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Care Coordination/Home Telehealth: Population Health Informatics to Support the Care of Veteran Patients with Chronic Conditions

Care Coordination/Home Telehealth: Population Health Informatics to Support the Care of Veteran Patients with Chronic Conditions

Summary and Problem Statement

The US faces an increase in healthcare dependence as the population continues to age and people live longer as well as a rise in rates of chronic diseases, among these are aging veterans. The public health problem associated with the changing population dynamics is an increase in need for services such as hospitalization, physician visits, prescriptions, and need for home-based health services (Zulman, Martins, Liu, Tu, Hoffman, Asch, & Goldstein, 2015).Veterans represent a complex group among the aging population with chronic diseases, and as such require establishment of ways to promote both self-management and assistant-based management to promote timely response to any arising health concern. Darkins, Ryan, Kobb, Foster, Edmonson, Wakefield, and Lancaster (2008) suggest the use of a telehealth program, the Care Coordination/Home Telehealth (CCHT), which is a non-institutional service that supports the care for veterans with chronic conditions in their home as they age.

Scope/Context and Challenges

The U.S. Veterans Health Administration (VHA) provides care to approximately more 5 million veterans annually with about 16.4 million primary care delivery (Rosland, Nelson, Sun. Dolan, Maynard, Bryson, Stark, Shear, Fihn, and Schectman, 2013). The VHA faces a challenge of how to redesign its system of care to ensure it can deliver services across diverse communities, and among people with different chronic illnesses and socio-economic vulnerabilities. Telehealth presents a possible response with the possibility of reaching a large number of patients with chronic diseases nationally while maintaining a practical and cost-effective means of care acceptable to patients and care providers (Gellis, Kenaley, McGinty, Bardelli, Davitt, & Have, 2012).

However, the use of telehealth faces the challenge of generalizability. A study by Gellis, Kenaley, and Have (2015) showed the various benefits of telehealth, but noted that the system may not be generalizable to all patients as some may require assistance with their ADLs, meaning it will work mainly for cognitively able patients and that retain a certain level of functionality. This nonetheless does not exclude patients with depression.

Informatics Solution and Stakeholder

Based on its applicability, CCHT offers the benefit of home telehealth and disease management technology that augments the VHA existing health information technology infrastructure (Darkin et al., 2008). The program further covers the predefined nature of patient services but extends to acute care management and health promotion and disease prevention. The CCHT program further provides veterans with support to care as needed and within rural areas, which has been a challenge for the VHA.

The public health stakeholders involved in the actualization of the CCHT program for veterans include social workers tasked with care coordination of the system (Darkins et al., 2008). The care coordinator receives vital signs data from the system, and works to determine the threshold of the patient daily, thus ensuring an ongoing checkup that captures anytime the patient health deteriorates.

Approach to Resolution

As the U.S. veteran population increases it is important to appreciate the importance of telehealth as an approach to ensure access to care for people that would have otherwise found it challenging as it supports their complex health care needs by offering a way to present health information, track medication, and communicate with providers (Whealin, Jenchura, Wong, &Zulman, 2016). The system provides the stakeholders with support, access to information, coordination of care, and a way for patients and coordinators to communicate and share information. This makes access to health care easier and faster irrespective of whether the patient is in a rural place.

Conclusion and Recommendations

CCHT provides the veteran health care system with a model that can easily promote quick reach of the patient. However, in the application of the model it is recommended that service providers adequately examine the capability of the patient to utilize the program.


Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A. E. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e-Health, 1118-1126. DOI 10.1089/tmj.2008.0021

Gellis, Z. D., Kenaley, B. L., & Have, T. T. (2014). Integrated telehealth care for chronic illness and depression in geriatric home care patients: The integrated telehealth education and activation of mood (I-TEAM) study. J. AM. Geriatr. Soc. 62: 889-895.

Gellis, Z. D., Kenaley, B., McGinty, J., Bardelli, E., Davitt, J., & Have, T. T. (2012).Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: A randomized controlled trial.The Gerontologist, 52(4): 541-552. DOI10.1093/geront/gnr134

Rosland, A., Nelson, K., Sun, H., Dolan, E. D., Maynard, C., Bryson, C., Stark, R., Shear, J. M., Kerr, E., Fihn, S. D., &Schectman, G. (2013). The patient-centered medical home in the Veterans Health Administration.Am. J Manag Care, 19(7): e263-e272.

Whealm, J. M., Jenchura, E. C., Wong, A. C., &Zulman, D. M. (2016). How veterans with post-traumatic stress disorder and comorbid health conditions utilize eHealth to manage their health care needs: A mixed-methods analysis. J. Med. Internet res, 18(10): e280. DOI 10.2196/jmir.5594

Zulman, D. M., Martins, S. B., Liu, Y., Tu, S. W., Hoffman, B. B., Asch, S. M., & Goldstein, M. K. (2015). Using a clinical knowledge based to assess comorbidity interrelatedness among patients with multiple chronic conditions. AMIA Annual Symp. Proc.: 1381-1389.