In-home monitoring helps at-risk veterans manage their health

Program reduces home care, ED visits, and hospitalization

Remote monitoring by trained telehealth care coordinators has improved the outcomes and saved costs for high-risk chronically ill patients in the VA Connecticut Healthcare System.

The telehealth program is an adjunct to the VA Connecticut's case management program in which the same nurses and social worker case managers follow the patients through the continuum, from the hospital to the community and back again.

"Telehealth is a tool that we use to augment primary, specialty, and mental health care services. Home telehealth allows for close monitoring and timely intervention based on data sent by patients from their homes. It has reduced the need to return to clinics for routine follow-up monitoring, has reduced the number of skilled home care visits, and has reduced emergency department visits and hospitalizations," says Donna Vogel, MSN, CCM, program director, care coordination and case management.

Patients who will benefit from telehealth

The telehealth program targets patients who are most at risk for decline, including those who may live alone, lack caregiver support, or those who are having trouble with self management and want to be more involved with their own health care.

Patients who are appropriate for telehealth may be failing at home, have out-of-control blood sugar or blood pressure, or other conditions that put them at high risk for emergency department visits or hospitalization.

"Not all patients would qualify for telehealth and some want nothing to do with having a device in their home," Vogel says.

Patients eligible for home health must have a home with a working telephone line.

The technology used at VA Connecticut's telehealth is user-friendly. Some of the devices allow for peripherals to plug into the unit to collect data to monitor blood pressure, pulse, weight, temperature, pulse oximetry, and finger-stick glucose.

"Some technology delivers patient education and allows the case managers to schedule reminders for a patient to take his or her medication or to perform a measurement," Vogel says.

Videophone technology helps veterans, nurses

Veterans who are home bound and have few interactions with the outside world can use videophone technology to communicate face to face with the RN telehealth care coordinator.

The videophone technology has allowed the care coordinators to identify patients whose condition has declined and to arrange for them to come into the hospital or clinic for care, Vogel adds.

The technology also can be used to monitor spinal cord injury patients for decubitus ulcers and other problems.

To identify patients eligible for the program, the case management department mines its data for high-cost, high-utilization patients with chronic diseases. Clients can be referred by primary care providers, specialist providers, or other clinicians.

Because it has received so much national attention, patients read about the VA and its telehealth programs and feel they could benefit from more frequent monitoring, Vogel says.

When someone is referred to the program, the case manager conducts an assessment of their health care needs. When the care coordination office gets a referral, a case manager conducts an assessment to determine what services the VA can offer and that the patient can benefit from receiving.

If the assessment shows that monitoring the patient's health more frequently can keep him or her out of the hospital and that the patient and/or caregiver are willing to use home health technology, the case manager refers the case to the telehealth coordinator.

The telehealth coordinator identifies what technology is most appropriate for each patient and configures the devices to make sure that the right dialogues are set up.

The telehealth coordinators enroll the eligible veterans in the program, get their consent, and educate the patient and caregiver on the equipment and how to use it. The education may take place on the hospital unit, at the case management office, or in the primary care clinic.

"We get the equipment configured, educate the patient on how to use it, and the patient can take it home with them that day," Vogel says.

The patients have instructions on how to install the equipment but if they have difficulty, the VA calls in a durable medical equipment contractor to help.

The telehealth care coordinators are all registered nurses who have completed an intensive web-based training program offered by the Office of Care Coordination Services in the VA Central office. They must complete competencies in telehealth coordination and undergo annual training.

They collaborate with the patient's interdisciplinary team to monitor the patient's condition and make sure his or her needs are being met.

If a patient who is being telemonitored is hospitalized and needs additional case management services such as a skilled nursing visit to the home for wound care or home infusion services, the telehealth care coordinator hands the patient off to the case management department to avoid duplication of services.

Back and forth communication

Each day, the patients use the telehealth unit to check their vital signs and send data on weight, blood pressure, blood oxygen, temperature, or other data needed to a secure web site monitored by the telehealth care coordinator.

If the data indicate that the patient's condition has worsened or his or her health is at risk, the telehealth care coordinator will call the patient and confirm that the data sent were obtained correctly and that any out-of-range responses to disease-specific survey questions were entered correctly. Depending on the data received, the telehealth coordinator will provide patient education, discuss the findings with the patient's primary care clinician, or recommend that he or she go to the emergency room or be seen at the clinic.

If the patient fails to enter the data, the telehealth care coordinator calls to remind him or her to send data and to make sure everything is OK.

The telehealth care coordinators monitor the site every business day to identify potential problems in real-time. They remind patients that data they send from home isn't viewed on weekends and holidays and reinforce the importance of self-management and knowing when it's critical for them to seek urgent or emergent care.

"We dedicated staff to watching the telehealth web site so they can see the data when they come in. When the patients' case managers were responsible for watching their own patients who were on telehealth, there was frequently a delay in viewing and intervening on data sent from the patient's home because the case manager was often busy seeing patients in the clinic or on the inpatient unit," Vogel says.

Where CMs come in

At VA Connecticut, part of the VA New England Healthcare System, case managers are specially trained RNs and social workers assigned to care lines as well as to a panel of providers where the patient receives primary care. The providers may be a physician, an advanced practice registered nurse, or a physician assistant in the VA health system.

Services provided by the case managers include assessment, care planning and implementation, education, referral, coordination, advocacy, monitoring, and periodic reassessment to meet an individual's health care needs.

The case managers see the patients in the clinic, hospital, or may need to follow them in a skilled nursing facility if the patient requires skilled nursing care. They may need to coordinate with hospice care or work with any other VA and non-VA providers to ensure seamless coordination of care.

"The constants in the patients' health care continuum are the nurses and the social worker case managers. Wherever that patient is, the care is coordinated by the same RN/social worker case management team to promote continuity. It's an efficient way to coordinate care and the patient always knows who is handling his or her care," Vogel says.

If a patient needs specialized case management, such as the telehealth monitoring, surgery, specialty care, or inpatient services, he or she may be handed off to another case manager. The primary case manager will be kept informed about the patient's condition and changes in the patient's health care needs. After the specialty or episodic case management needs are met, the specialty case manager will hand back the patient to the primary case manager.

The care of veterans who are receiving intensive mental health treatment may be coordinated by a mental health case manager.

"We may hand off our patients when there are specialized case managers and services that can help meet the patient's needs with the understanding that the patient will be referred back to the primary case manager once he or she no longer needs or is benefiting from specialized case management services. We don't want to duplicate services and we want to get the best trained case managers for that specific event or care need," Vogel says.

Case managers are assigned to clients who are at high risk for utilization including those who have been hospitalized for a crisis episode or those who have recent or repeated hospitalizations, as well as those with chronic illnesses. Chronic conditions include diabetes, congestive heart failure, chronic obstructive pulmonary disorder, chronic pain, spinal cord injury, hypertension, and end-stage renal disease.

VA Connecticut has an elaborate computerized patient record system that allows for the case manager to access information at whatever point the patient is in the continuum. When there is a change in patient status or an event that requires case management, it's easy for the case manager to access the information.