Miami VA TeleHealth Initiatives

The Miami VA Medical Center’s T-Care program is based on the premise that care coordination blended with technology can potentially decrease the economic burden of chronic disease. Three major chronic diseases are responsible for disproportionately high health care costs in the elderly population: CHF, DM, and COPD. Expenditures for chronically ill patients are disproportionately distributed, with 10% of the sickest patients accounting for more than 75% of expenditures. Programs that could prevent or limit the hospitalizations and ER visits of these frail elderly patients with chronic disease would substantially reduce the overall economic burden of these diseases.

Dr Dang’s blended telecare coordination program, “T-Care,” for elderly community-based veterans with CHF, DM, or COPD at the Veterans Affairs Medical Center in Miami, Florida, integrates care coordination with Internet technology aimed at daily assessment and adjustment of the care process. T-Care was started at the Miami VAMC as a clinical demonstration project funded by Veterans Integrated Service Network 8 (VISN 8), was established to examine the feasibility of a care-coordination model blended with technology for an older, chronically ill veteran population.  In this program, the daily monitoring of patients by the care coordinators is automated via a computerized, telephone-based, in-home messaging/monitoring device. The device also provides disease-specific education to patients and their caregivers that promotes disease self-management and enables them to make better-informed decisions about health care. The interdisciplinary patient-centered treatment plan provides : a) coordination of services for the veteran, whether in the home, the outpatient clinic, or the hospital; b) closer monitoring of outcomes coupled with quicker feedback from providers; and c) a proactive model for health care that focuses on both immediate crises and long-term health-care behaviors.

In the T-Care program, care coordination is directed at daily monitoring of critical, disease-specific parameters, e.g., blood sugar for DM, sputum change and shortness of breath in COPD, weight change and shortness of breath in CHF, via an in-home messaging device. The daily measures allow reassessment and readjustment of the care plan. The patient is empowered both in disease self-management and in communication with health-care providers, through a parameter-focused approach to the education process, monitored and communicated via technology.

In a report which presented preliminary data on the relative effect of T-Care on resource utilization in patients with CHF, COPD, and DM, as measured by inpatient admissions, bed days of care (BDOC), and ER visits. Health-care resource utilization for CHF patients showed a significant decrease by more than 50% in the total ER visits and hospital admissions (P = 0.03); total BDOC decreased, from 179 to 53 (P = 0.07), while total outpatient visits were similar, from 71 to 83 (P = 0.38). For COPD patients, total BDOC decreased from 115 to 46, but the decrease did not reach statistical significance (P = 0.24). Similarly, the slight increase in hospital admissions and ER visits and decrease in outpatient visits for COPD patients were not statistically significant. For DM patients, the outpatient visits decreased significantly, from 199 to 143 (P = 0.03), but the decrease in hospital admissions and the increases in ER visits and BDOC were not significant.

The greatest benefit in terms of utilization appears to be in the CHF group, with significant reductions in hospital admissions and ER visits and a decrease in the BDOC, which contributes most to utilization costs.

The Miami VA Medical Center’ TLC for Dementia program was designed to support caregivers of patients with Dementia. It educates them on key issues pertaining to dementia patients (wandering, agitation, feeding, dressing, etc.) and on stress and coping. It monitors their stress and burden, and provides care coordination.

Despite barriers that may inhibit the use of technology in the elderly, our results support previous studies showing that proper screening for the ability to use the technology and assistance from their caregivers can enable this population to benefit from the use of technology in managing their chronic diseases, even in terms of decreased health-care utilization.