- Email: [email protected]
Evaluation of a Veteran-specific Clinic Video Telehealth Pilot Project
BRIEF REPORT
Evaluation of a Veteran-specific Clinic Video Telehealth Pilot Project Rebecca Clanton, DNP, FNP-BC, L. Alice March, PhD, FNP-BC, and Sonny Ruff, DNP, FNP-BC ABSTRACT
Clinical video telehealth (CVT) combined with telemonitoring for homebound veterans with chronic illnesses may improve outcomes for veterans with a chronic condition cared for at home. This retrospective chart review examined the number of emergency room visits, admissions, length of stay, scheduled home visits, and unscheduled home visits. An independent t test found fewer emergency room visits during CVT care compared with after CVT care and an increased number of unscheduled home visits after CVT compared with before CVT. As CVT expands, more research will be added to the growing body of knowledge. Positive findings indicate that CVT should be further studied in the chronically ill homebound population. Keywords: chronic obstructive pulmonary disease, clinical video telehealth, congestive heart failure, diabetes mellitus, hospital readmission, hypertension, telehealth Published by Elsevier, Inc.
T
he burgeoning numbers in the aging population with multiple chronic illnesses has resulted in the need for health care facilities to strategize ways to develop innovative methods of care delivery. In 2006, the older adult population was 37.3 million or 12.4% of the United States population. This number is estimated to skyrocket to 72 million or 20% by 2030.1 Multiple chronic conditions (MCCs), the coexistence of 2 or more chronic conditions (where 1 is not necessary more central than the others), affect not only safety and effectiveness care but also cost, quality of life, and, ultimately, mortality. Besides physical conditions, MMCs include mental health disorders, thus increasing the number of people who are affected as well as the complexity of care.2 The burden of MCCs is particularly acute both for the individual patient and the health care system. People with MCCs have worse health outcomes and higher health care expenses.3 People with MCCs are more likely to visit the emergency room (ER) and experience admission to the hospital for care. During 2009, people without an MCC spent an average of $2,367 for health care, but people with 2 or 3 MCC spent $8,478; if they had 4 or more conditions, this nearly doubled to $16,257. Overall, 820
The Journal for Nurse Practitioners - JNP
the cost of caring for persons with an MCC is enormous, with 66% of current health care spending applied to only 27% of Americans who fall into this category.4 In addition to an aging population, the US is facing a physician shortage. Before the passage of the Affordable Care Act, the Association of American Medical Colleges estimated that by 2015 the probable physician shortage would be nearly 40,000.5 This deficit in primary care providers (PCPs) coupled with the influx of patients who have improved access to care because of the Affordable Care Act and the estimated increase in Medicare beneficiaries from the aging population will increase that physician shortage to an estimated 63,000 by the year 2015. By 2025, only 10 years later, the predicted shortage will double to an alarming 130,600.5 Even more concerning is the fact that only 25% of medical school graduates disclose plans to practice in a primary care setting.6 This projected provider shortage provides a perfect opportunity for other levels of PCPs, such as nurse practitioners (NPs), to fill this gap. The implementation of advanced telehealth programs designed to enhance patient care and improve patient outcomes is 1 innovative approach to a resolution. Southern states rank very low in physician and PCP coverage per capita, with some states as low as only Volume 10, Issue 10, November/December 2014
8.3 doctors per 10,000 residents, far less than the national average of 12 per 10,000.7 This lack of health care providers may be a contributing factor to the southern region’s historically dismal health outcome statistics. Available technology can provide medical care to remote communities lacking adequate provider coverage, yet more solutions are needed. Video telehealth assists providers in the care of remote patients living in rural areas. This effectively uses provider time by reducing travel yet still allows providers and patients the opportunity for real-time communication.8 To best address the health care of vulnerable older adults, methods must be created to manage disease processes more efficiently and better engage patients where they live rather than require difficult travel to clinics that may be far away from their residence. Telehealth supported by video