texas 
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service November 2011

Effective care models for chronic illnesses 

such as diabetes must include sustained selfmanagement support for patients. Improved 

clinical outcomes in diabetes depend on 

patients’ self-management behaviors, such 

as taking prescribed medications, following 

diet and exercise regimens, self-monitoring, 

and coping emotionally with the rigors of 

living with diabetes. Yet many patients face 

multiple barriers to effective diabetes selfmanagement. These barriers include lack of 

sufficient knowledge of diabetes or its treatment; lack of self-confidence, motivation, or 

skills to manage diabetes well; lack of financial resources for medications and supplies; 

and other comorbidities and physical limitations. In addition, many adults with diabetes 

lack effective support from their families and 

friends for their diabetes self-management. 

Even with frequent face-to-face office visits, 

they need more sustained support.

Promising Self-Management 

Models

To address these barriers, care models must 

include cost-effective ways to extend self-management support beyond clinic visits with health 

care providers. More frequent telephone contact 

with a nurse care manager between medical 

visits is effective in improving clinical outcomes 

among patients with diabetes, but these programs are labor- and resource-intensive. Many 

health care systems lack the resources to implement intensive nurse-led case management 

programs. Peer support among patients with 

the same chronic health problem may be a particularly effective strategy to complement health 

professional-led outreach programs. Interventions that mobilize and build on peer support 

are an especially promising way to improve selfmanagement support for patients with diabetes. 

The most effective models combine peer 

support with a more structured program 

of education and assistance. To date, most 

peer support programs have focused on 

clinic-based group visits, peer-led training sessions, and support groups. Strong evidence 

supports the benefits of face-to-face group 

self-management programs that combine discussion of key self-management issues, peer 

exchange and support, and behaviorally-based 

approaches to strengthen diabetes care selfefficacy, problem-solving skills, and efforts to 

set and follow through on specific behavioral 

goals. Peers serve as excellent role models for 

participants. Moreover, peer leaders can more 

easily hold group sessions outside of normal 

working hours than can health care professionals. Peers can also maintain contact with 

program graduates, thereby providing them 

with continued self-management support.

Many peer-led programs follow a model that 

was first developed and evaluated by Lorig, 

et al. at Stanford University—the Chronic 

Disease Self-Management Program (CDSMP), 

or Tomando Control de Su Salud, the Spanish version. The CDSMP is a program for patients 

with chronic conditions including diabetes, 

and it involves weekly 2.5-hour sessions over 

a six week period. Program content includes 

individualized exercises and cognitive symptom management programs; methods for 

managing negative emotions such as anger, 

fear, depression, and frustration; and discussion of topics such as medications, diet, health 

care providers, and fatigue. Leaders teach the 

courses in an interactive manner designed 

to enhance participants’ confidence in their 

abilities to execute specific self-care tasks (selfefficacy) and to promote discussion among 

participants and with peer leaders.

More recently, several peer-support care models tested in the VA resulted in significantly 

improved glycemic control when compared to 

usual nurse care management. These models 

supplemented periodic face-to-face sessions 

with peer mentor-led telephone support, or with 

telephone calls between paired patients facing 

similar diabetes self-management challenges.1

Such programs can either have peer mentors 

or coaches, with a volunteer or paid diabetes 

patient providing assistance to other diabetic 

patients, or can be bi-directional peer-support 

models. Although one of the key mechanisms 

by which peer support may work is to activate 

patients by having them help others, few models 

using this approach have been evaluated.

Internet-based support groups and other 

uses of the Internet to mobilize peer support have grown significantly over the past 

decade. Internet-based interventions are 

promising because of their low cost and 

ease of dissemination, and they may provide 

alternatives to more labor- and resourceintensive clinic programs. Results of several 

recent randomized controlled trials suggest 

that adding peer-support components (also 

referred to as “e-community” components) 

to Internet-based interventions can increase 

their effectiveness.2, 3 An example of a successful program is the Internet discussion 

boards established for patients and their family members by the Joslin Diabetes Center. 

Peer-support care models appear to provide 

a low-cost, flexible means to supplement 

formal health care support. When carefully 

designed and implemented, peer-support 

interventions can be a powerful way to help 

patients with chronic diseases live more successfully with their conditions.

References

1. Heisler, M. et al. “Diabetes Control With Reciprocal 

Peer Support Versus Nurse Care Management: A 

Randomized Trial,” Annals of Internal Medicine 2010; 

153:507-15. 

2. Tate, D.F. et al. “Effects of Internet Behavioral Counseling on Weight Loss in Adults at Risk for Type 2 

Diabetes: A Randomized Trial,” Journal American Medical Association 2003; 289:1833–6. 

3. Lorig, K.R. et al. “Internet-based Chronic Disease 

Self-Management: A Randomized Trial,” Medical Care

2006; 44:964–71.

