297

TELEMEDICINE AND e-HEALTHVolume 12, Number 3, 2006© Mary Ann Liebert, Inc.

Outcomes Associated with a Home Care Telehealth Intervention

FAITH HOPP, Ph.D.,1 PETER WOODBRIDGE, M.D., M.B.A.,2–4

USHA SUBRAMANIAN, M.D., M.S.,2,3,5,9 LAUREL COPELAND, Ph.D.,7,8

DAVID SMITH, M.D.,3,5 and JULIE LOWERY, Ph.D.1,6

ABSTRACT

To determine whether adding telehealth technology to traditional home care services increaseshealth-related quality of life (HRQOL) and home care satisfaction, and decreases resource uti-lization among home care patients. This trial included 37 home care patients receiving ser-vices in a Veterans Affairs medical center, randomized into intervention and control groups.Outcome measures included patient satisfaction and HRQOL at baseline and 6-month fol-low-up, and the use of inpatient and outpatient services before and during the 6-month studyperiod. Intervention group patients reported greater improvement in the mental health com-ponent of HRQOL, (t � 2.27; df � 15; p � 0.04). Satisfaction with the telehealth equipmentwas high (means exceeded 4.0 on six measures ranging from 1–5). However, no statisticallysignificant differences were observed between intervention and control groups in terms ofchanges in physical health, inpatient admissions, bed days of care, emergency departmentvisits, or general satisfaction with home care services. Intervention group members did showa trend (p � 0.10) toward fewer overall outpatient visits (mean � 29.1; standard deviation[SD] � 30.1) compared to those receiving traditional home care services (mean � 38.9; SD �28.9) The use of telehealth services as an adjunct to traditional home care is associated withgreater improvements in mental health status and a trend toward lower use of inpatient andoutpatient healthcare services. Further work, utilizing larger sample sizes, is needed to in-vestigate the relationship between telehealth services, the use of healthcare resources, andother outcomes.

1HSR&D Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Ann Ar-bor, Michigan.

2Richard L. Roudebush VAMC, Center of Excellence on Implementing Evidence-Based Practice, Indianapolis, In-diana.

3Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Med-icine, Indianapolis, Indiana.

4Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana.5Regenstrief Institute for Healthcare, Indianapolis, Indiana.6Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor

Michigan.7Department of Veterans Affairs, South Texas Veterans Health Care System VERDICT HSR&D, San Antonio, Texas.8Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.9Indiana Center for Aging Research, Indianapolis, Indiana.

6238_02_p297-307 6/12/06 1:31 PM Page 297

INTRODUCTION

HOME CARE PROGRAMS, faced with the chal-lenges of providing services to growing

numbers of frail older adults, have become in-creasingly interested in home care telehealthservices, programs that involve the use of in-teractive video to facilitate communication be-tween home-based patients and home carenurses. The Balanced Budget Act of 1997 andsubsequent Medicare, Medicaid, and StateChildren’s Health Insurance Programs BenefitsImprovement Act of 2000 established the mech-anism whereby home care agencies can be paidfor home telehealth services as part of theprospective payment system (PPS), a factor thathas resulted in increased interest in home tele-health programs.1 Under PPS, home care agen-cies are paid a fixed amount for a period ofhome care services regardless of intensity of ef-fort. As part of PPS, home care agencies mayuse home telehealth to “promote efficiencies orimprove quality of care” provided that it is partof a physician ordered treatment plan.2

The Veterans Health Administration (VHA)is the largest single provider of healthcare inthe United States. It is a fully integrated health-care system that is at risk for all lifetime costsof care of its beneficiaries. Eligible beneficiariescannot be denied benefits or lose enrollmentstatus. The VHA, through the Home-Based Pri-mary Care (HBPC) program, is among thelargest providers of home care services, with 88separate home care programs nationwide. Infiscal year 2003, 15,645 veterans received HBPCservices, with an average daily census of 8,386nationwide and annual expenditures of $72million (VA Central Office, written communi-cation, February 11, 2004). Recently telehealthhas been reported to have the potential to in-fluence processes and outcomes of care amonghome care patients.3,4 Consequently, health-care organizations, including the VHA, are de-voting considerable financial resources to re-search and development on telehealth, as ameans of furthering goals related to preventivemedicine and chronic illness management.5,6

