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Service Delivery Innovation Profile

At-Home Palliative Care for Veterans Enhances Medication Adherence and Connections With Families and Providers, While Also Lowering Costs


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Snapshot

Summary

The Advanced Illness Palliative Care program is a multidisciplinary initiative that provides care management and palliative care to chronically or terminally ill veterans in their homes via telehealth technology. During a 2-year pilot study, 98 percent of participants reported adherence to their medications, and 92 percent felt more connected to their providers; overall health care expenditures for program participants decreased by 67 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation cost comparison, along with post-implementation surveys in which patients report on whether the program has resulted in improvements in key metrics, such as medication adherence, understanding of their medical condition, level of connectedness, and patient–provider communication.
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Developing Organizations

North Florida/South Georgia Veterans Health System; Veterans Health Administration in its Florida-Puerto Rico Network (VISN 8)
Lake City, FLend dobegin pp

Patient Population

Vulnerable Populations > Military/dependents/veterans; Rural populations; Terminally illend pp

Problem Addressed

Chronically and terminally ill patients are extremely costly to the health care system, yet they are also not well served. Patients often die in pain in the hospital despite wishing to die comfortably at home with loved ones.
  • Dying in hospitals, against wishes and at high cost: Americans would prefer to die pain-free in their own homes. Only 25 percent die at home, whereas 50 percent of patients older than 65 years die in the hospital; most of these patients would not require hospitalization if an appropriate home-care program were available.1 The net result is high end-of-life care costs; during the last year of life, mean Medicare expenditures average $24,600, more than 2.5 times the $9,400 average previous-year costs for the same beneficiaries.2
  • Lack of provider skills: Providers often lack the skills needed to handle end-of-life issues, as they traditionally view a patient's death as a failure.3 Only 38 percent of physicians believe that they are qualified to provide palliative care, and, of those who provide palliative care, only 39 percent are certified in palliative medicine. Although medical schools are now required to address end-of-life care in their curricula, there is no standardized program addressing best practices for palliative care.1 According to a 2009 report on hospice care, the average hospice patient receives hospice care for only about 3 weeks,4 an insufficient amount of time to provide holistic end-of-life care to patients and families.
  • Veterans not immune to the problem: The North Florida/South Georgia Veterans Health System found that 4 percent of patients classified as "high risk" consumed 40 percent of the network's total resources. Most chronic or terminally ill veterans cannot receive at-home services because case management services are typically only provided during the hospital stay.5 Furthermore, many patients live in rural areas, far away from Veterans Affairs (VA) services, thus making it difficult to receive care at home.

What They Did

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Description of the Innovative Activity

The Advanced Illness Palliative Care program provides care management and palliative care services to chronically or terminally ill veterans in their homes. Care team members monitor veterans' physical, emotional, and spiritual symptoms using a comprehensive case management program implemented via a text-messaging device placed in the patient's home. Key elements include:
  • Care team: The Advanced Illness Palliative Care team consists of an advanced practice registered nurse who monitors medical issues flagged by the text messaging device (see below for more details), a chaplain who attends to the spiritual needs of the patient and family, and a social worker who coordinates community services.
  • Referral: The program encourages physicians to refer patients who, due to their diagnoses or comorbidities, appear to have only 2 or 3 more years to live.
  • Care management and coordination: Patients communicate with the care team daily, which allows providers to monitor symptom trends and intervene in the early stages of potential problems. Communication occurs via a text-messaging device that transmits information using a normal phone line connection; patients enrolled in the program must have a regular analog phone line and a working electrical outlet. Using the device, which has clinical, content-based questions that replicate logical face-to-face encounters between patients and health care providers, the care team provides the following services to patients:
    • Daily symptom monitoring and communication: Each day, patients answer questions related to their symptoms using the device, which incorporates a branching logic tree that bases subsequent questions on previous responses. The device transmits patient responses to the nurse's computer; the nurse then follows up with the patient. For example, the device asks a heart failure patient to report daily weight; if weight is elevated, the nurse contacts the patient to confirm the weight and to gather information about the patient's general health status. In nonurgent cases, the nurse contacts the patient's health care provider via the computerized medical record, and the provider responds with instructions for medication changes or other care steps; in some cases, the nurse advises the patient to take extra medication until the nurse can consult with the provider. In urgent cases, nurses instruct patients to go a nearby urgent care facility. Nurses then followup with patients by telephone. All patient/provider interactions are documented in the patient's computerized medical record.
    • Support with end-of-life issues: Patients also respond to questions related to emotional status. If the patient provides an answer that indicates a potential problem, a computerized message is sent to the chaplain, who then contacts the patient to discuss his or her emotional needs and educate the patient and family about common end-of-life issues. In addition, this process is a means of investigating whether hospice care is warranted, thus allowing earlier referrals to hospice than might otherwise occur.
    • Caregiver support: The branching logic includes questions for the patient's caregiver, such as "Are you feeling overwhelmed?" The care team is notified if the caregiver indicates a need for additional help. The social worker may then arrange for home care or respite care; the chaplain may also provide emotional and spiritual support to the caregiver.
    • Connectivity: The care team seeks to make patients feel more connected to their providers and family members. For example, the team can send a videophone to a patient's loved ones or arrange for the chaplain to speak with the patient over the videophone.
  • Education: In addition to providing patient care, the program educates providers and patients about palliative medicine.
    • Providers: The program educates health system providers about palliative care and the Advanced Illness Palliative Care referral process. This education takes place during program marketing efforts, during interactions with physicians while managing patients, and in written information sent to providers from program staff.
    • Patients and families: In combination with interactions with the team, the branching logic on the text-messaging device educates patients and families about specific diagnoses and provides useful information and support related to spiritual, emotional, and other needs at the end of life.