technology engages patients where ever they live to closely self-monitor health data, provides clinical assessment, promotes self-care, and delivers education.9 Clinical video telehealth (CVT) uses telemonitoring of the patient’s vital signs and other video and audio capabilities to allow the NP to conduct real-time yet remote health assessments. Immediate intervention is readily available when health conditions warrant and the ability to provide out-of-hospital follow-up care is greatly improved. The purpose of this pilot study was to answer the following research question: does CVT reduce ER visits, admissions, length of stay (LOS), scheduled home visits, and unscheduled home visits? The fiscal aspects of CVT are of much interest. A systematic review of 36 articles concluded there were conflicting data on the effects of CVT and questioned whether telehealth was truly cost-effective. In particular, the review noted that 61% of studies found telehealth was less costly, 31% found it more costly, and 9% reported mixed results. Overall, the review reported that CVT was most cost-effective for the provision of home care and use by on-call hospital specialists. The results also varied for CVT participants in rural areas. Delivery of services locally, between hospital and primary care, was not cost-effective.10 The Veterans Administration (VA) implemented CVT programs throughout the US for utilization by pharmacology departments for outpatient medical management of veterans living in remote areas. One www.npjournal.org
site reported a decreased in no-show visits (4% vs 10% comparing post-telehealth vs pre-telehealth visits) and a saving of 26,784 miles traveled by veterans during 1 year, thus reducing travel time and fatigue. Veterans were reimbursed travel pay for mileage; therefore, a substantial cost savings also occurred. Patient satisfaction with the program was between 90% and 95%. It was posited that the use of CVT may benefit numerous services such as primary care, pain management, endocrinology, and other specialty clinics.11 THE CVT PROGRAM
CVT (ie, the use of real-time video and audio communication) allowed the NP to visualize the veteran, take pictures, review vital signs, and auscultate body sounds. Each CVT unit contained a blood pressure cuff, oxygen saturation monitor, and scale. Vital signs were transmitted daily and were then reviewed by the NP. The patient had a laminated card with a diagram of the chest that included landmarks clearly marked with numbers. During an examination, the veteran or caregiver was instructed to place the stethoscope on the corresponding number. Real-time video also allowed visualization of lesions and stored images for later comparison to assist in the assessment of wound health and the progression of healing. The active 2-way communication was very helpful with medication reconciliation. This program implemented to improved outcomes was offered to all veterans (outpatient and home-base primary care [HBPC]) regardless of residential distance from the VA medical center (VAMC). Services were offered to any veteran who met specified criteria and had 1 or more of the following diagnoses: congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, or hypertension. Additional enrollment criteria included difficulty adhering to medication regiments, 2 or more ER visits or hospitalizations in the past 6 months, and 2 or more clinic visits within 6 months for the same diagnosis. The original telehealth system captured weight, blood pressure, pulse, and respirations. The CVT component of the telehealth pilot project enhanced the telemonitoring aspect of the equipment by adding oxygen saturation and real-time video and audio capabilities. The Journal for Nurse Practitioners - JNP
821
Each veteran received a touch screen devise that prompted a recorded voice message when activated. The veteran was guided through a module that provided disease process education, allowed assessment of activity levels, and contained a screen to enter vital signs. During the initial setup, telehealth technicians assembled and delivered the equipment and guided each veteran through the operating procedure. Specific telehealth technicians were dedicated to troubleshooting calls and providing assistance when needed. As a condition of CVT participation, the veteran entered data at least 50% of the time for 3 months or they were discharged from the program. NPs monitored vital signs each day for subtle changes. When an alarming trend was noted, such as increased weight in a patient with congestive heart failure, the PCP was alerted by the computerized patient record system (CPRS) or via a telephone call. The NPs assigned to provide CVT referred veterans to the ER for evaluation when necessary. Every 30 to 90 days, the NP entered data tracking vital signs into the CPRS for later review by the PCP. This 138-bed tertiary care VAMC hospital teaching facility in the Southeastern US served a diverse population of black, white, Latino, and Native American veterans. The CVT telehealth pilot program operated for 1 year and was conducted by the HBPC department, a program that provides comprehensive care to chronically ill homebound veterans. The goal of HBPC is to promote health care and reduce cost, hospital admissions, and ER visits. METHODS