Despite the growing use of telehealth inhealthcare delivery, reviews of the literaturehave concluded that relatively little informa-tion is available concerning telehealth out-

comes.7,8 With regards to studies involvinghome care applications, some nonrandomizedstudies have shown improved outcomes for pa-tients receiving telehealth services in conjunc-tion with home care services, compared tothose receiving traditional home care. For ex-ample, a study was conducted involving 16newly enrolled home care patients in a pro-gram involving the use of home video systemsdesigned to facilitate communication betweenpatients and home care staff members.9 Out-comes for those receiving video telehealth ser-vices in addition to traditional home healthcarewere compared to outcomes with those for areference group (n � 16) receiving traditionalhome care services, and the two groups werematched by age, functional status and gender.The videophone group showed significantlygreater improvements in functional status (ac-tivities of daily living [ADL]), communication,and social cognition compared to the referencegroup, suggesting that the use of videophoneswas associated with improved independencecompared to traditional home care services. Pa-tient satisfaction and the use of healthcare ser-vices were not examined as outcomes. A recentstudy involved a multifaceted intervention for791 veterans involving the use of care coordi-nators, home video, and store-and-forward de-vices.10 The comparison group was randomlyselected from a stratified sample that was de-scribed as similar to the intervention group interms of diagnoses, age, and gender. The com-parison group was not matched by prior use ofhealthcare services and prior cost of services,both of which were criterion used to target pa-tients for the intervention group, and the au-thors note that the intervention group waslikely biased toward more adverse events priorto the intervention. The intervention group pa-tients demonstrated greater reductions inemergency department use, nursing home ad-missions, and hospital admission and bed daysof care over a 1-year period compared to thecomparison group.

Reviews of the literature have uncovered fewrigorous studies, particularly randomized clin-ical trials, of telehealth applications,11 andamong the few randomized trials conducted ofhome telehealth, results have been mixed. A re-cent study randomized 163 patients with dia-

HOPP ET AL.298

6238_02_p297-307 6/12/06 1:31 PM Page 298

betes to either telehealth video system in con-junction with home care services (interventiongroup) or to traditional home care services (con-trol group) with 60-day follow-up.12 No groupdifferences were observed in terms of func-tional status, quality of life, or patient satisfac-tion at follow-up. However, patients in the con-trol group were more likely to need continuedhome healthcare at follow-up, and were alsomore likely than the intervention group to bedischarged to a hospital or skilled nursing fa-cility. One of the largest studies to date of hometelehealth involved 212 patients who were ran-domized to either telehealth (video monitoringin conjunction with home care services) or tra-ditional home care.13 The study reports that nodifferences were seen in the use of services be-tween the two groups. However, interventiongroup members had lower average total healthcare costs (excluding home care costs) com-pared with the control group ($1,948 versus$2,674), differences that were largely attribut-able lower hospitalization costs in the interven-tion group. Home health costs for the interven-tion group were higher than for controls ($1,830versus $1,167). No differences were found be-tween intervention (telehealth) and control (tra-ditional home care) groups on patient satisfac-tion and information on health-related qualityof life (HRQOL) was not reported. A study ofhome care patients receiving an intervention in-volving telehealth devices that forwarded in-formation on vital signs from patient homes tohome care nurses was conducted in the VAConnecticut Healthcare System.14 A compari-son of persons randomized to the interventionversus traditional home care services found sig-nificantly greater 6-month declines in bed daysof care, urgent care clinic visits, emergency de-partment visits, and A1c levels among inter-vention group members compared to controls.Significant differences were not observed interms of changes in level of functioning or self-rated health status. The results are promising,but because the intervention did not involve theuse of interactive video, the results are not di-rectly comparable to the majority of home caretelehealth studies, including the present study,that evaluate an intervention involving livevideo interactions between home care patientsand nurses.

In summary, despite considerable invest-ment in telehealth technologies, very few rig-orous studies have been conducted to deter-mine whether these technologies actuallyreduce the use of hospital services, beyond thatwhich might be expected from existing homecare or care management programs. Thosestudies that have been conducted using rigor-ous methodologies have shown mixed results.The present randomly controlled trial (RCT)further examines the outcomes associated withthe provision of telehealth care among homecare patients in a VA medical center, comparedto those for patients receiving traditional homecare services. Research hypotheses for thestudy include the following:

1. Patients receiving home care telehealth ser-vices, compared to patients receiving tra-ditional home care, will report more posi-tive changes in HRQOL and patientsatisfaction with home care services, be-tween baseline and the 6-month follow-up.

2. Patients receiving home care telehealth,compared to patients receiving traditionalhome care, will have lower levels ofhealthcare resource use, in terms of num-ber and duration of inpatient admissions,number of outpatient visits for primaryand specialty care, number of emergencyroom visits, and number and duration ofnursing home admissions during the 6-month study period.

METHODOLOGY

Study design

The study was a randomized trial evaluatingthe effects of a telehealth intervention amongpersons receiving home care services. Patientswere recruited over a 2-year period, and datawere collected at or prior to enrollment, andagain 6 months later. Prior to initiation of thestudy, Institutional Review Board (IRB) approvalwas obtained for all aspects of the protocol.

Study population

All patients receiving home care services atthe Richard L. Roudebush VAMC in Indi-

HOME CARE TELEHEALTH INTERVENTION 299

6238_02_p297-307 6/12/06 1:31 PM Page 299

anapolis, Indiana, were reviewed for potentialinclusion in the home telehealth research study.

