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We assessed a home monitoring/care coordination programme for veterans with diabetes. Patients enrolled in the programme (n = 387) were followed for four years and compared with a retrospective control group (n = 387). Each patient in the intervention group used a messaging device in the home that was connected by a conventional telephone line. Care coordinators monitored the answers from the devices daily so that early interventions could be made. There were significantly more deaths in the control group (n = 102, 26%) compared with the intervention group (n = 75, 19%). There was longer survival for the intervention group versus the control group (mean survival time 1348 vs 1278 days; P = 0.015). A multivariate analyses indicated that the telemonitoring programme was associated with reduced 4-year all-cause mortality (hazard ratio = 0.7, 95% CI 0.5-0.9, P = 0.013). The results suggest that daily management of patients with diabetes through home monitoring by a registered nurse reduces mortality.

Purpose: The study purpose was to implement a stroke-specific, care coordination home telehealth (CCHT) programme for US veterans with stroke and their family caregivers., Methods: In a non-randomized open trial using a mixed methods design, we tested the utility of a stroke-specific, home telehealth programme with 18 veterans and 14 caregivers for 14 days. Programme questions assessed physical impairment, depressive symptoms, and fall prevalence among veterans, and burden level among family caregivers. Nine veterans and six caregivers completed post-programme interviews exploring their experiences with telehealth., Results: During the 14-day trial, 55% of the veterans screened positive for depression at least once, 36% of the caregivers had clinically significant burden, half of the veterans and caregivers reported post-stroke concerns, and 90% believed post-stroke contact from a care coordinator would have been helpful. In the interviews, seven veterans indicated they had fallen or almost fallen post-stroke. Themes centred on tailoring CCHT to individual needs, coordinating with support services, identifying safety issues, and providing information about stroke prevention., Conclusions: Home telehealth offers innovative ways to target post-stroke rehabilitation programmes to the needs and concerns of patients and their caregivers, and should include regular real-time contact between stroke patients and their healthcare providers.

Chronic illnesses account for approximately 75% of all healthcare costs in the United States today, resulting in functional limitations and loss of independence, as well as increased medical expenditures. The elderly population is at a higher risk for developing chronic conditions, increasing their risk for disabilities. Given the rapid growth of the aging population, and the chronic illnesses, disabilities, and loss of functional independence endemic to elders, novel methods of rehabilitation and care management are urgently needed. Telehealth models that combine care coordination with communications technology offer a means for managing chronic illnesses, thereby decreasing healthcare costs. We examined the effects of a Veterans Administration (VA) telerehabilitation program (Low Activities of Daily Living [ADL] Monitoring Program-LAMP) on healthcare costs. LAMP is based on a rehabilitative model of care. LAMP patients received adaptive equipment and environmental modifications, which focused on self-care and safety within the home. LAMP Care Coordinators remotely monitored their patient's vital signs and provided education and self-management strategies for decreasing the effects of chronic illnesses and functional decline. The matched comparison group (MCG) received standard VA care. Healthcare costs 12 months preenrollment and 12 months post-enrollment were examined through a difference-in-differences multivariable model. Using actual costs totaled for these analyses, no significant differences were detected in post-enrollment costs between LAMP and the MCG. For LAMP patients, the provision of adaptive equipment and environmental modifications, plus intensive in-home monitoring of patients, led to increases in clinic visits post-intervention with decreases in hospital and nursing home stays.

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

By its very nature, telehealth relies on technology. Throughout history, as new technologies emerged and afforded people the ability to send information across distances, it was not long before this capability was applied to the most basic need of all: maintaining health. While much of the early work in telehealth was driven by technology (e.g., making opportunistic use of the systems and devices that were available at the time), recent trends are beginning to push the demand for and the development of new technologies specific to the individual needs of telehealth applications. The future of telehealth will benefit greatly from this technology innovation, in particular, in areas such as home telehealth and remote monitoring, e-health and patient portal applications, personal health records, interactive Internet technologies, and robotics. Telehealth, while not a panacea for all of the challenges facing modern healthcare systems, has a substantial and ever-expanding potential to revolutionize the ways in which people receive medical care while offering the possibility to contain costs, manage chronic diseases, and prevent secondary complications. By demanding innovative solutions and speaking out in support of the field, the telehealth community can and should be leading the charge for greater attention to human factors in technology development, interoperable medical records, staff training and competencies, standards and guidelines, and support for expanded telehealth coverage at the national, state, and local levels.