This pilot study used a retrospective chart review. Human subject approval was obtained. Data were extracted from the CPRS database and entered into a deidentified data set. A study number was assigned to charts meeting the inclusion criteria. The CVT charts qualifying for inclusion were assessed for demographic characteristics (number of CVT visits, age, race/ethnicity, and sex) and reviewed for outcome variables (ER visits, hospitalizations, LOS, unscheduled home visit, and unscheduled clinic visits). RESULTS
This retrospective chart review of 11 critically ill veterans to determine if CVT had an effect on 822
The Journal for Nurse Practitioners - JNP
scheduled home visits, unscheduled clinic visits, ER visits, hospital admissions, and LOS found that the mean number of unscheduled clinic visits pre-CVT was less than the mean number of unscheduled clinic visits post-CVT. In addition, the mean number of ER visits during CVT was less than the mean number of ER visit post-CVT. In all other cases, CVT did not have an effect. DISCUSSION AND LESSONS LEARNED
Given the severity of end-stage illness and the expected trajectory of health decline among this population, the finding of more visits after CVT is more likely the function of worsening health rather than a failure of the CVT program. The CVT program used dial-up connections, and the connection speed and video quality varied from site to site and day to day. It was not uncommon to have excellent CVT capabilities one day and have limited aspects to visits during another session. This likely had an effect on assessment, resulting in faulty clinical decision making, and affected referral to definitive care. One approach to a resolution is the consideration that a broadband Internet connection may enhance the quality of assessments and therefore offer the possibility of improved clinical outcomes. Other limitations included the fact that the retrospective chart review the pilot project contained a small sample size. Although veterans were encouraged to enter vital sign data daily, compliance with data input varied. This limited the ability to identify subtle changes in health status. To improve this potential lack of data input, it might be reasonable for the NP to review the use of the equipment with the veteran during scheduled home visits or to send a technician out to the home about 6 weeks after installation to answer questions and check the veteran’s understanding of equipment use. Not unexpectedly, with only records from 1 VAMC reviewed, there is no ability to generalize findings. In the future when reviewing the effectiveness of a program, the research should include examination of admissions, LOS, ER visits, and visits occurring at non-VA or private facilities. These were not included in this data analysis, and these additional data may have changed the findings. Volume 10, Issue 10, November/December 2014
RECOMMENDATIONS FOR PRACTICE
The literature suggests that there is a decrease in hospital admission and overall cost reduction with the use of telehealth.12 The use of broadband internet services with future CVT programs would further promote successful implementation. Further studies with larger sample sizes and the use of broadband connectivity would be helpful. Conflicting findings are present in the literature related to the cost-effectiveness of CVT, and costeffectiveness of CVT varies in rural areas.10 When planning to implement new CVT programs, facilities must consider connectivity issues related to rural areas. The cost of broadband and other services may be higher in rural areas and yet the availability lower. Even though telehealth is usually implemented to improve physical health outcomes, other outcomes such as improved mental health, functional status, and quality of life should be considered.13 The rural nature of many states results in a greater number of miles needed to travel for care; therefore, CVT may result in travel savings for veterans and the VAMC. Additionally, travel to the facility often results in hardships for veterans and families. It is not uncommon for HBPC veterans to rely on ambulance transportation. Regardless, each trip to the facility can result in significant cost to the family and the VAMC. CONCLUSION
