Enhancing elder chronic care through technology and care coordination: report from a pilot.

The Rural Home Care Project is one of eight clinical demonstration pilots in an initiative of the Veterans Health Administration (VHA) Sunshine Network in Florida and Puerto Rico. In this project three care coordinators consisting of two nurse practitioners and a social worker collaborate with primary care providers in the management of high-risk, high-cost veterans with multiple chronic diseases such as diabetes and heart failure. The project staff uses home telehealth devices to monitor and educate patients to prevent health crises. The evaluation methodology is a quasiexperimental design that uses a nonequivalent control group of usual care veterans. Data were gathered through personal interviews with patients and providers, and statistical analysis was based on a series of repeated-measure of covariance modeling designed by a research team from the University of Maryland. Findings demonstrate that care coordination enhanced by technology reduces hospital admissions, bed days of care, emergency room visits, and prescriptions as well as providing high patient and provider satisfaction. Veterans also had improved perception of physical health as evidenced by a standardized functional status measure.