Although telemental healthcare has been available for many years, is generally accepted as effective, and has steadily growing numbers of consumers and providers, more and better research in this area needs to be done in order to convince insurers, policymakers, and funding agencies that mental healthcare delivered from a distance is at least as good as that delivered face-to-face. Because there is a wide spectrum of potential mental health disorders that might be encountered, there are significant gaps in telemental health research that need to be addressed before payment for services or funding for large-scale studies of this application can be expected. This white paper will review the current state of telemental health research and will offer suggestions for future directions necessary for telemental research to take in order to firmly establish its effectiveness.

The number of home telehealth programs implemented both domestically and abroad and the number of peer-reviewed publications detailing positive outcomes for chronic disease management, preventive care, and self-management have increased over the past 5 years. The most dramatic growth has been in populations with diabetes, chronic obstructive pulmonary disease, and congestive heart failure. A review of home telehealth developments, current status, opportunities, and challenges provides a foundation for understanding why we need to mainstream what we already know works.

Properly designed randomized controlled trials (RCTs) are the gold standard to use when examining the effectiveness of telehealth interventions on clinical outcomes. Some published telehealth studies have employed well-designed RCTs. However, such methods are not always feasible and practical in particular settings. This white paper addresses not only the need for properly designed RCTs, but also offers alternative research designs, such as quasi-experimental designs, and statistical techniques that can be employed to rigorously assess the effectiveness of telehealth studies. This paper further offers design and measurement recommendations aimed at and relevant to administrative decision-makers, policymakers, and practicing clinicians.

Organizations that provide training for their employees are interested in translating training expenditures into benefits. Even though there are several common methodologies that are used to train employees, finding the right methodology to stimulate learning and develop a competent workforce while reducing fiscal burdens can be challenging. One such method that continues to grow in popularity is e-learning. For the purpose of this discussion, e-learning refers to Internet-based or online training. The Veterans Health Administration's (VHA's) Office of Care Coordination (OCC) was established in July 2003 to oversee the national implementation of its telehealth initiatives. As part of this implementation, the OCC created a national center, the Sunshine Training Center, to work directly with the VHA's Employees Education System (EES) to develop a home telehealth Web-based curriculum. After 3 years, the Sunshine Training Center and EES initiated an Impact Evaluation Process. Over five hundred staff completed the online impact survey. This number represented a 74% response rate. Staff responded overwhelmingly in the positive on the benefits of e-learning for building telehealth skills.

The cancer care dialogues model emphasizes daily telehealth interactions between patients and a care coordinator (a registered nurse serving as a liaison to the oncologist) to assist patients in the management of common chemotherapy-related symptoms at home. We examined the impact of the dialogues on age-related differences in health-related quality of life (HRQOL) among newly diagnosed cancer patients receiving chemotherapy. We assessed HRQOL among 34 patients, including 15 older adults (65 years or older) and 19 younger adults who were followed for 6 months. Older patients consistently reported better HRQOL scores over the treatment period. In multivariate analysis, older patients reported 10.35 points higher in HRQOL (P = .007). In addition, patients who reported no nervousness while undergoing chemotherapy had an 8.60-point increase in HRQOL scores (P = .012). The dialogues model can make important improvement in symptom management and HRQOL, especially in older adults receiving chemotherapy. Older and younger adults with cancer may benefit equally in cancer treatment in a setting with appropriately managed symptoms. The dialogues model offers promising potential for promoting nurses' better understanding of both the patient needs as the patient receives treatment and innovative technologies in patient management.