Video telehealth is a relatively new technology. An extensive literature review was conducted, but there are limited studies that have examined home-based primary care and evaluated cost factors. Most articles discussed the use of video telehealth by specialty care clinics or in rural areas, and CVT articles that evaluated health outcomes were not prevalent. No articles using both approaches (telemonitoring and CVT) and comparing the outcome variables for this study were found. Additionally, there were no randomized clinical trials comparing CVT with usual care during the same observation period. This type of study may help explore how time and disease trajectory affect outcomes. It is anticipated that as
www.npjournal.org
CVT expands more research will be added to the growing body of knowledge. This material is the result of work supported with resources and the use of facilities at the Jackson, MS VA medical center. References 1. Centers for Disease Control and Prevention. The state of aging and health in America. 2007. http:www.cdc.gov/aging/pdf/saha2007.pdf. Accessed December 1, 2013. 2. Lin W-C, Zhang J, Leung GY, Clark RE. Chronic physical conditions in older adults with mental illness and/or substance use disorders. J Am Geriatr Soc. 2011;59:1913-1921. 3. Parekh AK, Goodman RA, Gordon C, Koh HK. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126:460-471. 4. Anderson G. Chronic care: making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation; 2010. http://www.rwjf.org/files/research/ 50968chronic.care.chartbook.pdf. Accessed April 4, 2014. 5. Mann S. Addressing the physician shortage under reform. Association of American Medical Colleges. 2011. www.aamc.org/newsroom/reporter/ april2011. Accessed April 4, 2014. 6. Iglehart JK. Expanding the role of advanced nurse-practitioners-risks and rewards. N Engl J Med. http://dx.doi.org/10.156NEJMhpr1301084. Accessed April 4, 2014. 7. Jeter L. Incentivizing medical professionals. Mississippi Medical News. August 2013;1:8; & 9. 8. Povencher MT, Nuccio PF. Telemonitoring in COPD. J Respir Care Pract. 2011:26-29. 9. Carter A. Remote telemonitoring technology will expand, but progress depends on more research and federal support. Home Healthc Nurse. 2011;29:389-390. 10. Wade VA, Karnon J, Elshaug AG, Hiller JE. A systematic review of economic analysis of telehealth services using real time video communication. BMC Health Serv Res. 2010;20:233. 11. Coakley C, Hogh A, Dwyer D, Parrah D. Clinical video telehealth in a cardiology pharmacotherapy clinic. Am J Health Syst Pharm. 2013;70:1974-1975. 12. Fischer HH, Eisert SL, Everhart RM, et al. Nurse-run, telephone-base outreach to improve lipids in peoples with diabetes. Am J Manag Care. 2012;11:1-4. 13. Jennings MB. Patient outcomes research: seizing the opportunity. Adv Nurs Sci. 1991;14:59-72.
Rebecca Clanton, RN, DNP, FNP-BC, works at the Veterans Administration in Jackson, MS. She can be reached at Rebecca. [email protected]. L. Alice March, PhD, RN, FNP-BC, CNE, is the assistant dean of graduate programs and an associate professor at The University of Alabama Capstone College of Nursing. Sonny Ruff, RN, DNP, FNP-BC, CEN, works at Hospital Physician Partners, Madison River Oaks in Canton, MS. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. This material is the result of work supported with resources and the use of facilities at the Jackson, MS VA medical center. 1555-4155/14/$ see front matter Published by Elsevier, Inc. http://dx.doi.org/10.1016/j.nurpra.2014.08.027
The Journal for Nurse Practitioners - JNP
823
Evaluation of a Veteran-specific Clinic Video Telehealth Pilot Project Rebecca Clanton, DNP, FNP-BC, L. Alice March, PhD, FNP-BC, and Sonny Ruff, DNP, FNP-BC ABSTRACT
Clinical video telehealth (CVT) combined with telemonitoring for homebound veterans with chronic illnesses may improve outcomes for veterans with a chronic condition cared for at home. This retrospective chart review examined the number of emergency room visits, admissions, length of stay, scheduled home visits, and unscheduled home visits. An independent t test found fewer emergency room visits during CVT care compared with after CVT care and an increased number of unscheduled home visits after CVT compared with before CVT. As CVT expands, more research will be added to the growing body of knowledge. Positive findings indicate that CVT should be further studied in the chronically ill homebound population. Keywords: chronic obstructive pulmonary disease, clinical video telehealth, congestive heart failure, diabetes mellitus, hospital readmission, hypertension, telehealth Published by Elsevier, Inc.