Research Highlight

Peer-Support Care Models for Patients 

With Diabetes

Michele Heisler, M.D., M.P.A., HSR&D Center for Clinical Practice Management 

Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
VA Office of Research & Development, Health Services Research & Development Service November 2011

FORUM — Translating research into quality health care for Veterans 7

Telehealth is use of communication technology to deliver health services where the care 

recipient and care provider are separated by 

distance. Altering the communication channel 

between providers and patients can overcome 

geographic barriers and improve access to 

health services. A common use of telehealth 

technologies is to deliver care from a distance 

that would normally be provided face-to face. 

Thus, rather than traveling to the medical 

center, a Veteran can be seen by a specialist 

via clinical video telehealth at a clinic location 

closer to home, while still receiving the same 

care that would be provided in a face-to-face 

encounter. The VHA Office of Telehealth 

Services supports three kinds of technologyfacilitated care: 1) clinical video telehealth 

(typically physician delivered clinic visits provided using interactive video to distant clinics); 

2) store and forward (generating and uploading image data for viewing by specialists); and 

3) home telehealth, employing technologyfacilitated monitoring along with care management in Veterans’ homes. Technologies used 

in home telehealth include videophones, messaging devices, interactive voice response, and 

devices that record and transmit vital sign data 

only. The remainder of this article will focus 

on home telehealth.

A New Model of Care

Home telehealth enables a new model of care 

that was not previously available or efficient 

for patients or providers. That is, while patients 

theoretically could telephone a nurse or physician each day with vital sign information, that 

approach is impractical when large numbers 

of patients need monitoring. Home telehealth 

technologies can be incorporated into a variety 

of care management programs. A number of 

studies have evaluated the effectiveness of home 

telehealth in chronic disease management, and 

results have been mixed. These mixed findings 

likely reflect variation in program design and 

implementation across studies. Home telehealth 

programs are often bundled interventions that 

may also include home visits, clinic visits, and 

other modes of communication such as email, 

telephone, and use of patient portals, in addition 

to patient data transmission. Interventions vary 

in terms of interaction between a patient and 

care manager via video/telephone, the specific 

content delivered via a messaging device, or 

whether vital sign data only are transmitted. 

The type of intervention that care managers 

deliver in response to patient data presents 

an important source of variability in currently 

published studies. Thus, it can be difficult to 

ascertain the mechanism of effect in successful programs, or what is missing in ineffective 

programs. A systematic review of interventions 

used in multi-component outpatient heart 

failure management programs found that the 

number of individual interventions across studies ranged from one to seven. Although the 

most commonly used interventions were patient 

education, symptom monitoring by study staff, 

symptom monitoring by patients, and medication adherence strategies, these were not used in 

all studies.1 Although not all of the studies in the 

review included a telehealth component, similar 

variation is found in reviews of home telehealth 

studies. Variation also exists in workload (number of patients assigned to a care manager), type 

and acuity of patient needs, and the design of 

the workflow of reviewing and responding to 

patient-reported variances. 

Further Research Needed

Currently published literature describing trials of home telehealth programs does not 

provide sufficient detail on individual program components to enable identification of 

the appropriate number and combination of 

interventions needed to improve outcomes 

or translate findings to practice. Researchers 

identify eight domains to describe chronic 

disease management programs: 1) risk status, 

demographics, and comorbidities of the sample; 2) the primary target(s) of the program 

(patients, informal caregivers, clinicians, and/

or systems of care); 3) individual components 

of the intervention, e.g., patient education, 

medication management, post-discharge care; 

4) who is involved in intervention delivery, 

both clinical and non-clinical staff; 5) method 

of communication, such as face to face, audiovisual, and/or electronic or telecommunication technology; 6) frequency of provision 

of the intervention delivery components, 

duration of the intervention, and the mix of 

program components for each intervention 

target; 7) location(s) where each intervention 

component is delivered, including the hospital, clinic, patient home, or community-based; 

and 8) outcomes, including clinical, resource, 

and patient-centered measures, such as adherence.2

 Consistent reporting of program 

components and interventions is needed to 

determine what works.

Finally, organizational characteristics of successful telehealth programs are consistent with 

implementation of other types of health services 

interventions. These characteristics include senior management support, formally established 

staff responsibilities for the program, program 

evaluation with feedback to staff, flexibility, 

creativity in developing and implementing new 

programs, and a business plan that supports the 

mission of the organization.3

References

1. Wakefield, B.J. et al. “Heart Failure Care Management Programs: A Review of Study Interventions and 

Meta-Analysis of Outcomes,” Journal of Cardiovascular 

Nursing (in press).

2. Krumholz, H.M. et al. “A Taxonomy for Disease 

Management: A Scientific Statement from the 

American Heart Association Disease Management 

Taxonomy Writing Group,” Circulation 2006; 114(13): 

1432-45.

3. Whitten, P. et al. “Keys to a Successful and Sustainable Telemedicine Program,” International Journal of 

Technology Assessment in Health Care 2010; 26(2):211-6.

Research Highlight

Home Telehealth: Looking Under 

the Hood

Bonnie J. Wakefield, Ph.D., R.N., Center for Comprehensive Access and Delivery 

Research & Evaluation, Iowa City VA Medical Center
Peter L. Almenoff, M.D., FCCP, 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Director, VA 

Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

FORUM

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