The 2001 Institute of Medicine report indicted that the US healthcare system fails to provide high-quality care, and offered 6 aims of improvement that would redesign the delivery of care for the 21st century. This study compared the use of Department of Veterans Affairs (VA) inpatient and outpatient services of cancer patients enrolled in a Cancer Care Coordination/Home-Telehealth (CCHT) program that involved remote management of symptoms (eg, emotional distress, pain) via home-telehealth technologies to a control group of cancer patients receiving standard VA care. Using a matched case-control design, 2 control patients per case were selected, matched by tumor type and cancer stage. There were 43 Cancer CCHT patients and 82 control group patients. Based on a medical record review of each patient, the total number of cancer-related services (defined as visits that were expected given the patients' cancer diagnosis and treatment protocol) and preventable services (defined as visits needed outside of those expected given the cancer diagnosis and planned treatment) were calculated over a 6-month period. Poisson multivariate regression models were used to estimate the adjusted relative risks (RRs) for the effects of the Cancer CCHT program on the service use outcomes. Cancer CCHT patients had significantly fewer preventable services (clinic visits: RR = 0.03, 95% confidence interval [CI] = 0.00-0.24; bed days of care (BDOC) for hospitalization [all-cause]: RR = 0.50, 95% CI = 0.37-0.67; hospitalizations [chemotherapy related]: RR = 0.43, 95% CI = 0.21-0.91; and BDOC for hospitalizations [chemotherapy related]: RR = 0.49, 95% CI = 0.34-0.71) than the control group. This study offered some preliminary evidence that patients enrolled in a Cancer CCHT program can successfully manage multiple complex symptoms without utilizing inpatient and outpatient services.

We examined the feasibility of a Cancer Care Dialogues Model, with daily telehealth interactions between patients at home and their care coordinator, who acted as an adjunct to the oncologist. The patient and the care coordinator used a home messaging device, connected via the ordinary telephone network. Thirty-four patients with a new diagnosis of cancer and whose treatment plan included chemotherapy taken at a single clinic were enrolled and followed for six months. The home messaging device collected information daily on common symptoms associated with chemotherapy. On average, the patients had the home messaging device for 120 days (range 30-180). The mean cooperation rate was 84% (range 4-100). No variables were significantly associated with patient cooperation in the dialogues over time. The health-related quality of life (HRQL) mean score at baseline was 73.9 (SD 15.4), and the mean score at six months was 78.4 (SD 14.5). After adjusting for demographic and clinical factors, there was a 6.5-point increase in HRQL score between the baseline and end of treatment, which represented an important clinical difference. Management of nervousness/worry over time through cancer care dialogues is important in maintaining HRQL and can be assisted by remote home messaging.

The Advanced Illness/Palliative Care (AIPC) program started as a 2-year pilot project to determine if a telehealth model of care would benefit veteran patients with life-limiting illness. The goals of the project were to manage the physical, emotional, functional, and spiritual care needs during the last 2 years of patients' lives and to foster an earlier enrollment of patients into hospice by educating providers about palliative care. The AIPC program partners the skills and expertise of both spiritual and medical care practitioners, along with cutting-edge home telehealth devices to improve symptom management and quality of life for veterans and families coping with end of life.

Objectives: To assess healthcare use among veterans with diabetes mellitus (DM) enrolled in a Department of Veterans Affairs (VA) Care Coordination Home Telehealth (CCHT) program during 24 months and to contrast this utilization with the service use of a comparison group of veterans with DM not enrolled in the program., Study Design: Two-year, retrospective, concurrent matched cohort study design., Methods: The VA CCHT program included older veterans with type 2 DM at high risk for multiple VA inpatient and outpatient visits. Healthcare utilization (hospitalizations, length of stay, and outpatient visits by type) was assessed at baseline and at 24 months after intervention for the treatment (n = 400) and comparison (n = 400) groups. Propensity scores were used to improve the balance between the treatment and comparison groups. A difference-in-differences approach was used to control for selection bias and for intervening time factors., Results: Two years after enrollment, the treatment group exhibited a statistically significant reduction in the likelihood of all-cause and DM-related hospitalizations. In a subgroup analysis in which we controlled for patients' baseline glycosylated hemoglobin levels, the treatment group had a lower likelihood of having any care coordinator-initiated primary care clinic visits (in which the care coordinator initiated referral to primary care based on health information received from patients' CCHT technology)., Conclusion: After controlling for selection bias and for intervening time factors, the VA CCHT program reduced avoidable healthcare services for DM (such as hospitalizations) and reduced care coordinator-initiated primary care clinic visits.