Previous research has shown that prior use ofhealth services is among the strongest predictorsof future health service use.15–18 Therefore, to se-lect patients at high risk, our inclusion criteria included one or more hospitalizations, two ormore emergency department visits, or 10 or moreoutpatient visits in the prior twelve months.Other inclusion criteria included a care planspecifying two or more home care visits permonth and an expected need of future visits forat least 1 month, as determined by a review ofthe care plan and the patient’s condition by thehome care treatment team. This last criterion wasincluded in order to allow sufficient time to ob-serve the effects of the intervention. Exclusioncriteria included not having a telephone, beingjudged incapable of operating the telemedicinesystem if sufficient caregiver support was lack-ing, or having a survival expectation of less than6 months. The latter exclusion criterion providedsome assurance that patients would complete the6-month study follow-up.

Between September 2001 and August 2003,370 home care patients were reviewed for pos-sible inclusion in the study. Among those re-viewed, 252 (68.1%) were excluded becausethey did not meet one or more of the inclusioncriteria. Patients were frequently excludedfrom participation because they were expectedto have a stay in the home care program of lessthan 1 month. Among the remaining patients(n � 118), 81 (68.6%) declined to participate inthe trial, and 37 (31.4%) were enrolled. Amongthose who refused, many mentioned a per-ceived lack of benefit from the intervention asa reason for nonparticipation. Consequently,only a small subset of home care patients en-rolled in the randomized trial.19

Enrollment procedure

A research assistant (RA) contacted eligiblepatients by telephone to explain the study andarrange a meeting. At this meeting, the RA pro-vided additional information about the studyand obtained informed consent. After comple-tion of a baseline survey, the RA unsealed anenvelope containing the randomized group as-signment. Persons assigned to the treatment

(telehealth) group had videophone units in-stalled in their homes within a week after en-rollment.

Intervention description

Traditional home care patients received nurs-ing services at home and periodic telephone con-tact with the clinical staff concerning their homecare services. Intervention group patients, in ad-dition to receiving traditional home care services,had contact with the home care staff using tele-health units. The telemedicine equipment was anAviva 1010 video monitor manufactured byAmerican TeleCare, Inc. Each unit was 16 incheswide, 13 inches deep, and 10 inches tall. The sys-tem required a 110-V electrical connection and aregular analog telephone line. Each telemedicineunit consisted of several components: a homeunit with interactive voice and video technology,and a video camera allowing the patients to beseen by the nurses in the home care program.Some patients were also given units with pe-ripheral attachments, such as blood pressuremonitors, stethoscopes, and glucose monitors. Acentral unit (base station) was available to clini-cal providers. Patients were able to see the clin-ical staff members on the video monitor, andclinical staff members were able to see the pa-tient at home. When the unit was turned off,there was no ability for clinical staff and patientsto communicate.

The focus of the telehealth visits was on pro-viding nursing contacts beyond those availableunder traditional home care, to increase con-tact between patients and home care staff mem-bers, facilitate more frequent monitoring of patient conditions, and provide greater en-couragement for self-care practices. The fre-quency of video encounters was determined bythe home care nurse, in consultation with thepatient’s primary care provider and a reviewof the patient’s medical record. Video sessionsincluded the following components: discussionof the patients overall health status; review ofmedications in terms of type and dosage; dis-cussions of any health concerns by the patient;and nurse reminders concerning appropriateself-care behaviors, including diet, exercise,and monitoring of symptoms such as bloodpressure and weight.

HOPP ET AL.300

6238_02_p297-307 6/12/06 1:31 PM Page 300

Measures and data sources

Data were obtained from two major sources:a questionnaire at baseline and 6 months afterbaseline to obtain information on HRQOL andpatient satisfaction with home care servicesand national VA databases, to obtain data onnumber and duration of inpatient days, nurs-ing home admissions and days, outpatient vis-its, emergency department visits, and in-per-son home care visits by a registered nurseduring the 6-month study period. Data werealso collected on the total number of registerednurse contacts, including both in-person andtelehealth visits, during the 6-month study pe-riod. The primary independent variable wasstudy group (intervention versus control).

Telehealth contacts. For the interventiongroup, data were compiled on the total num-ber of telehealth contacts during the 6-monthstudy period.

HRQOL. HRQOL data, which assess the abil-ity to perform usual social, recreational, andwork activities, were obtained from the Med-ical Outcomes Study Short-Form 36-item Vet-erans’ version (SF-36V), a modified version ofthe SF-36 adapted for use with VA patientswith demonstrated reliability and validity.20

The physical component scale (PCS) and men-tal component scale (MCS) were computed ac-cording to established algorithms, includingtreatment of missing data.21 We calculatedchanges in HRQOL between baseline and 6-month follow-up.

Patient satisfaction. Patient satisfaction ques-tions were based on a previously validatedversion of an instrument designed to assesssatisfaction with outpatient clinical care, andadapted so that patients were specificallyasked about their perceptions of home careservices.22 The scale is a sum of four items,each of which ranges from 1 to 5; higherscores on this measure indicate more satis-faction with home care.

