Changing the location of care: Management of patients with chronic conditions in Veterans Health Administration using care coordination/home telehealth

Abstract

The way that societal changes influence how health services are delivered to people with chronic diseases and conditions exemplifies how policy responses must now acknowledge patient and caregiver preferences for care. New healthcare-associated information technologies are allowing patients to choose their location for care and realize their preferences [1]. Previous long-term care policy projections had anticipated that today's healthcare system would be challenged to meet the growing need for long-term institutional care and to care for an aging population whose chronic disease incidence and prevalence would rise dramatically [2-3]. During the intervening 25 years, many factors [4-6], including reduced disability levels in the elderly, increased disposable income, changes in chronic disease patterns, and initiatives to increase caregiver and community support, have moved the long-term care equation toward noninstitutional settings. When appropriate and given the choice, many people prefer to remain living independently in their homes and/or communities and to avoid or delay placement in long-term institutional care facilities [7]. Healthcare systems must respond to a complex and continually evolving long-term care agenda that expects these systems to restructure how they provide care and, in doing so, develop noninstitutional care services that reach directly into patients' homes. Among the noninstitutional care services routinely delivered by the Veterans Health Administration (VHA) is care coordination. Care coordination has been explicitly designed to meet the changing healthcare needs of a veteran population that is aging and coping with the limitations imposed on their lives and longevity by chronic diseases and conditions, e.g., diabetes, chronic heart failure (CHF), spinal cord injury (SCI), posttraumatic stress disorder (PTSD), depression, chronic obstructive pulmonary disease (COPD), stroke, multiple sclerosis (MS), and hypertension. VHA defines care coordination as-- the use of health informatics, telehealth, and disease management to enhance and extend care and case management activities to facilitate access to care and improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time (http://www.va.gov/occ/). VHA uses a range of telehealth technologies to support three classes of care coordination programs in its 154 Department of Veterans Affairs medical centers. Care coordination/home telehealth (CCHT) programs use telehealth technologies, including digital cameras, videophones, messaging/ monitoring devices, and telemonitors, to coordinate care directly from a patient's home. Care coordination/general telehealth (CCGT) programs use videoconferencing technologies to provide clinical services, e.g., telemental health between hospitals and community-based outpatient clinics (CBOCs). Care coordination/ store-and-forwards (CCSF) allow VHA to provide teleretinal imaging, dermatology, wound care, and pathology services to rural and remote locations. CCHT, CCGT, and CCSF enable VHA to make specialist care, e.g., rehabilitation, more widely available and accessible to veteran patients, especially those who find access to care challenging because they live in remote or rural areas. Care coordination enhances care by changing its location to a more accessible site or supporting the ongoing provision of care at a current site in which, for example, recruitment of specialist staff such as eye care professionals is problematic, e.g., in a remote or rural location. Fundamental to VHA's ability to change the location of care by reconfiguring face-to-face care and introducing services that extend into patient's homes, community settings, and CBOCs has been the full implementation of a comprehensive computerized health record (CHR). Currently, the patients with chronic diseases to whom changing location of care applies most are those at risk of long-term institutional care placement. …