The American Telemedicine Association (ATA) established the Home Telehealth Special Interest Group (SIG) in 1999. Its mission is to support the expansion and use of telehealth, remote monitoring and disease management applications in the home. The SIG has many areas of interest and has focused on raising public and professional awareness about the benefits of home telehealth, developing and standardizing clinical guidelines for the delivery of services and advocating for reimbursement through state and federal funding. SIG membership has grown dramatically, to more than 425 members today. These numbers make it the fastest growing and largest of the ATA's Special Interest Groups.

We evaluated a Veterans Health Administration (VHA) care coordination/ home-telehealth (CC/HT) program on the utilization of health care services and health-related quality of life (HRQL) in veterans with diabetes. Administrative records of 445 veterans with diabetes were reviewed to compare health care service utilization in the 1-year period before and 1-year period post-enrollment and also examined self-reported HRQL at enrollment and 1 year later. Multivariate analyses indicated a statistically significant reduction in the proportion of patients who were hospitalized (50% reduction), emergency room use (11% reduction), reduction in the average number of bed days of care (decreased an average of 3.0 days), and improvement in the HRQL role-physical functioning, bodily pain, and social functioning. The results need to be interpreted with caution because we used a single-group study design that may be influenced by regression to the mean. Ideally, future research should use a randomized controlled trial design.

This study examined the effectiveness of a veterans affairs (VA) patient-centered care coordination/home-telehealth (CC/HT) program as an adjunct to treatment for veterans with diabetes. Using an adapted version of the Chronic Care Model, we analyzed the differences in healthcare service use between a cohort of 400 veterans with diabetes who were enrolled in a VA CC/HT program and a matched comparison cohort of 400 veterans with diabetes who received no CC/HT intervention. Propensity scores were used to improve the balance between the treatment and comparison groups. Service use outcomes were assessed at 12 months before and after enrollment. A difference-in-differences approach was used in the multivariate models to assess the treatment effect for patients in the CC/HT programs. Twelve months after enrollment, there was a significant difference between the treatment and comparison groups in terms of need-based primary care visits (newly scheduled visits that enable the veteran to be seen "just in time," where the health status is monitored and met before health deteriorates), increasing in the treatment group and decreasing in the comparison group (P < .01). In a subgroup analysis, where we were able to control for the patients' Hb A1c values, we found that the treatment group had a lower likelihood of having 1 or more hospitalizations than patients in the comparison group. Our findings have implications for management in that the CC/HT program appears to improve the ability of older veterans with diabetes to receive appropriate, timely care, thereby improving the quality of care for them and making more efficient use of VA healthcare resources.

Successful implementation of home telehealth programs require unique skills and personality traits of professionals driving the program. Understanding these traits and skills, and how they predict performance will help staff recognize superior applicants when recruiting individuals for such positions. An extensive literature review ties research published on human factors, what they are, the role they play in performance, and how this may translate into a successful telehealth program. We compared case examples of some successful home telehealth programs. Furthermore, a summary of problems approached and resolved by the home telehealth professionals illustrated decision making and action steps taken that correlated to research published on human factors. Further research is needed to validate the tools used by other fields of study to select and identify successful individuals.

Patients are exposed to iatrogenic injury when hospitalized. In the Tech Care Coordination Program, older veterans with chronic diseases and high healthcare utilization were followed with an in-home technology device, the Health Buddy, and risk management software. Program staff could identify at-risk patients based on their responses to a series of questions about symptoms, behavior, and knowledge. Patients followed in the program for at least 6 months experienced a 45% decrease in hospital admissions, 67% decrease in nursing home admissions, 54% decrease in emergency room visits, and 38% decrease in pharmacy prescriptions. The patients also demonstrated improved compliance with treatment regimens and both patients and providers reported high levels of program satisfaction.

This study compared health-related outcomes, during a 1-year period, for two groups of frail elders-one that received care coordination via distance monitoring (home-telehealth) and one that received no intervention. A case-control design was employed. The home telehealth intervention group was made up of 111 male veterans who were enrolled in a Veterans Health Administration project. The control group consisted of 115 men who were referred from either senior service agencies or hospital rehabilitation programs, but did not receive home-telehealth. Subjects in both groups had primary diagnoses of hypertension, diabetes, respiratory disease, or heart disease. The two groups were similar in terms of age, race, marital status, and independence in instrumental activities of daily living (IADL) at baseline. A paired t-test was used to study the before-after (baseline to 12-month follow-up) improvements in the outcome measures within each group. Regression models were used to compare the outcome improvements between the two groups. Over 1 year, the intervention group improved 2.2 points more in IADL, 14.4 points more in FIM motor scores, and 2.7 points more in FIM cognitive scores than the control group (p < 0.0001). This evidence supports the use of a specific home-telehealth strategy for care coordination to improve functional independence in non-institutionalized veterans with chronic disease. A randomized controlled trial should be employed to confirm these findings.

The Community Care Coordination Service (CCCS) program was implemented in April, 2000, at the Veterans Integrated Service Network (VISN 8). The goals of the CCCS were to improve the coordination of care for clinically complex patients, referred to as veterans, and to increase their access to care while reducing complications, hospital admissions, and emergency room (ER) visits. This program used a coordinated care approach, a process whereby veterans were followed throughout the continuum of care. The information presented in this case study is specific to three medical centers that implemented the CCCS: Ft. Myers, Lake City, and Miami. Analysis of utilization and clinical impact were conducted after 18 months. Inpatient admissions were reduced by 46% at Ft. Myers, 68% at Lake City, and 13% at Miami. ER encounters were reduced by 19% at Ft. Myers, 70% at Lake City, and 15% at Miami. Reductions in bed days were demonstrated at Ft. Myers (29%) and Lake City (71%). In Miami, there was a 13% increase in the number of bed days of care for the patients after 1 year in the program. In addition to these changes in health-care utilization, quality of life was significantly improved as evidenced by increases in the four of the eight components scores of the Medical Outcomes Study 36-item Short Form health survey for veterans (SF36V) at Lake City and Ft. Myers. In the CCCS model of care using home telehealth technology, the Care Coordinators bridged the gap between office visits by providing a daily connection between the coordinators and the patients. This daily communication made it possible for problems to be identified early and interventions implemented before problems escalated.

The Rural Home Care Project is one of eight clinical demonstration pilots in an initiative of the Veterans Health Administration (VHA) Sunshine Network in Florida and Puerto Rico. In this project 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 monitor and educate patients to prevent health crises. The evaluation methodology is a quasiexperimental design that uses a nonequivalent control group of usual care veterans. Data were gathered through personal interviews with patients and providers, and statistical analysis was based on a series of repeated-measure of covariance modeling designed by a research team from the University of Maryland. Findings demonstrate that care coordination enhanced by technology reduces hospital admissions, bed days of care, emergency room visits, and prescriptions as well as providing high patient and provider satisfaction. Veterans also had improved perception of physical health as evidenced by a standardized functional status measure.

Although technology has sometimes been the cause of rising healthcare costs, telemedicine technology has been proposed as a means to increase productivity in the workplace and reduce resource utilization for high-risk populations. The Veterans Health Administration (VHA) in April of 2000, implemented an expansive telemedicine technology initiative in its Sunshine Network, covering veterans in south Georgia, Florida, Puerto Rico, and the Virgin Islands through the Community Care Coordination Service (CCCS). The initiative uses home telehealth technology to support veteran healthcare. Choosing appropriate tools to enhance care coordination and matching technology to specific patient needs was vital to the success of the CCCS model. A technology algorithm was developed across the Network initiative and grew out of a need to identify and benchmark best practices. An evaluation methodology developed by a health economist and his research team at the University of Maryland was used to determine patient satisfaction with technology and functional status through a validated instrument. Outcomes were for 791 chronic medical and 120 mental health patients. Patient satisfaction was extremely high, patients used technology without difficulty and acceptance was greater than expected. Patients' perception of health as surveyed with the functional status instrument showed improved perception in many factors including pain, physical, and social functioning.