For the intervention group, separate ques-tions were asked concerning satisfaction withthe telehealth equipment. These questions werefrom the VA National Ambulatory Care Sur-

vey, originally designed to assess perceptionsof outpatient service use, and modified for usein evaluating telehealth services.23

Resource utilization. Information on VAhealth resource use, for the 6 months prior toand 6 months after enrollment, was gatheredfrom the patient treatment file (PTF) and theoutpatient care (OPC) file, national VA data-bases that are compiled from local hospitalrecord systems.24 Separate dependent variableswere constructed summarizing the use ofhealthcare resources: (1) total bed days of in-patient care; (2) total number of hospitaliza-tions; (3) total number of outpatient visits forprimary and specialty care; (4) total number ofemergency department visits; (5) total numberof in-person home care visits; (5) total numberof nursing home visits; and (6) duration ofnursing home visits.

Comorbidity. Comorbidity was measured forthe 6 months prior to study enrollment to en-sure case–mix adjustment between the twogroups. Diagnosis with each of eight condi-tions, as an inpatient or outpatient, was as-sessed. These indicators were then summed, re-sulting in a scale with a range of 0 to 8. Theeight conditions tracked were diabetes, hyper-lipidemia, hypertension, coronary artery dis-ease, atrial fibrillation, congestive heart failure(CHF), stroke, and chronic obstructive pul-monary disease (COPD), as used in previousstudies.25 Details on the International Classifica-tion of Diseases, 9th edition (ICD-9) codes usedto define these conditions are available on re-quest.

Statistical analysis

Student’s t tests for continuous variablesand �2 analysis for categorical variables wereconducted to establish comparability of thestudy groups in terms of demographics andseverity of illness measures. Statistical testsused to examine each hypothesis are de-scribed below.

The first hypothesis, that intervention groupmembers would have greater changes inHRQOL and patient satisfaction, was exam-ined with Student’s t tests of the change scores,

HOME CARE TELEHEALTH INTERVENTION 301

6238_02_p297-307 6/12/06 1:31 PM Page 301

appropriate because the data were normallydistributed. Possible demographic covariateswere considered, but because no differenceswere detected between the groups on any de-mographic variables, and the power of theanalyses was limited, none was included inmodels of these outcomes. Sample sizes variedbecause of item-specific missing data.

The second hypothesis, that the interven-tion group members would have a lower levelof healthcare resource use, was examined us-ing linear, Poisson, and negative binomial re-gression. Negative binomial regression is avariant of Poisson regression that handlescount data where the variance exceeds themean, a violation of the Poisson distribu-tion.26 Prior service use was included as a co-variate in the models, to control for serviceuse prior to enrollment. Survival was in-cluded as a covariate in the models of health-care services to control for the shorter follow-up period among those who did not survivethe 6-month study period.

RESULTS

Patient characteristics

Among all study participants (interventionand control patients combined), the mean agewas 69.6 (standard deviation [SD] � 12;range � 40–89), 100% were male, 14% wereHispanic, 35% were African American, and51% were Caucasian. Among those with avail-able data on educational attainment (n � 33),mean years of education were 11.3 (SD � 2.8;range � 7–17). Patients typically had multiplecomorbidities (mean � 3.4; SD � 1.8). Mosthad one or more of these chronic conditions(n � 34; 92%), and the majority (68%) had threeor more comorbid conditions. The most com-mon comorbidities were diabetes (54%) and hy-pertension (80%). Baseline measures of HRQOL,including both the PCS (mean � 24.83; SD �7.47) and MCS (mean � 40.52; SD � 11.98), werebelow norms established for a general popula-tion.20 As shown in Table 1, no significant dif-ferences were observed between interventionand control groups on baseline measures ofthese variables. The mean number of telemedi-

cine visits for the experimental group over the6-month study period was 10.89 (SD � 10.80).Two patients from each group (4 total) died dur-ing the 6-month follow-up period.

HRQOL

Outcomes related to HRQOL and patient sat-isfaction are shown in Table 2. Intervention pa-tients showed greater increases on the PCS ofthe SF-36V compared with controls, but no sta-tistically significant differences were observed(t � 0.30; df � 15; p � 0.77). Intervention pa-tients showed improvement on the MCS of theSF-36V (n � 10; MCS � �4.05), while the con-trol group members declined on this measure(n � 7; MCS � �4.11). This difference was sta-tistically significant (t � 2.27; df � 15; p � 0.04).

Patient satisfaction

High levels of satisfaction were found for bothintervention and control groups at baseline(mean � 15.2; SD � 3.7) and follow-up (mean �14.0; SD � 3.6). As shown in the third row ofTable 2, no statistically significant difference was observed between intervention and controlgroup in terms of changes in general home caresatisfaction (t � 0.48, df � 18; p � 0.64).

