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Some high-risk, high-use, high-cost patients within the VISN (Veterans Integrated Service Network) 8 Veteran Affairs (VA) medical system are using technology to better control their disease from home. With a dialogue box, or "buddy system," they answer a set of questions each day specific to their disease or multiple disease state to help them manage symptoms and learn better self-care techniques.
For example, overweight, diabetic patients might be asked if they weighed that day. If they push the "yes" button, the box would ask them to indicate their weight range. The collected data go into a web-based site where a care coordinator at a medical center can access and evaluate the information. The computer tags the answers with a green, yellow, or red flag. Red indicates a potentially serious problem, prompting the care coordinator to contact the patient; and if action is warranted, the patient’s health care provider is notified.
More than 90% of the patients using the dialogue box feel more educated and knowledgeable about their disease state than they did prior to the use of this care coordination and technology approach, says Marlis Meyer, MA, program director for VISN 8 Community Care Coordination Services in Lake City, FL.
This and four other types of technology were up and running by June 2000 on a trial basis. Its purpose is to coordinate the care of patients with complex health problems, assess their condition at home, and intervene early in medical problems. "The technology gives us feedback on a regular basis in a way that we did not have before. By intervening earlier, we can make a difference in the quality of the patients’ lives and in the use of medical resources," says Meyer.
The outcomes based on results from patients who have been in the system one year have been impressive. There has been a great improvement in patients’ functional ability, which helps them stay independent longer. Patients with diabetes have reduced their hemoglobin A1C level by 1.26 units, which is a significant reduction for this population and improves their medical condition. Blood pressure levels have also improved. More than 90% of the patients found the technology easy to use and about that same amount were highly satisfied.
The care coordination has also reduced the use of medical center resources. Consider the following outcomes:
"These patients developed a better understanding of what medications they are taking and why. Therefore, they are better able to manage their medication regimen," reports Meyer.
The model combines care coordination with various technologies aimed at specific high-cost patients who generally cost the system $25,000 or more in prior years. It was first developed in 1998; and in 1999, requests for proposals within VISN 8 were issued, which include VA facilities in South Georgia, Florida, Puerto Rico, and the Virgin Islands.
Eight demonstration projects were selected that would best test care coordination and care management principles and the use of new technologies to assist in monitoring patients in their home. "[We had not seen] the combination of what we were doing we had not seen anywhere else — especially in the magnitude that we were doing it," says Meyer. They wanted to test the principles, see what would work best, and establish best practices, she explains.
In the beginning, care coordinators would review computer generated listings of high-cost patients and determine which patients matched their selection criteria. They would then contact the primary care provider and suggest that the patient become part of the program. If the physician agreed, then the patient was invited to participate. Now, providers refer and patients self-refer; if they meet the criteria, the patients become part of the program. Currently, there are close to 1,300 patients involved.
"We never believed that one size would fit all and felt very strongly that we needed to match the technology to the medical needs as well as the patient’s needs," says Meyer. To help meet the patients’ needs, the technology is simple and easy to use. Simplicity also makes for fewer difficulties once the technology is placed in the home, and there is less frustration as a result, she says.
One piece of equipment, a Polaroid-style camera, is used in the diabetes limb wound care program. Typically, diabetic patients with open wounds that aren’t healing properly eventually must have the limb amputated. Also, they must frequently travel to the clinic to have their wound checked by their provider. Now they are taught to take photos of the wound and send them to their care coordinator (a wound care specialist) on a weekly basis in preaddressed envelopes via mail. If the wound is not healing properly, the care coordinator contacts the patient to see if the treatment protocol needs to be changed.
"We have reduced the time it takes for the wound to heal. Traditionally, it took from three to six months on average; now it takes from four to six weeks, and that is a big difference," says Meyer.
One of the reasons for the significant difference in healing time is that the patients begin to understand what the wounds look like when they are healing after discussing the pictures with their care coordinator. "They realize the wound doesn’t look right sooner than they did before," she says.
A videophone is used to help educate patients with chronic disease in order to improve their self-care skills. For example, patients with chronic obstructive pulmonary disease are shown how to correctly use an inhaler if the care coordinator sees that the patient is using it incorrectly when demonstrated on the videophone. "With the videophone, care coordinators are trying to train and teach people how to use whatever device they need to use in order to follow their treatment plan," says Meyer.
This piece of technology also is used with the mental health population. While medical feedback on their condition is not important to the care coordinator, their emotional responses often are. "With the mental health group, seeing a patient’s facial expressions is beneficial," says Meyer.
A video monitoring system has different types of medical monitoring capabilities, such as measuring blood pressures, as well as viewing capabilities. It is used less than the other instruments because it costs the most. However, the system is often placed in assisted-living facilities where several patients can make use of the system to maximize its use. With the visualization capabilities, care coordinators can make sure that patients are doing the monitoring correctly.
For example, if a patient’s blood pressure readings don’t look right, the care coordinator can watch to determine if he or she is putting the cuff on correctly or making another mistake. This technology has reduced hospitalization for this group of patients in an assisted-living setting by 67%.
Computers are used to connect mental health patients with each other as well as their care coordinator. Supervised chat rooms on the Internet with each patient connected by a camera and speaker so he or she can hear and see each other provide the connection. E-mail keeps care coordinators connected to the patients and up to date on their emotional state.
This technology works well for patients suffering from post-traumatic stress syndrome because they prefer not to be in closed settings with other people and therefore find it difficult to come to the clinic for treatment, says Meyer. Consequently, the patient’s condition can escalate into critical mode, which could require hospitalization.
The e-mail contact helps those patients avoid acute episodes. For example, a patient was given new medications during a routine visit to the psychiatrist and started taking them when he got home. They soon made him agitated, so he e-mailed his care coordinator, who immediately contacted him. Once the issues were discussed, the care coordinator contacted the psychiatrist, who immediately changed the prescription and mailed it out to the patient.
For educational purposes, a series of mental illness informational web sites have been created for the mental health group.
As new technology is introduced, VISN 8 Community Care Coordination Services will explore these capabilities to continue improving patient care and help care coordinators work more efficiently as well as maximize use of existing resources. The program never was designed to replace the existing system or duplicate services but rather fill a gap. Care coordinators are not providers; they just make that patient to provider connection when needed without the clinic visit or hospitalization. Care coordinators are nurse practitioners, RNs, or social workers. Frequently, a nurse practitioner and social worker will work in tandem with patients to provide social as well as medical or mental health needs, says Meyer.
While this method of providing health care by combining technology with the oversight of care coordinators may not be appropriate for the entire health care system, it does work for a specific group of patients. "We believe there is a real role in health care for this way of managing patients. It keeps patients in the home, doesn’t require as much structure or overhead as traditional care, is safer, and improves the patient’s functional ability," says Meyer.
For more information about the VISN 8 Community Care Coordination Services, contact: