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Outcomes of the Kaiser Permanente Tele-Home Health Research Project
Barbara Johnston, RN, MSNM&L;
Linda Weeler, RN, MSNM&L;
Jill Deuser, RN, MBA;
Karen H. Sousa, RN, PhD
Arch Fam Med. 2000;9:40-45.
ABSTRACT
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Context Level of acuity and number of referrals for home health care have been escalating exponentially. As referrals continue to increase, health care organizations are encouraged to find more effective methods for providing 0high-quality patient care with cost savings.
Objective To evaluate the use of remote video technology in the home health care setting as well as the quality, use, patient satisfaction, and cost savings from this technology.
Design Quasiexperimental study conducted from May 1996 to October 1997.
Setting Home health department in the Sacramento, Calif, facility of a large health maintenance organization.
Participants Newly referred patients diagnosed as having congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care were eligible for random assignment to intervention (n = 102) or control (n = 110) groups.
Intervention The control and intervention groups received routine home health care (home visits and telephone contact). The intervention group also had access to a remote video system that allowed nurses and patients to interact in real time. The video system included peripheral equipment for assessing cardiopulmonary status.
Main Outcome Measures Three quality indicators (medication compliance, knowledge of disease, and ability for self-care); extent of use of services; degree of patient satisfaction as reported on a 3-part scale; and direct and indirect costs of using the remote video technology.
Results No differences in the quality indicators, patient satisfaction, or use were seen. Although the average direct cost for home health services was $1830 in the intervention group and $1167 in the control group, the total mean costs of care, excluding home health care costs, were $1948 in the intervention group and $2674 in the control group.
Conclusions Remote video technology in the home health care setting was shown to be effective, well received by patients, capable of maintaining quality of care, and to have the potential for cost savings. Patients seemed pleased with the equipment and the ability to access a home health care provider 24 hours a day. Remote technology has the potential to effect cost savings when used to substitute some in-person visits and can also improve access to home health care staff for patients and caregivers. This technology can thus be an asset for patients and providers.
INTRODUCTION
THE ACUITY level of patients receiving home health care and the number of referrals for home health care have been escalating exponentially along with the cost for providing home health care services. Medicare expenditures for home health care increased from 2.1 billion dollars in 1988 to 15.7 billion dollars in 1995.1 As the number of referrals continues to rise, health care organizations are being encouraged to find more efficient methods of providing high-quality care with cost savings.
As the largest nonprofit health maintenance organization in the country, Kaiser Permanente (KP) provides comprehensive health care benefits to more than 9.1 million Americans in 19 states and operates 11 home health care agencies in northern California. The mean monthly number of referrals to KP's Sacramento Home Health Department alone rose from 320 in 1996 to more than 680 in 1997. Most of these referrals were given for patients with chronic illnesses. As membership in the Kaiser Foundation Health Plan continues to grow, innovative methods of providing high-quality home health care are crucial.
The purpose of this project was to evaluate the use of remote video technology in the home health care setting (Tele-Home Health). Outcome measures included quality of care, access to care, patient satisfaction, and costs. Investigators evaluated the effects, appropriateness, and response by patients to receiving some of their home health care visits via a remote video system. The goal was to replace some in-person visits with remote video visits without compromising patient care or raising home health care costs.
PATIENTS AND METHODS
The data were collected between May 1996 and October 1997 at the Home Health Department at KP Medical Center in Sacramento, which serves a large metropolitan and rural population. Cost data were collected during the time patients were in the study.
PATIENT POPULATION
Patients diagnosed as having congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, or secondary diagnoses of anxiety and those needing wound care were eligible for the study. Additional inclusion criteria were a plan of care for 4 or more weeks of care and a projected need for 2 or more visits per week. Patients were assessed to assure that they could operate the video system, and the home had to be a safe environment for the technology (1 home was eliminated owing to an unsafe environment).
STUDY DESIGN
Patients who were newly referred for home health care and who met the inclusion criteria were offered an opportunity to participate in this quasiexperimental research project. The KP Medical Care Program Northern California Region Internal Review Board approved the study protocol and informed consent was obtained. Following the consent process, patients were randomly assigned to an intervention or control group.
Both groups received an initial assessment at home as well as a standardized care plan within 24 to 48 hours after receiving the referral. The number of home visits to be made was based on individual patient needs as assessed by the home health nurse case manager in collaboration with the primary care physician. Home health care discharge criteria included no need for further care, admission to a hospital or skilled nursing facility, relocation to an area outside the KP service area, or death. All visits during the study were conducted by registered nurses and licensed vocational nurses.
Control Group
Patients in the control group had access to routine home health care (ie, in-person and phone visits). This care included initial assessment in the home as well as in-person follow-up visits made by the nurses to the patients' homes. Patients could contact a home health nurse by phone between 8:30 AM and 5 PM for additional information or for triage. Additional verbal contact after normal working hours was available through the hospital's telephone advice center or at the emergency department. This same process is available to all Kaiser Foundation Health Plan members. Patients also had the option of being transported to an emergency department or urgent care clinic to receive in-person assessment if the advice nurse, patient, or patient's family member believed this measure was necessary. For situations that the telephone advice nurse judged to be nonurgent, a home health nurse would follow up with a phone call within 24 to 48 hours.
Intervention Group
Patients in the intervention group received video visits in addition to in-person and telephone visits. This care included initial assessment in the home as well as in-person and follow-up visits by the nurses to the patients' homes or video visits from the Home Health Department. The video equipment (American Telecare PTS 100 home video system; American Telecare Inc, Minneapolis, Minn) gave patients access to a home health nurse 24 hours a day. After normal working hours, these patients had access to the on-call home health nurse by having the Home Health Department contact the patient using the remote video equipment. This process allowed immediate in-depth assessment and triage without patients having to leave home.
Installation and teaching of the home video system by a nurse case manager required about 30 minutes. The home video system allowed the nurse and patient to see and talk with each other in real time. The peripheral units of the video system included an analog stethoscope, digital blood pressure machine, and a magnifying lens that attached to the camera for closeup viewing. The stethoscope was placed by the patients or their caregivers at sites requested by the nurse. Patients were given a diagram of the chest and lung fields with sites marked to guide them in placing the stethoscope correctly. The nurse could see where the patient was placing the stethoscope and recommend adjustments in positioning as necessary. The nurse had a headset at the receiving station to hear lung, cardiac, or bowel sounds that eliminated extraneous sounds and allowed clear auscultation. Peripheral equipment enabled nurses to assess cardiopulmonary status, visualize facial expressions, and evaluate bowel sounds or signs of infection. The magnifying lens was used to assess correct medication dosages when patients were being taught how to draw up medications such as insulin. The second phone line necessary for using the analog stethoscope was installed by KP at no cost to the patients.
Data Collection
Data for this analysis were collected from patient interviews and surveys, from medical record audits, and from KP's computer databases. To evaluate homogeneity of the control and intervention groups, we collected information about initial health status, prior use of services (visits to the emergency department, urgent care clinic, or physician's office; days in a skilled nursing facility; previous health care interventions at home; and days in the hospital), referral source, and demographic characteristics. The computer databases included information about health plan membership, demographics, use of services; direct costs for KP inpatient and outpatient services; claims for services received outside the KP system (eg, visits to non-KP emergency departments, days in skilled nursing facilities, and days in non-KP hospitals). The data used to derive costs included direct costs for pharmacy services, laboratory, physician visits, emergency department visits, and inpatient treatment. Home health care costs included direct costs for payroll, benefits, travel, and cellular phone usage. In the intervention group, additional costs included capital equipment and telecommunication charges.
The 3 quality indicators—patients' compliance with medication regimen, knowledge about their disease, and ability to move toward self-care—were evaluated from abstracts of medical records and were routinely collected as part of a patient's standardized care plan. The 12-Item Short-Form Health Survey developed by Ware et al,2 which measures physical and mental functioning, was given to each patient during initial assessment to assess baseline homogeneity between the control and intervention groups. The reliability and validity of this 12-item questionnaire (a shortened version of a 36-item Health Survey instrument) has been adequately shown.2
The patient satisfaction survey was given to each patient at discharge from home health care. The survey was developed for this project and was designed to emphasize the technology and in-person encounters. The survey addressed ease of use, system reliability, effectiveness and degree of provider interaction, confidence in providers' ability to assess health condition remotely, appropriate levels of care, convenience, access to care, and preferences.
STATISTICAL ANALYSIS
The  2 test was used to determine differences between control and intervention groups by sex, ethnicity, primary diagnosis, source of referral, and prior home health care services received; the quality indicators were analyzed using the Fisher exact test. Because values collected for the 2 independent groups were not normally distributed as determined from box plots, the Mann-Whitney test was used to evaluate the utilization data (before and during the study), number of phone and in-person caregiver visits, health status, and direct costs.
RESULTS
COMPARABILITY OF GROUPS
Control and intervention groups had comparable demographic characteristics, use of services during the previous year, and self-reported health status as measured by the 12-Item Short-Form Health Survey (Table 1 and Table 2). Mean (SD) age for the control group was 69 (14.20) years and for the intervention group was 71 (12.91) years. More than half the patients had cardiopulmonary disease; 32% had congestive heart failure, and 23% had chronic obstructive pulmonary disease. Differences between the 12-Item Short-Form Health Survey physical and mental scores obtained from the questionnaire results were not statistically significant. The mean (SD) difference in duration of home health care also was not statistically significant for the control (40 days [51.09]) and intervention groups (53 days [38.40]).
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Table 1. Demographic Characteristics of Patients in Study
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Table 2. Prestudy Medical Use by Patients in Study and Their Survey of Health Status
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ACCESS TO CARE
The intervention group had 1003 in-person home health care visits, and the control group had 1197 home health care in-person visits. The difference was not statistically significant (z = 1.9159, P = .06). Mean number of in-home visits per patient was 9.8 in the intervention group and 11.1 in the control group. However, the intervention group had more phone contact than the control group (z = 2.7434, P = .01). Mean number of phone visits was 1.0 in the intervention group and 0.5 in the control group. The intervention group had a total of 416 video visits during their length of stay in home health care (mean, 3.9 video visits per patient in the intervention group; data not applicable in the control group). Most of the remote video visits were scheduled as part of the patient's plan of care. The response time for a home health nurse to respond to a request for an unscheduled remote video visit was within 30 minutes for intervention patients. Eleven patients requiring unscheduled visits were treated by remote video, and one was triaged to the emergency department because the video assessment indicated the patient needed a higher level of care. Home health nurses conducted all these remote video visits.
Control patients had access to home health nursing staff during normal working hours. These patients called in to advice nurses or the emergency department for assistance between 5 PM and 8:30 AM. Telephone triage was available, and patients received advice over the telephone, were sent to the emergency department, or received a call from a home health nurse the following day. This is the standard of care for home health care patients at the facility.
QUALITY OF CARE
Table 3 shows the results of analyzing the quality of care indicators. At discharge from home health care services, patients in the control and intervention groups did not differ in their compliance with medication regimen, knowledge about their condition, or ability to move toward self-care.
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Table 3. Patients' Responses Regarding Quality of Care Received in Home Setting
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PATIENT SATISFACTION
Table 4 shows survey results regarding the intervention group's satisfaction with the remote video visit. More than 90% of the intervention group agreed or strongly agreed that they appreciated the care provided at the remote video visits, were confident in the assessment received, were comfortable discussing personal problems, believed they received an appropriate level of care, found the remote visit convenient, and appreciated receiving timely access to care. Both groups responded similarly regarding their satisfaction with in-person caregiver visits (Table 5), even though the intervention group received 194 fewer in-person visits.
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Table 4. Intervention Group's Survey Responses Regarding Satisfaction With Remote Video Visits*
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Table 5. Patients' Survey Responses Regarding Satisfaction With In-Person Nursing Visits
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COSTS OF USING THE TECHNOLOGY
The mean length of time was 45 minutes to provide an in-person visit and 18 minutes for a remote video visit. The current productivity standards allow one nurse to visit 5 to 6 patients per day. Although not demonstrated, a time study indicated that remote video visits allow 15 to 20 video visits per day. For home health services, the average direct costs, including cost for purchase of capital equipment and telecommunication expenses, were $1830 in the intervention group and $1167 in the control group (Table 6). The total mean costs of care, excluding home health care costs, were $1948 in the intervention group and $2674 in the control group. This reduction in total mean costs, excluding home health care services, was most attributable to hospitalization costs, which were $1087 in the intervention group and $1940 in the control group. Outpatient costs did not vary materially between the 2 groups.
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Table 6. Total Costs Excluding Home Health Care Services Costs
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COMMENT
Mauser1 stated that the most recent changes in Medicare benefits and conditions of participation require health care organizations to assure high-quality care, good access to care, appropriate use of services, use of continuous quality improvement methodology, and models of care effecting cost savings. However, innovative models of home health care for chronically ill patients have been criticized for not being scientifically based.3 Despite numerous articles about the potential for telemedicine and telehealth applications, research-based studies are lacking.4-5 Telemedicine has existed since the 1960s, but its widespread use was prevented by equipment problems and by the prohibitive costs of home health care. As better, lower-cost products become available, new models of care using remote video access6 should be scientifically evaluated for use by patients receiving home health care. The video technology chosen for this study was functional, reliable, and simple to use for patients and providers. Diagnostic categories chosen for the study proved to be appropriate because the patient population identified are high users of services and so potentially would benefit most from using remote video technology. A sufficient number of patients with chronic illnesses receive home health care to justify investment in this technology.
The use of this video technology in the home health care setting yielded mean cost savings per patient, although less than expected, in part owing to low power but also because the cost of Tele-Home Health services reported here included the full cost of equipment and telecommunications start-up (Table 7). If these items had been included in the calculation as depreciation expenses, the cost of home health care services in the 2 groups would not differ materially and the reduction in expense would be closer to $900 per patient. That is, a factor in this cost analysis was that the equipment was purchased for this pilot project; in practice, the equipment would be leased or amortized over several years. The difference between the costs for the 2 groups may thus be artificially high because of capital equipment costs and lack of depreciation in the intervention group, but further study is required.
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Table 7. Home Health Care Study Costs
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Results of this pilot study thus led to consensus that enough evidence exists to justify incorporating Tele-Home Health as a model of care within the KP organization. Tele-Home Health will be part of the standard plan of care for identified patients, and about half the visits will be made by remote video. Incorporating this technology into the home health care patient's plan of care as a substitute model should further support potential cost-effectiveness. Early resistance to the concept of Tele-Home Health is resolving as data are gathered that support positive outcomes for patients. Guidelines will continue to require the patient's agreement with participation. Nurses have historically been advocates for patients, and it is to their credit that they were cautious about this change in how they care for their patients. Kaiser Permanente leadership agrees that when Tele-Home Health is part of the patient's plan of care, the potential exists to decrease costs of home health care. Stakeholders who are responsible for home health care budgets agree that this type of intervention would break even within 12 months, and its potential warrants its further study.
CONCLUSIONS
In our study, use of remote video technology in the home health care setting yielded cost savings that were less than expected because the potential for using video visits to reduce the number of in-person caregiver visits was not fully realized. Patients who used the video technology seemed very pleased with its ease of use and seemed to appreciate the 24-hour access to health care that the video system provided. Some patients also described an enhanced sense of control over their health and seemed to become more actively involved in attending to their own health care needs. Technology in health care can be an asset for patients and providers and has the potential to save costs; therefore, this technology must be a part of continuous planning for quality improvement.
AUTHOR INFORMATION
Accepted for publication April 8, 1999.
We thank Bob Bodine, BS, for supporting the development of the project, and the medical editing department, Kaiser Foundation Research Institute, Sacramento, Calif, for providing editorial assistance.
Corresponding author: Barbara Johnston, RN, MSNM&L, California Children's Services, Kaiser Permanente Medical Offices, Geographic Managed Care, 1650 Response Rd, Sacramento, CA 95815 (e-mail: barbj{at}pacbell.net).
From the Home Health Department, Kaiser Permanente Medical Center, Sacramento, Calif.
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1. Mauser E. Medicare Home Health initiative: current activities and future directions. Health Care Financ Rev. 1997;18:275-291.
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