TEAhM—Technologies for Enhancing Access to Health Management: A Pilot Study of Community-Based Telehealth

Introduction

Akey feature of telehealth technology is that it extends physician and nursing care beyond the walls of traditional office settings at relatively low cost. ^1,2 If appropriately incorporated into existing community-based infrastructures, telehealth may offer opportunities to manage chronic conditions more aggressively, with fewer risks, at lower cost, and in a manner that is efficient in reaching high-risk populations. ³ A recent systematic review of the impact of community-based blood pressure (BP) telemonitoring on BP control and other outcomes showed that telemonitoring resulted in BP reductions in 13 of 15 studies meeting review criteria, with magnitudes of effect were comparable to those observed in efficacy trials of antihypertensive drugs. ⁴ The Technologies for Enhancing Access to Health Management (TEAhM) pilot study extends work on community-based telemonitoring of hypertension by exploring implementation of this technology in community-based senior centers. The primary goals of TEAhM were to collect information on the logistics and operational considerations associated with implementing nurse-monitored telehealth kiosks in community-based senior centers and to conduct a preliminary examination of BPs and other characteristics among hypertensive seniors who use senior centers. ⁵

Subjects and Methods

Results

Participant screening and enrollment are summarized in Figure 1. Baseline data were available for 112 of 113 enrolled participants, and these are summarized in Tables 1 –3. Compared with the intervention group, the control group was slightly older and had higher baseline BPs but lower body mass index. A surprising finding was that almost 84% of participants reported having used an automatic BP device outside of a doctor's office, and nearly 43% of these individuals reported using one ≥100 times. Forty-one telemonitoring participants and 71 control participants had at least one follow-up contact completed during the 10 months of follow-up. Six percent of enrolled participants (n=7) did not complete follow-up: Of these, one died, three were withdrawn by investigators, two refused contact, and one withdrew because of illness. Table 4 shows high levels of comfort with the BP cuff and the health station among individuals in the telemonitoring group. Table 5 shows that participants were less anxious and that using the equipment was easier at the end of the study than at baseline. However, a higher percentage of people said that using the BP cuff was “very easy” at baseline than at the end of the study.

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Fig. 1.

Enrollment and follow-up in the Technologies for Enhancing Access to Health Management pilot study.

Participants used the telehealth kiosk in 70% of all follow-up weeks, and 61% of high readings were followed by a second reading (Table 6). Referrals were completed on the same day in 63% of cases where a high reading was noted and within 1 day for 71% of high readings. Although participants were not asked to take BP readings on multiple times during the same week, they did so 17% of the time. During the first 5 months of the study, there was a steady increase in the percentage of weeks with at least one BP reading, peaking at 80% in Month 5. This peak was followed by declines in kiosk use over the last 5 months of the study, ending with a low of 47% in Month 10 (Table 7). Table 8 shows cumulative incidence rates and mean event frequencies for various outcomes as well as BPs measured at Month 10. Relative to baseline, mean BPs in Month 10 were lower and the percentage with controlled BP was higher in the telemonitoring group compared with the control group, although means in both groups declined between baseline and follow-up.

When interviewed after the study was completed, senior center staff reported that they saw clear value in telehealth technology and that senior centers were an appropriate venue in which this service could be provided. Center directors reported that their clients were able to see the value added in this service and that they embraced use of this technology after appropriate training. These impressions were substantiated by interview data collected directly from participants (Tables 4 and 5). Finally, although center directors said that they would be willing to permanently house telehealth stations in their facilities, they reported that equipment acquisition and maintenance costs represented significant barriers to adoption of this technology.