Context of the Innovation

The Advanced Illness Palliative Care team is part of North Florida/South Georgia Veterans Health System, which serves more than 1.7 million veterans, many of whom live in rural areas. The Advanced Illness Palliative Care program is based on the Community Care Coordination Services model, created by the VA Veterans Integrated Services Network, which is a structured disease management program for chronically ill veterans. However, rather than using traditional case management services, Community Care Coordination Services uses technology to implement case management in the home, allowing providers to monitor medical symptoms remotely and in a timely fashion so that patients can receive care before a medical crisis occurs. North Florida/South Georgia Veterans Health System funded grants to internal staff members who wanted to replicate the Community Care Coordination Services model for specific diseases and patient populations.

Did It Work?

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Results

Results from a 2-year pilot study indicate that the program has resulted in an increase in patient satisfaction with provider communication and understanding about medical condition, improvements in symptom management, and a 67-percent reduction in costs of care. Key results are as follows:
  • Improved self-management of symptoms: Patients enrolled in the program consistently maintained their blood pressure at or below the VA clinical practice guideline specification of 130/80 mm Hg. Diabetic patients consistently maintained their hemoglobin levels at or below 9 percent.
  • Strong medication compliance: Ninety-eight percent of program participants reported taking all of their medications as prescribed.
  • Improved communication/connection between patients and providers: Eighty-two percent of program participants report increased satisfaction with the communication with their providers. Ninety-two percent of participants say that they feel more connected to their providers due to the responsiveness of the palliative care team. Because of the strong bond they have developed with palliative care team members, patients are often reluctant to relinquish their ability to communicate with the team when they leave home for an assisted-living or nursing home facility.
  • Improved understanding of medical condition: Eighty-nine percent of program participants report that they have a better understanding of their medical condition.
  • Substantially reduced costs: Total care costs for 58 patients were $799,860 in the 6 months before enrollment in the Advanced Illness Palliative Care program, compared with $167,205 in the 6 months after enrollment, representing a 67 percent decrease in total expenditures.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation cost comparison, along with post-implementation surveys in which patients report on whether the program has resulted in improvements in key metrics, such as medication adherence, understanding of their medical condition, level of connectedness, and patient–provider communication.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Choosing and testing technologies: Advanced Illness Palliative Care team members tested different technologies and selected the technology based on the capabilities and adaptability of the device. (Note: A number of telehealth technologies are used within the VA Community Care Coordination Services, which maintains a list of technologies approved for use within the system; each telehealth program selects the technology that best meets its own needs.)
  • Refining the software: The software was adapted to meet the needs of the organization regarding monitoring advanced illness/palliative care patients. Community Care Coordination Services developed many of the medical questions included in the branching logic tree; however, the Advanced Illness Palliative Care team added questions related to spirituality and end-of-life issues.
  • Designing an evaluation system: Advanced Illness Palliative Care team members designed a survey to help them evaluate the program.
  • Piloting the system: The care team piloted the system; based on the pilot's success, the program was fully integrated into North Florida/South Georgia Veterans Health System's budget and services.
  • Expansion of disease monitoring: About 6 months after program implementation, clinicians recognized the need to expand the number of disease processes being monitored. The organization added software to monitor advanced illness/palliative care patients with congestive heart failure, chronic obstructive pulmonary disease, hypertension, and/or diabetes mellitus, based on VA/Department of Defense clinical practice guidelines.
  • Revision and update: The VA identified the program as one of six disease management programs to be revised and updated during fiscal year 2009; the development of the revised program will occur in partnership with staff from the VA Care Coordination/Home Telehealth and Hospice and Palliative Care department.