T
he burgeoning numbers in the aging population with multiple chronic illnesses has resulted in the need for health care facilities to strategize ways to develop innovative methods of care delivery. In 2006, the older adult population was 37.3 million or 12.4% of the United States population. This number is estimated to skyrocket to 72 million or 20% by 2030.1 Multiple chronic conditions (MCCs), the coexistence of 2 or more chronic conditions (where 1 is not necessary more central than the others), affect not only safety and effectiveness care but also cost, quality of life, and, ultimately, mortality. Besides physical conditions, MMCs include mental health disorders, thus increasing the number of people who are affected as well as the complexity of care.2 The burden of MCCs is particularly acute both for the individual patient and the health care system. People with MCCs have worse health outcomes and higher health care expenses.3 People with MCCs are more likely to visit the emergency room (ER) and experience admission to the hospital for care. During 2009, people without an MCC spent an average of $2,367 for health care, but people with 2 or 3 MCC spent $8,478; if they had 4 or more conditions, this nearly doubled to $16,257. Overall, 820
The Journal for Nurse Practitioners - JNP
the cost of caring for persons with an MCC is enormous, with 66% of current health care spending applied to only 27% of Americans who fall into this category.4 In addition to an aging population, the US is facing a physician shortage. Before the passage of the Affordable Care Act, the Association of American Medical Colleges estimated that by 2015 the probable physician shortage would be nearly 40,000.5 This deficit in primary care providers (PCPs) coupled with the influx of patients who have improved access to care because of the Affordable Care Act and the estimated increase in Medicare beneficiaries from the aging population will increase that physician shortage to an estimated 63,000 by the year 2015. By 2025, only 10 years later, the predicted shortage will double to an alarming 130,600.5 Even more concerning is the fact that only 25% of medical school graduates disclose plans to practice in a primary care setting.6 This projected provider shortage provides a perfect opportunity for other levels of PCPs, such as nurse practitioners (NPs), to fill this gap. The implementation of advanced telehealth programs designed to enhance patient care and improve patient outcomes is 1 innovative approach to a resolution. Southern states rank very low in physician and PCP coverage per capita, with some states as low as only Volume 10, Issue 10, November/December 2014
8.3 doctors per 10,000 residents, far less than the national average of 12 per 10,000.7 This lack of health care providers may be a contributing factor to the southern region’s historically dismal health outcome statistics. Available technology can provide medical care to remote communities lacking adequate provider coverage, yet more solutions are needed. Video telehealth assists providers in the care of remote patients living in rural areas. This effectively uses provider time by reducing travel yet still allows providers and patients the opportunity for real-time communication.8 To best address the health care of vulnerable older adults, methods must be created to manage disease processes more efficiently and better engage patients where they live rather than require difficult travel to clinics that may be far away from their residence. Telehealth supported by video technology engages patients where ever they live to closely self-monitor health data, provides clinical assessment, promotes self-care, and delivers education.9 Clinical video telehealth (CVT) uses telemonitoring of the patient’s vital signs and other video and audio capabilities to allow the NP to conduct real-time yet remote health assessments. Immediate intervention is readily available when health conditions warrant and the ability to provide out-of-hospital follow-up care is greatly improved. The purpose of this pilot study was to answer the following research question: does CVT reduce ER visits, admissions, length of stay (LOS), scheduled home visits, and unscheduled home visits? The fiscal aspects of CVT are of much interest. A systematic review of 36 articles concluded there were conflicting data on the effects of CVT and questioned whether telehealth was truly cost-effective. In particular, the review noted that 61% of studies found telehealth was less costly, 31% found it more costly, and 9% reported mixed results. Overall, the review reported that CVT was most cost-effective for the provision of home care and use by on-call hospital specialists. The results also varied for CVT participants in rural areas. Delivery of services locally, between hospital and primary care, was not cost-effective.10 The Veterans Administration (VA) implemented CVT programs throughout the US for utilization by pharmacology departments for outpatient medical management of veterans living in remote areas. One www.npjournal.org
site reported a decreased in no-show visits (4% vs 10% comparing post-telehealth vs pre-telehealth visits) and a saving of 26,784 miles traveled by veterans during 1 year, thus reducing travel time and fatigue. Veterans were reimbursed travel pay for mileage; therefore, a substantial cost savings also occurred. Patient satisfaction with the program was between 90% and 95%. It was posited that the use of CVT may benefit numerous services such as primary care, pain management, endocrinology, and other specialty clinics.11 THE CVT PROGRAM