The majority of patients in the interventiongroup reported satisfaction with the telehealthequipment, as shown by their responses to afive-point Likert scale indicating their agree-ment with statements concerning telehealthservices. Most reported being taught the use ofthe equipment (21%, somewhat; 57%, defi-nitely), although fewer persons reported theirfamily members being taught the use theequipment (21% not sure, 14% somewhat, 36%definitely). Most reported that the equipmentsomewhat (38%) or definitely (54%) workedproperly, and the majority (64%) reportedknowing whom to call at the VA hospital incase of problems. The majority of participantsreported that they somewhat (50.0%) or defi-nitely (36%) learned more about self-care by us-ing the equipment, and most also reported thatthe equipment somewhat (36%) or definitely(43%) increased their contact with VA healthproviders. Almost three quarters (71%) re-ported that they definitely wanted to continueusing the equipment.

HOPP ET AL.302

6238_02_p297-307 6/12/06 1:31 PM Page 302

Use of health services

Table 3 displays the regression results com-paring the intervention and control groups onthe use of health services, including inpatientadmissions and bed days of care, outpatientcare, and emergency department use, as de-scribed below.

Number of inpatient admissions and days of care.Patients in the intervention and control groupsdid not differ significantly in terms of the num-ber of inpatient admissions during the 6-monthstudy period (mean of 0.67 for treatment group

versus 1.26 for control group members; p �0.61). There were differences in total inpatientbed days of care between the interventiongroup (mean days � 2.83) and the controlgroup (mean � 7.11). However, they were notstatistically significant in the negative binomialregression model, which adjusted for overdis-persion (the control group included a patientwith a 53-day hospitalization).

Number of outpatient visits. No significant dif-ferences were found between the two studygroups in terms of the number of primary care

HOME CARE TELEHEALTH INTERVENTION 303

TABLE 1. BASELINE PATIENT CHARACTERISTICS (n � 37)

Intervention Control(n � 18) (n � 19)

Measurea Mean (SD) Mean (SD)

Age 69.8 (11.6) 69.5 (12.7)Gender all participants were maleEthnicity

Hispanic 11% (2) 16% (3)African American 33% (6) 37% (7)Caucasian 56% (10) 47% (9)

Education in years 12.2 (3.1) 10.6 (2.3)Comorbidities

Diabetes 50% (9) 58% (11)Hyperlipidemia 39% (7) 53% (10)Hypertension 78% (14) 84% (16)CAD 33% (6) 47% (9)Atrial fibrillation 6% (1) 16% (3)CHF 39% (7) 47% (9)Stroke 17% (3) 16% (3)COPD 39% (7) 63% (12)

Number of conditions 3.0 (1.8) 3.8 (1.7)General satisfaction 15.3 (3.2) 15.6 (4.2)Physical component summary (PCS)b 26.6 (7.7) 22.9 (7.0)Mental component summary (MCS)b 40.2 (10.4) 40.9 (13.9)

aNo significant differences were detected on any measures.bHigher scores denote higher health-related quality of life. The PCS and MCS summary scores are norm-based

scores; thus, obtained values can be compared with a healthy population (mean � 50 and SD � 10).21

CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; SD,standard deviation.

TABLE 2. PATIENT SATISFACTION AND PHYSICAL AND MENTAL HEALTH OUTCOMES (n � 20)

Intervention ControlMeasure (mean, 95% CI) (mean, 95% CI) p-value

Change in SF-36V Physical Component Summary (PCS) �1.56 �0.64 0.77(�3.53, 6.64) (�3.83, 5.11)

Change in SF-36V Mental Component Summary (MCS) �4.05 �4.11 0.04(�0.40, 8.51) (�12.13, 3.90)

Change in General Home Care Satisfaction Scale �1.00 �1.56 0.64(�2.37, 0.38) (�3.93, 0.82)

CI, confidence interval.

6238_02_p297-307 6/12/06 1:31 PM Page 303

or specialty care outpatient visits. There was atrend (p � .10) toward fewer overall outpatientvisits for patients in the intervention group(mean visits � 29.06) compared to the controlgroup (mean visits � 38.89).

Number of emergency department visits. No sig-nificant difference was found between the twogroups in terms of the number of emergencydepartment visits (p � 0.83).

Number and duration of nursing home admis-sions. Although the use of nursing home ad-missions was of interest, there were insufficientnumbers of study patients receiving this typeof care for analysis. Two patients in the exper-imental group had nursing home admissionsduring the 6-month study period (lasting 1 dayand 152 days, respectively).

DISCUSSION

Home care providers need more informationon the outcomes of existing telehealth pro-grams in order to make critical decisions con-cerning the allocation of scarce medical re-sources. Results from this study indicate asignificant improvement in the mental healthcomponent of HRQOL among patients receiv-ing telehealth services compared to controls.However, no statistically significant differenceswere observed between intervention and con-trol groups in terms of changes in physicalhealth, inpatient admissions, bed days of care,

emergency department use, or general satis-faction with home care services. Patients in thisstudy rated telehealth services positively, sup-porting previous research that suggests that theintroduction of telehealth technologies can po-tentially enjoy wide acceptance.27,28 However,both intervention and control groups ratedhome care services highly, and hence there wasa possible ceiling effect that may have contrib-uted to the lack of significant differences ob-served between the groups in terms of the ef-fect of adding telehealth services to an existinghome care program.27 There was also a trendtoward fewer total outpatient visits among tele-health patients.

An issue that has not been fully resolvedamong home care telehealth providers con-cerns whether home telehealth services shouldsubstitute or supplement in-person home carevisits. Home telehealth has been suggested asa means of improving the efficiency of homecare services by reducing the number of in-per-son visits conducted by home care nurses. Forexample, a review of home care agencies inboth urban and rural areas in the United Statesfound that approximately half (46%) of allhome care visits could be conducted usinghome telehealth technology.29 However, as hasbeen the case in previous studies,13 the nursesinvolved in the intervention for this study werereluctant to use home telehealth as substitutesfor in-person visits, and instead viewed videovisits as a supplement to in-person care. The is-sue of substitution versus supplementationshould be carefully considered as home tele-

HOPP ET AL.304

TABLE 3. COMPARISON OF HEALTH SERVICES UTILIZATION (n � 37)

Intervention (n � 18) Control (n � 19) p value

Inpatient careNumber of hospital admissionsa 0.67 � 1.03 1.26 � 2.00 0.61Total inpatient bed days of carea 2.83 � 4.12 7.11 � 12.86 0.41

Outpatient visitsTotal number of outpatient visits 29.06 � 30.11 38.89 � 28.88 0.10

(excluding home care)a

Number of primary care visitsa 3.39 � 3.85 3.89 � 5.03 0.43Number of specialty care visitsa 2.06 � 2.49 2.47 � 2.61 0.41

Emergency department visitsb 1.00 � 1.33 2.11 � 2.89 0.83

aNegative binomial regression. Group differences in mean hospital days of care were influenced by an outlier, apatient in the control group who had a 53-day hospitalization.

bPoisson regression.

6238_02_p297-307 6/12/06 1:31 PM Page 304

health programs are further developed. Espe-cially given the additional costs associated withthe implementation of telehealth programs,and the equivocal findings to date regardingthe benefits of these programs when used forsupplementing existing services, the true ben-efits of telehealth programs may lie in substi-tuting less costly telehealth services for morecostly in-person home visits. However, moreresearch is needed to determine the extent towhich telehealth visits can substitute for in-person visits in a safe and efficient manner.

There are several strengths to the study de-sign compared with previous studies. First, thiswas one of very few randomized trials of hometelehealth conducted to date. Such a rigorousdesign is an essential step for obtaining infor-mation on the outcomes associated with hometelehealth compared to a control group receiv-ing home care treatment from the same pro-gram, and who are recruited using the same in-clusion and exclusion criteria. Second, prior useof healthcare services (a known predictor of fu-ture use) was included as a covariate in themodel. These covariates have not been used inprevious studies, and are suggested for inclu-sion in future work examining the effect of tele-health services. Third, the outcomes examined,which included HRQOL, patient satisfaction,and the use of both inpatient and outpatienthealth care services, are more comprehensivethan those reported for other studies, whichhave frequently examined a limited number ofoutcome measures. Finally, the interventiongroup for this study consisted of persons re-ceiving telehealth services in addition to tradi-tional home care, and the control group pa-tients received only traditional home careservices. Such a design makes it possible to de-termine if telehealth services are associatedwith improved outcomes beyond those thatmight be expected from traditional home care.In contrast, previous studies have involvedmulti-faceted interventions that include tele-health as part of a comprehensive program ofcare management, and compared the results tothose for patients who do not receive care management or telehealth services.10 Althoughsuch designs allow for information to be ob-tained on the outcomes associated with com-prehensive programs, it is not possible to de-

termine whether similar results could be ob-tained from programs involving care manage-ment in the absence of telehealth services.

There are several limitations to this researchstudy. First, as in previous studies,30 it is likelythat type II error, related to the smaller than ex-pected sample size, is a factor contributing to thelack of significant differences for the utilizationoutcomes. For the HRQOL measures, there weremissing data on response items, and only 17 of37 enrolled patients had items available for anal-ysis, a factor that also contributed to lower thanexpected statistical power. Second, related to theissue of small sample size, a greater number ofpatients than anticipated had short home caredays that resulted in their exclusion from thestudy. Many of these patients were recently dis-charged from the hospital and were evaluatedas needing home care services for only a shortperiod of time. Such persons were not eligiblefor home telehealth services, because the timerequired for equipment setup and training wasnot believed to be justified given their expectedshort stay in the program. A third limitation isthat this was a single-site study, and involvedonly VA patients, all of whom were male. Moreinformation is needed on the outcomes associ-ated with home telehealth care across a broaderrange of VA sites, and ultimately on patients re-ceiving services in home care programs outsidethe VA health care system. Detailed informationwas also not available on the extent to which pe-ripheral devices, such as the use of blood pres-sure monitors, stethoscopes, and glucose moni-tors. Future research, using more detailedinformation on the use of these peripherals andassociated outcomes, is an important area for fu-ture research. Finally, the telehealth program ex-amined in this study was relatively new at thetime the study was conducted, a factor that mayhave contributed to reluctance to participate inthe program.

The results from this study suggest severalareas for future research. First, given the in-creasingly large number of patients who are inhome care programs for short periods of time,more research should be conducted on the fea-sibility of developing short-term telehealthprograms for this short-stay population. Quitepossibly, interventions can be designed to pro-vide short-term education and monitoring, and

HOME CARE TELEHEALTH INTERVENTION 305

6238_02_p297-307 6/12/06 1:31 PM Page 305

if telehealth units can be deployed and re-trieved quickly, such programs could benefitthe short-term home care population. Second,some research suggests that lower cost strate-gies, including telephone care, may be equallyeffective compared with higher cost programssuch as the video-based telehealth services ex-amined in the present study. For example, a re-cently published study conducted among CHFpatients involving randomization to telehealth,telephone follow-up, or traditional home care,reports that home telehealth did not offer anincremental benefit beyond that obtained fromusual telephone follow-up in terms of healthresource use.30 More studies, based on ran-domization to a variety of technologies (in-cluding telephone care), would help better de-termine the most cost effective and optimalway of coordinating care for persons withchronic conditions.

A third area for future research concerns theneed for new study designs, including multi-site randomized trials as well as quasiexperi-mental designs. Given the large amount of timeand effort needed to develop and implementhome telehealth programs, single-site studiesoften produce small sample sizes.7 Conse-quently, future studies, involving multiplesites, are needed for rigorous evaluations of theeffectiveness of this technology. One challengeto home telehealth studies is that once theseprograms have been implemented, programadministrators may be reluctant to enroll pa-tients in randomized trials, because this wouldinvolve restricting access to telehealth for per-sons randomized to the control group. In situ-ations where randomization is not feasible,well-designed quasiexperimental designs, in-volving a comparison of outcomes for patientsparticipating in a home telehealth programwith a comparison group of patients in a dif-ferent program who do not receive telehealthservices, may provide important informationon telehealth outcomes. For such designs to bevalid, it is essential that the comparison grouppatients have similar characteristics to thoseparticipating in the intervention, includingseverity of illness and past use of health careservices. Multiple measurements of study out-comes for both groups, both before and afterthe start of the intervention, can help to ensurethat the observed outcomes are caused by the

intervention and not simply due to regressiontowards the mean.31

CONCLUSION

Despite considerable interest and investmentin telehealth services for home care programs,findings concerning the outcomes associatedwith the use of this technology remain equiv-ocal. The present study found significantlygreater increases in self-reported mental healthstatus among telehealth versus traditionalhome care control patients, as well as a trendtoward lower use of outpatient healthcare ser-vices among this group. Given the considerableinvestment in telehome care technology byhome care providers, more information basedon larger clinical trials is needed in order to ob-tain critical information necessary for improv-ing the care of patients receiving home care ser-vices.

ACKNOWLEDGMENTS

Funding for this study was obtained from aVA Health Services Research and Developmentgrant, entitled “An Evaluation of Home-BasedTelemedicine Services” (Grant No: VA HSRD–Tel: 20015-1). The study was presented in partas a poster display, American Geriatrics Soci-ety Annual Meeting on March 15, 2003. Themain study was presented as a poster at the So-ciety of General Internal Medicine AnnualMeeting, May 12–14, 2004. The authors wish tothank other study staff involved in data collec-tion, including Aaron Goldsmith, M.S.W.,Theresa Bubenzer, R.N., and Heather Wallace,B.A. Carla Anderson, R.N., M.S.N., Director ofthe Home Care Program, provided neededclinical expertise in the design and develop-ment of the program.

REFERENCES

1. Puskin D. Telemedicine: Follow the money.www.nursingworld.org/ojin/topic16/tpc16_1.htmLast accessed November 1, 2005.

2. Kinsella A. About home telehealth. www.longterm-carelink.net/eldercare_home_telehealth.htm Last ac-cessed November 1, 2005.

HOPP ET AL.306

6238_02_p297-307 6/12/06 1:31 PM Page 306

3. Kaye LW. Telemedicine: Extension to home care.Telemed J 1997;3:243–246.

4. Warner I. Telemedicine applications for home healthcare. J Telemed Telecare 1997;3(Suppl 1):65–66.

5. Veterans Health Administration. Telemedicine Strate-gic Planning Document. Washington, D.C.: Depart-ment of Veterans Affairs,1999.

6. VA Health Services Research and Development.HSR&D Priorities for Investigator Initiated Research:Fiscal Year 2002. www1.va.gov/resdev/ps/psrhrd/HSRD_Umbrella_Solicitation_021202.doc. Last ac-cessed 10 Feb 2004.

7. Grigsby J, Kaehny M, Sandberg E, Schlenker R,Chaughnessy P. Effects and effectiveness of telemed-icine. Health Care Financ Rev 1995;17:115–131.