Resources Used and Skills Needed

  • Staffing: The program includes one full-time advanced practice registered nurse, one full-time chaplain, a part-time social worker (0.33 full-time equivalents), and a part-time administrative assistant, who cover approximately 100 patients at any given time.
  • Costs: Costs include staffing costs and equipment costs. Staffing costs are unavailable. Each patient receives a text-messaging device for the home, and patients whose families are far away receive a videophone; the program invested $75,000 to $100,000 to purchase adequate technology to serve 100 patients.
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Funding Sources

Veterans Health Administration in its Florida-Puerto Rico Network (VISN 8); VHA Florida-South Georgia Network
Initial funding for the pilot project was provided by a grant from North Florida/South Georgia Veterans Health System. Ongoing funding is built into the annual budget of the health system.end fs

Tools and Other Resources

The technology used in this program is available from Bosch. Available at: http://www.healthbuddy.com/content/language1/html/55_ENU_XHTML.aspx

VA/Department of Defense guidelines for the management of various conditions are available at:

Adoption Considerations

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Getting Started with This Innovation

  • Focus on clinical care: Emphasize the clinicians and the case management program rather than the technologies, which are simply tools to facilitate the delivery of program services.
  • Obtain senior management support: Enlist the support of top management, ensuring that they understand the value of the program and the role of care coordination in the disease management process. Demonstrating positive clinical and financial results can help win support.
  • Evaluate program success: Care team members developed a program evaluation tool (a patient survey) to measure their success. Measuring program success from the outset makes it easier to demonstrate the program's value to different audiences, including clinical, quality improvement, and top administrative staff members.
  • Identify palliative care champions: Identify clinical champions who can promote palliative medicine and telehealth to their peers.
  • Provide palliative care education to clinicians: Educate clinicians about end-of-life issues by providing training and offering opportunities to serve on committees.
  • Solicit support from frontline staff: Build enthusiasm among frontline staff by including them in key decisionmaking processes. Frontline staff may fear that technology will interfere with the patient–provider connection but eventually will find that it actually fosters communication.

Sustaining This Innovation

  • Ensure seamless care transitions: Work closely with inpatient units and primary care doctors to provide seamless care transitions.
  • Solicit patient feedback: Regularly ask patients what they think of the program and how it can be improved, and incorporate their suggestions.
  • Reeducate physicians about palliative care: Periodically reeducate physicians about the value of the program, as they are traditionally focused on curative medicine and thus may neglect to refer patients.

Spreading This Innovation

A number of organizations interested in starting a similar program have contacted the North Florida/South Georgia Veterans Health System for information.

Additional Considerations

  • Teams at the North Florida/South Georgia Veterans Health System also use the Care Coordination Services model to provide care to patients with hypertension, heart disease, diabetes, spinal cord injuries, Alzheimer's disease, chronic pain, bipolar disorder, schizophrenia, substance abuse, and posttraumatic stress disorder.

More Information

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Contact the Innovator

Jim Maudlin, MDiv
Chaplain
Advanced Illness Palliative Care Program
North Florida/South Georgia Veterans Health System
619 South Marion Avenue
Lake City, FL 32025
(352) 518-9326
E-mail: james.maudlin@med.va.gov

Nunnie Emery, ARNP
Care Coordinator
Advanced Illness Palliative Care Program
North Florida/South Georgia Veterans Health System
619 South Marion Avenue
Lake City, FL 32025
(352) 498-2493
E-Mail: nunnie.emery@va.gov

Rita Kobb, MN, ARNP-BC
Education Program Specialist
Director, Sunshine Telehealth Training Center (08A)
Office of Telehealth Services
North Florida/South Georgia Veterans Health System
619 South Marion Avenue
Lake City, FL 32025
(386) 754-6437
E-mail: rita.kobb@va.gov

Innovator Disclosures

Mr. Maudlin, Ms. Emery, and Ms. Kobb have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Maudlin J, Keene J, Kobb R. A road map for the last journey: home telehealth for holistic end-of-life care. Am J Hosp Palliat Care. 2006;23(5):399-403. [PubMed] Available at: http://ajh.sagepub.com/cgi/reprint/23/5/399.pdf

Meyer M, Kobb R, Ryan P. Virtually healthy: chronic disease management in the home. Disease Management. 2002;5(2):87-94.

Ryan P, Kobb R, Hilsen P. Making the right connection: matching patients to technology. Telemed J E Health. 2003 Spring;9(1):81-8. [PubMed]

Footnotes

1 Ryan P, Kobb R, Hilsen P. Making the right connection: matching patients to technology. Telemed J E Health. 2003;9(1):81-8. [PubMed]
2 Taylor DH Jr, Ostermann J, Van Houtven CH, et al. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007;65(7):1466-78. [PubMed] Available at: http://www.nhpco.org/sites/default/files/public/Statistics_Research/Cost_Study_Duke_Oct-2007.pdf
3 Oasis Healthcare, Inc. Physicians urged to guide patients to more effective use of hospice care. Quality of Life Matters. 2005 Aug/Sept/Oct;7(2):1-2.
4 National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. October 2009.
5 Meyer M, Kobb R, Ryan P. Virtually healthy: chronic disease management in the home. Disease Management. 2002 June;5(2):87-94.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 05, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
Beyond serving patients' clinical needs, Advanced Illness Palliative Care staff members have been creative in finding ways to serve patients' emotional needs as well. Jim Maudlin, MDiv, Chaplain of the Advanced Illness Palliative Care program, remembers how the program brought comfort to one dying patient and his family. "When I...

Read more