CVT (ie, the use of real-time video and audio communication) allowed the NP to visualize the veteran, take pictures, review vital signs, and auscultate body sounds. Each CVT unit contained a blood pressure cuff, oxygen saturation monitor, and scale. Vital signs were transmitted daily and were then reviewed by the NP. The patient had a laminated card with a diagram of the chest that included landmarks clearly marked with numbers. During an examination, the veteran or caregiver was instructed to place the stethoscope on the corresponding number. Real-time video also allowed visualization of lesions and stored images for later comparison to assist in the assessment of wound health and the progression of healing. The active 2-way communication was very helpful with medication reconciliation. This program implemented to improved outcomes was offered to all veterans (outpatient and home-base primary care [HBPC]) regardless of residential distance from the VA medical center (VAMC). Services were offered to any veteran who met specified criteria and had 1 or more of the following diagnoses: congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, or hypertension. Additional enrollment criteria included difficulty adhering to medication regiments, 2 or more ER visits or hospitalizations in the past 6 months, and 2 or more clinic visits within 6 months for the same diagnosis. The original telehealth system captured weight, blood pressure, pulse, and respirations. The CVT component of the telehealth pilot project enhanced the telemonitoring aspect of the equipment by adding oxygen saturation and real-time video and audio capabilities. The Journal for Nurse Practitioners - JNP
821
Each veteran received a touch screen devise that prompted a recorded voice message when activated. The veteran was guided through a module that provided disease process education, allowed assessment of activity levels, and contained a screen to enter vital signs. During the initial setup, telehealth technicians assembled and delivered the equipment and guided each veteran through the operating procedure. Specific telehealth technicians were dedicated to troubleshooting calls and providing assistance when needed. As a condition of CVT participation, the veteran entered data at least 50% of the time for 3 months or they were discharged from the program. NPs monitored vital signs each day for subtle changes. When an alarming trend was noted, such as increased weight in a patient with congestive heart failure, the PCP was alerted by the computerized patient record system (CPRS) or via a telephone call. The NPs assigned to provide CVT referred veterans to the ER for evaluation when necessary. Every 30 to 90 days, the NP entered data tracking vital signs into the CPRS for later review by the PCP. This 138-bed tertiary care VAMC hospital teaching facility in the Southeastern US served a diverse population of black, white, Latino, and Native American veterans. The CVT telehealth pilot program operated for 1 year and was conducted by the HBPC department, a program that provides comprehensive care to chronically ill homebound veterans. The goal of HBPC is to promote health care and reduce cost, hospital admissions, and ER visits. METHODS
This pilot study used a retrospective chart review. Human subject approval was obtained. Data were extracted from the CPRS database and entered into a deidentified data set. A study number was assigned to charts meeting the inclusion criteria. The CVT charts qualifying for inclusion were assessed for demographic characteristics (number of CVT visits, age, race/ethnicity, and sex) and reviewed for outcome variables (ER visits, hospitalizations, LOS, unscheduled home visit, and unscheduled clinic visits). RESULTS
This retrospective chart review of 11 critically ill veterans to determine if CVT had an effect on 822
The Journal for Nurse Practitioners - JNP
scheduled home visits, unscheduled clinic visits, ER visits, hospital admissions, and LOS found that the mean number of unscheduled clinic visits pre-CVT was less than the mean number of unscheduled clinic visits post-CVT. In addition, the mean number of ER visits during CVT was less than the mean number of ER visit post-CVT. In all other cases, CVT did not have an effect. DISCUSSION AND LESSONS LEARNED
Given the severity of end-stage illness and the expected trajectory of health decline among this population, the finding of more visits after CVT is more likely the function of worsening health rather than a failure of the CVT program. The CVT program used dial-up connections, and the connection speed and video quality varied from site to site and day to day. It was not uncommon to have excellent CVT capabilities one day and have limited aspects to visits during another session. This likely had an effect on assessment, resulting in faulty clinical decision making, and affected referral to definitive care. One approach to a resolution is the consideration that a broadband Internet connection may enhance the quality of assessments and therefore offer the possibility of improved clinical outcomes. Other limitations included the fact that the retrospective chart review the pilot project contained a small sample size. Although veterans were encouraged to enter vital sign data daily, compliance with data input varied. This limited the ability to identify subtle changes in health status. To improve this potential lack of data input, it might be reasonable for the NP to review the use of the equipment with the veteran during scheduled home visits or to send a technician out to the home about 6 weeks after installation to answer questions and check the veteran’s understanding of equipment use. Not unexpectedly, with only records from 1 VAMC reviewed, there is no ability to generalize findings. In the future when reviewing the effectiveness of a program, the research should include examination of admissions, LOS, ER visits, and visits occurring at non-VA or private facilities. These were not included in this data analysis, and these additional data may have changed the findings. Volume 10, Issue 10, November/December 2014
