For much of the last decade, disease management has become something of a sub-industry within healthcare service delivery. Early on, expected reductions in home healthcare financing by insurers encouraged review of the costliest of patients and patient groups receiving home care services. Chronic disease patients were easily identified as those using the most resources in any home care agency and requiring the most services more frequently. 'Top ten' lists of the most prevalent and/or costliest diseases in home care were compiled, with diabetes, congestive heart failure (CHF), and respiratory conditions always at the top of the lists, if not as the most prevalent then usually among the costliest.
A sampling of the number and annual costs of chronic disease patients is provided in Table 1.
That there are many difficult and costly chronic diseases is by now well known. The current thrust of enquiry is toward determining which of these disease groups and patients living with these diseases respond well to different, less costly (or, eventually, more cost effective) interventions, such as the more frequent contact available via telehealthcare. Not all chronic diseases are good candidates for alternative interventions. Arthritis, for instance, the most common chronic disease in the U.S., is not responsive to telehealthcare services. Newer, more useable design of everyday tools for the arthritic patient may ameliorate certain physical difficulties experienced in the home but telecommunications capabilities built into the tools are not a needed feature. Another instance is certain chronic respiratory diseases such as emphysema and bronchitis. How frequently changes in respiration need to be measured is arguable. Many clinicians appear to think that, unlike asthma, which is prone to more frequent and preventable exacerbations, tracking of certain types of chronic obstructive pulmonary disease (COPD) simply demonstrates a very gradual and unpreventable deterioration. As telecommunications-ready tools for chronic disease patient care are getting more exposure in the home, and expectations of their promised cost savings/cost effectiveness increase, there is an obvious need to target those conditions and patient groups who both need and will do well with the technology that enables more frequent communications to and from the home.
A number of studies published in recent years note excellent results from short-term demonstration projects and provide evidence of the value of telehealth interventions. By now, those (relatively) few diabetics or patients with CHF who have done well with more frequent contact via telehealth have garnered a good deal of press. These patients have a range of daily needs that require careful attention and tracking. In short-term pilot studies with these and other patients in their group, agencies have been able to show that by undertaking frequent contact via telephone, video-visit, and telehealth workstation interaction, hospitalizations have been avoided, substantial monies saved. For the most part, telehealth pilot studies are begun by hammering out protocols regarding how often patients should be contacted and which measurements should be taken repeatedly and tracked during the course of the pilots. Essentially, each new project starts from scratch to learn how to use the technology, how to teach patients to use the technology, and how to define measurable parameters for a successful pilot.
Why haven't many more patients done well with the technologies of telehealth. Especially when the numbers who could be involved include the estimated 15 million people in this country with diabetes, or the 60 million with heart disease who are known to potentially benefit from more frequent contact. The reason may very well have nothing whatsoever to do with the efficacy of the technology. Today, marketing strategies for telehealth products continue to provide scenarios and flow charts for reduced monies for tele-visits compared to the cost of conventional, on-site home care. A typical estimate may range from $12-25 per televisit, compared to about $100 for an in-person visit, at a savings to the agencies averaging $70-80 per visit. The marketing pitch is attractive and convincing. In large part, these scenarios simply try to show how replicating the conventional home visit by using telecommunications to accomplish familiar tasks is possible and at a significant cost saving. Telehealth seems altogether do-able. What's wrong with this picture? Possibly a good deal although much of the problem, again, has nothing whatsoever to do with the efficacy of the technology to provide services to today's needy, chronic disease patients. Other issues have to be studied in tandem with the planning of telehealthcare technologies and use.
As changing, more limited reimbursement systems are moving toward payment per patient and per episode, the need to focus on disease prevention and wellness is becoming better recognized. The amount and kind of conventional services that have been undertaken can no longer be paid for; in addition, there has to be a mechanism to reduce visits yet help patients toward a certain degree of wellness over a long term, when the visits will be discontinued entirely (unless the patient is re-admitted to home care). New technologies may help providers and patients in the drive for achieving some degree of wellness and self management. The ability to bring many tools into the home and to teach and remind patients when to use them or when to take specific medications adds a dimension of care that home care nurses never had access to in the past. According to Ilene Warner, a home health nurse and telehealth industry observer, telehealth "will fundamentally alter our model by focusing on prevention rather than rescue" (Warner 1997).
Telehealth tools can play an important, assistive role for providers to help their patients toward shouldering the long-term goal of self management. Some agencies (but certainly not all of the relatively small number of agencies involved in telehealth) are using telecare for helping patients, especially elderly chronic disease patients, to achieve some degree of long-term self maintenance. For instance, in-person visits can be used to show patients with congestive heart failure (CHF) how to take and record their daily weight, how to control their diet and salt intake, and how to correct and/or report noticeable changes in weight or breathing. The patients' use of the tools (an automated weight scale, for instance) and their use of long-term plans of daily care that on-site and remote visits help to inculcate over the short term, will have helped them reach a degree of capability for self management, to, simply, 'know what to do' after the home care visits discontinue.
It is important to consider the amount and kind of information that can be sent into the patient's home and the potential for greatly expanding both the information and the services that can be provided via telehealthcare. Much of these services involve better educating the patient and can be relatively inexpensive. Phone calls to keep in contact, to rather casually assess a patient's progress, or to provide a medication reminder are an important part of the range of services that are available today that are affordable and that can be customized for particular patient's needs. In addition, many other telecommunications-ready tools are available, some not specifically designed only for home telecare applications. Many of these can be adapted for bringing a range of needed resources and services into the home. They can be used to effectively supplement the services and information that are provided conventionally via in-person care, as indicated in the following example.
A woman with breast cancer who has recently undergone surgery and chemotherapy can use home telecare equipment to:
These examples indicate the potential uses of easy-to-operate telehealth equipment in patient teaching and assistance, which, in this case, may eventually translate into the patient's taking effective preventative measures for self-care. The challenge for today's providers is to find more ways to help patients self manage over a long term, especially when, needless to say, their admission to home care services ends. Bringing a telehealth tool into the home does not in itself reduce costs over a long term. Programs that can help patients self manage or to simply 'know what to do' after home care (or even 'telehealthcare') visits have to be included with the tools and customized for patients over the long term or their chronic diseases. Beginning with telehealth tools to extend conventional care services is an excellent start to improved care needed for chronic disease patients. However, building longer-term programs for these patients is key to helping them self manage over a much longer period than conventional home care service admission allows - namely, over their lifetimes.
Fowler F J. Disease management's front steps. Home Healthcare Dealer, July/August, 1996: 126-7.
Hoffman C, Rice D, Sung H Y. Persons with chronic conditions: their prevalence and costs. Journal of the American Medical Association, November 13, 1996, 276(18): 1473-9. (Link last checked on December 15, 2004).
Kinsella A. Home healthcare: wired and ready for telemedicine, the second generation Sunriver, OR: Information for Tomorrow, 1998.
Roglieri J L, Futterman R, McDonough K L, Malya G, Karwath K R, , Bowman D, Skelly J , Warburton Jr. S W. Disease management interventions to improve outcomes in congestive heart failure. The American Journal of Managed Care, December, 1997, 3(12): 1831-9. (Link last checked on December 15, 2004).
Schiller Jr. A E, Bondmass M, Avitall B. Technology-based home care for disease management. The Remington Report, Sept/Oct, 1997: 10-12.
Warner I. Introduction to Home healthcare: wired and ready for telemedicine, the nurses' edition Sunriver, OR: Information for Tomorrow, 1997.
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