Chronic obstructive pulmonary disease

The VeTerAns heAlTh AdminisTrATion: TAking home TeleheAlTh serVices To scAle nATionAlly 7

Leaders of other health care organizations have been dismissive of the applicability of the VHA’s results, noting that the VHA is both payer and pro- vider and therefore has completely aligned incentives and underlying systems for aggressive management of chronic diseases. However, other programs—some in highly fragmented environments—have been able to achieve similar results to those of the VHA. For instance, the Health Buddy Project, a Medicare tele- health demonstration project, was able to enroll more than 700 patients in two areas of the Pacific Northwest. The program’s first phase, from 2006 to 2009, showed a 240 percent return on investment for Medicare.15

KEY SUCCESS FACTORS IN TAKING HOME TELEHEALTH FROM PILOT TO SCALE The VHA first considered a role for telehealth in noninstitutionalized care in the mid-1990s. Rather than technology being the driver, the impetus for introducing telehealth was the need to address the care demands of chronically ill, aging veterans and

to expand access to care services and make the home the preferred place of care. The decision to imple- ment telehealth received strong support from the VHA leadership, and a telehealth pilot involving the remote monitoring and patient self-management of nearly 900 patients was launched in 2000. The results of the pilot, which demonstrated reductions in hospital admissions and bed days of care as well as high levels of patient satisfaction, formed the basis for the model that has become the national standard in the VHA since 2003.

Although initial evidence for an innovation is necessary, it is often not sufficient for widespread dif- fusion. Ongoing monitoring of the clinical outcomes has demonstrated repeatedly high levels of patient satisfaction and reduced resource utilization and has supported the continued growth of telehealth within the VHA, validated the positive benefits, and strengthened the program’s ability to spread home telehealth ser- vices more broadly throughout the organization.

The VHA’s experience with home telehealth programs highlights the potential of alternatives to traditional care models to drive substantial benefits. The experience also demonstrates that implementation at scale is possible and can yield substantial returns across both time and geography. Successful implemen- tation was centered around reengineering of existing processes coupled with a strong IT infrastructure and a commitment to training.

The following are key factors that have led to the VHA’s ability to successfully pilot and implement home telehealth at scale.

Systematic evidence of targeted outcomes. The pilot program validated the evidence initially found in the literature of small-scale interventions suc- cessfully using home telehealth with chronic disease patients to support independent living and reduce hospital admissions. The program has continued to demonstrate systematic evidence of targeted outcomes: reductions in bed days of care and hospital admissions, as well as high levels of patient satisfaction, all with- out diminishing the health status of participants. Such evidence has been important in expanding the scale of the program. As it has grown, the evidence has made a

Exhibit 3. Outcomes: VHA Care Coordination/Home Telehealth 2004–07

Condition Number of

patients

Percent decrease in utilization

Diabetes 8,954 20.4

Hypertension 7,447 30.3

Congestive heart failure 4,089 25.9

Chronic obstructive pulmonary disease 1,963 20.7

Post-traumatic stress disorder 129 45.1

Depression 337 56.4

Other mental health 653 40.9

Single condition 10,885 24.8

Multiple conditions 6,140 26.0

Source: A. Darkins, P. Ryan, R. Kobb et al., “Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions,” Telemedicine and e-Health, Dec. 2008 14(10): 1118–26.

8 The commonweAlTh Fund

strong clinical and business case that facilitates buy-in from clinicians and managers. The VHA has found that disseminating its findings broadly throughout the sys- tem, through an annual meeting for key staff members and a quarterly newsletter, for instance, reinforces the continuous cycle of learning within the organization.

Standardization of core program elements. From the outset, the VHA tried to systemize clinical, technological, and business processes. A core principle of this standardized approach has been national poli- cies and operational procedures that ensure the care a veteran receives is consistent throughout the VHA system. In addition, care coordinators monitor core biometric data and changes in patients’ health status, provide support to patients through education and self- management, and intervene to prevent patients’ clinical deterioration and avoidable hospital admissions.

Technology-enabled tools and resources. The electronic patient record is a critical tool that enables just-in-time decisions that support patient care, particularly in chronic care management. The VHA’s electronic health information system, VistA, has been instrumental in providing a technical health informa- tion infrastructure that supports systemwide imple- mentation of the home telehealth program. Another important technological tool is the algorithm the VHA uses to match patients to appropriate technologies. The home telehealth devices have been chosen for their simple user interface design and ease-of-use to ensure they can be implemented systematically among a very large number of patients and perform reliably.

Staff training and development. The OTS has established national training centers dedicated to each of its three telehealth service areas with the capac- ity to facilitate remote training and to train hundreds of staff members each year. A robust training program has helped contribute to overcoming the initial resistance that clinicians have had to the telehealth approach. The training program for CCHT has also created a cohort of graduates who serve as ambassadors for the program and who can help solve programmatic issues at the local level.