8. Telemedicine for the Medicare Population. Summary,Evidence Report/Technology Assessment: Number24. AHRQ Publication Number 01-E011, February2001. Agency for Healthcare Research and Quality,Rockville, MD. www.ahrq.gov/clinic/epcsums/telemedsum.htm Last accessed November 1, 2005.

9. Nakamura K, Takano T, Akao C. The effectiveness ofvidoeophones in home healthcare for the elderly. MedCare 1999;37:117–125.

10. Meyer M, Kobb R, Ryan P. Virtually healthy: Chronicdisease management in the home. Dis Manag2002;5:87–94.

11. Hailey D, Roine R, Ohinmaa A. Systematic review ofevidence for the benefits of telemedicine. J TelemedTelecare 2002;8:1–7.

12. Dansky K, Bowles KH, Palmer L. How telehomecareaffects patients. Caring 1999;18:10–14.

13. Johnston B, Weeler L, Deuser J, Sousa KH. Outcomesof the Kaiser Permanente tele-home health researchproject. Arch Fam Med 2000;9:40–45.

14. Noel HC, Vogel DC, Erdos JJ, Cornwall D, Levin F.Home telehealth reduces healthcare costs. Telemed JeHealth 2004;10:170–183.

15. Boult C, Dowd B, McCaffrey D, Boult L, HernandezR, Krulewitch H. Screening elders for hospital ad-mission. J Am Geriatr Soc 1993;46:811–817.

16. Coleman E, Wagner E, Grothaus L, Hecht J, SavarinoJ, Buchner D. Predicting hospitalization and func-tional decline in older health plan enrollees: Are ad-ministrative data as accurate as self-report? J Am Geri-atr Soc 1998;46:419–425.

17. Smith D, Norton J, Roberts S, Maxey W, McDonald C.Unexpected hospital admissions among patients withdiabetes Mellitus. Arch Intern Med 1983;143:41–47.

18. Wolinsky F, Culler S, Callahan C, Johnson R. Hospitalresource consumption among older adults: A prospec-tive analysis of episodes, length of stay, and chargesover a seven year period. J Gerontol 1994;49:S240–S252.

19. Subramanian U, Hopp F, Lowery J, Woodbridge P,Smith. D. Research in home telemedicine: Challenges inpatient recruitment. Telemed J e-Health 2004;10:155–161.

20. Kazis L. The SF-36V. Bedford, MA: Center for HealthQuality, Outcomes, and Economic Research, 1997.

21. Ware JE, Kosinski M, Keller SD. SF-36 Physical andMental Summary Scales: A Users Manual. Boston, MA:The Health Institute, 1994.

22. Ware JE, Snyder MK, Wright R, Davies AR. Definingand measuring patient satisfaction with medical care.Eval Program Plann 1983;6:247–263.

23. Meterko M, Jacobs M, Sisson E, Humble C. Customersatifaction in the Veterans Health Administration. In:Jacobs M, Nelson A, Berrio M, eds. Measurement toolsto support outcomes evaluation. Milwaukee WI: Na-tional Center for Cost Containment, 1998;119–125.

24. Veterans Affairs Information Resource Center. Re-searchers’ Guide to VA Data. www.virec.research.med.va.gov/ Last accessed November 1, 2005.

25. Subramanian U, Weinberger M, Eckert GJ, L’ItalienGJ, Lapuerta P, Tierney W. Geographic variation inhealth care utilization and outcomes in veterans withacute myocardial infarction. J Gen Intern Med2002;17:604–611.

26. Cameron, A. C and Trivedi, PK. Regression analysis ofcount data. Cambridge, UK, Cambridge UniversityPress, 1988.

27. Baines B. Tele-home care in a managed care setting.Remington Rep 1996;November/December:27–29.

28. Johnston B, Wheeler L, Deuser J. Kaiser PermanenteMedical Center’s Pilot Tele-Home Health Project.Telemed Today 1997;August:14–18.

29. Allen A, Doolittle G, Boysen C, Komoroski K, WolfM, Collins B, Patterson JD. An analysis of the suit-ability of home health visits for telemedicine. J TelemedTelecare 1999;5:90–96.

30. Jerant AF, Azari R, Nesbitt TS. Reducing the cost offrequent hospital admissions for congestive heart fail-ure: A randomized trial of a home telecare interven-tion. Med Care 2001;39:1234–1245.

31. Hayward, Rod. Quasi Experimental Designs forStudying QI Interventions: Strengths and Pitfalls. VAHealth Services Research and Development, HSR&DCyber Seminars. hsrd.webex.com/hsrd/k2/tool/record/recordings.php?Rnd[t=]1663926607 Last ac-cessed November 1, 2005.

Address reprint requests to:Faith Hopp, Ph.D.

Research InvestigatorVA Ann Arbor Healthcare System

HSR&D Center for Practice Management and Outcomes Research

P.O. Box 130170Ann Arbor, MI 48113

E-mail: Faith.Hopp@med.va.gov

HOME CARE TELEHEALTH INTERVENTION 307

6238_02_p297-307 6/12/06 1:31 PM Page 307