RECOMMENDATIONS FOR PRACTICE
The literature suggests that there is a decrease in hospital admission and overall cost reduction with the use of telehealth.12 The use of broadband internet services with future CVT programs would further promote successful implementation. Further studies with larger sample sizes and the use of broadband connectivity would be helpful. Conflicting findings are present in the literature related to the cost-effectiveness of CVT, and costeffectiveness of CVT varies in rural areas.10 When planning to implement new CVT programs, facilities must consider connectivity issues related to rural areas. The cost of broadband and other services may be higher in rural areas and yet the availability lower. Even though telehealth is usually implemented to improve physical health outcomes, other outcomes such as improved mental health, functional status, and quality of life should be considered.13 The rural nature of many states results in a greater number of miles needed to travel for care; therefore, CVT may result in travel savings for veterans and the VAMC. Additionally, travel to the facility often results in hardships for veterans and families. It is not uncommon for HBPC veterans to rely on ambulance transportation. Regardless, each trip to the facility can result in significant cost to the family and the VAMC. CONCLUSION
Video telehealth is a relatively new technology. An extensive literature review was conducted, but there are limited studies that have examined home-based primary care and evaluated cost factors. Most articles discussed the use of video telehealth by specialty care clinics or in rural areas, and CVT articles that evaluated health outcomes were not prevalent. No articles using both approaches (telemonitoring and CVT) and comparing the outcome variables for this study were found. Additionally, there were no randomized clinical trials comparing CVT with usual care during the same observation period. This type of study may help explore how time and disease trajectory affect outcomes. It is anticipated that as
www.npjournal.org
CVT expands more research will be added to the growing body of knowledge. This material is the result of work supported with resources and the use of facilities at the Jackson, MS VA medical center. References 1. Centers for Disease Control and Prevention. The state of aging and health in America. 2007. http:www.cdc.gov/aging/pdf/saha2007.pdf. Accessed December 1, 2013. 2. Lin W-C, Zhang J, Leung GY, Clark RE. Chronic physical conditions in older adults with mental illness and/or substance use disorders. J Am Geriatr Soc. 2011;59:1913-1921. 3. Parekh AK, Goodman RA, Gordon C, Koh HK. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126:460-471. 4. Anderson G. Chronic care: making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation; 2010. http://www.rwjf.org/files/research/ 50968chronic.care.chartbook.pdf. Accessed April 4, 2014. 5. Mann S. Addressing the physician shortage under reform. Association of American Medical Colleges. 2011. www.aamc.org/newsroom/reporter/ april2011. Accessed April 4, 2014. 6. Iglehart JK. Expanding the role of advanced nurse-practitioners-risks and rewards. N Engl J Med. http://dx.doi.org/10.156NEJMhpr1301084. Accessed April 4, 2014. 7. Jeter L. Incentivizing medical professionals. Mississippi Medical News. August 2013;1:8; & 9. 8. Povencher MT, Nuccio PF. Telemonitoring in COPD. J Respir Care Pract. 2011:26-29. 9. Carter A. Remote telemonitoring technology will expand, but progress depends on more research and federal support. Home Healthc Nurse. 2011;29:389-390. 10. Wade VA, Karnon J, Elshaug AG, Hiller JE. A systematic review of economic analysis of telehealth services using real time video communication. BMC Health Serv Res. 2010;20:233. 11. Coakley C, Hogh A, Dwyer D, Parrah D. Clinical video telehealth in a cardiology pharmacotherapy clinic. Am J Health Syst Pharm. 2013;70:1974-1975. 12. Fischer HH, Eisert SL, Everhart RM, et al. Nurse-run, telephone-base outreach to improve lipids in peoples with diabetes. Am J Manag Care. 2012;11:1-4. 13. Jennings MB. Patient outcomes research: seizing the opportunity. Adv Nurs Sci. 1991;14:59-72.
Rebecca Clanton, RN, DNP, FNP-BC, works at the Veterans Administration in Jackson, MS. She can be reached at Rebecca. [email protected]. L. Alice March, PhD, RN, FNP-BC, CNE, is the assistant dean of graduate programs and an associate professor at The University of Alabama Capstone College of Nursing. Sonny Ruff, RN, DNP, FNP-BC, CEN, works at Hospital Physician Partners, Madison River Oaks in Canton, MS. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. This material is the result of work supported with resources and the use of facilities at the Jackson, MS VA medical center. 1555-4155/14/$ see front matter Published by Elsevier, Inc. http://dx.doi.org/10.1016/j.nurpra.2014.08.027
The Journal for Nurse Practitioners - JNP
823