Discussion

Despite extensive public and professional education and the availability of efficacious treatments, hypertension remains the most common and strongest risk factor for cardiovascular disease in North America. ⁶ About 69% of people who have a first heart attack, 77% who have a first stroke, and 74% who have congestive heart failure have BPs higher than 140/90 mm Hg; hypertension is present in more than 70% of Americans 80 years of age and older, and it is the single most important risk factor for stroke. ^{7 –10} Improved approaches to patient self-management are increasingly viewed as an integral part of the healthcare process and can offer particular promise for conditions like hypertension. ¹¹ Easy access to technology that can help seniors better manage this condition has the potential to have a significant public health impact, in terms of both improved management and reduced costs. It is not surprising that several professional organizations support reimbursement for BP home monitoring. ¹² Furthermore, there is growing interest on the part of policy makers about how telehealth and other supportive technologies can improve care for the elderly, making it more responsive and available to support aging in place. ¹³

One of the goals of the TEAhM pilot study was to explore the idea that senior center–based telemonitoring could be a vehicle to move technology-enabled chronic care management into the community. Results of this pilot study indicate that there is great potential to incorporate the point of care into a well-recognized and trusted community resource using telehealth technology as a vehicle to empower seniors in their own care management. TEAhM participants were able to have their BP tracked by qualified clinical personnel and to engage in these self-management activities as often as they liked—frequently more than once per week—in a comfortable environment and familiar location that is part of their normal routine. Incorporation of community-based self-monitoring of hypertension is consistent with currently accepted approaches to self-management and is recognized as a valuable tool in patient empowerment and cardiovascular disease risk reduction. ^{12 –16} Moreover, evidence of the efficacy of this model in high-risk populations ³ is ripe for expansion into congregate settings to reach large at-risk populations that might not otherwise engage in self-monitoring.

In the TEAhM pilot, ongoing tracking of BPs permitted immediate identification of acute episodes of hypertension, meaningful changes in BP readings, and timely referrals to PCPs or the emergency department. Our data showed that nurses were able to contact the vast majority of seniors with a BP alert within 1 day and that clinically relevant changes in BP were identified as a direct result of using the technology. Several TEAhM participants had very high BP readings on several occasions, and nurses were able to immediately direct these participants to their PCPs or to seek appropriate care. Absent tracking of BPs via telehealth, these life-threatening readings would have been undetected until the participants' next PCP visit, rendering the patient at increased risk of stroke or other unfavorable cardiovascular events. These observations underscore the ability of telehealth to efficiently identify high-risk patients and act immediately on findings in between routine office visits. Interventions of this type may offer promise to prevent strokes, to titrate medications as soon as a titration is indicated, and to provide counseling about diet and exercise in a particularly efficient manner. The fact that 95% of participants reported being “very comfortable” with use of the telehealth kiosk at the end of the study suggests that acceptance of this type of care management would be high if made available to this target population. However, the slight reduction in comfort with use of the cuff from baseline to study end suggests that additional training on cuff placement may be prudent.

Although the ability of study nurses to act on BP alerts was notable and nurses reported a high degree of satisfaction with the technology, they also indicated that having access to the HCP (in addition to being able to receive alerts) on a mobile device would have been a useful addition to the technology platform. Nurses also reported making repeated phone calls to a subset of participants with consistently elevated pressures and that these repeated contacts resulted in frustration on the part of some participants despite the fact that these contacts were part of the approved study protocol to which participants consented. Nonetheless, nurses were able to provide quick and effective nursing interventions in response to elevated BP readings, thereby bridging a critical gap in routine care management between traditional office visits.

Despite a perception on the part of study investigators that participants would have limited experience with automatic BP cuffs, 84% of participants had used automatic cuffs, and many reported using them more than 100 times prior to the study. Even with this high degree of familiarity with the automated cuff, some participants experienced anxiety as they learned to use the kiosks, and at times when connectivity, software, or hardware problems occurred, participants' anxiety increased and sometimes resulted in elevated BP readings. It is interesting that we observed that elevated BP readings appeared to be associated with certain activities that are common at senior centers such as card games. Some participants who monitored their BP immediately after a card game had high initial measurements that decreased at the second reading. It should be noted that participants were instructed to take their BP measurements after a period of rest ¹⁷ but did not consistently follow these instructions.

A primary goal of this project was to explore the feasibility of using senior centers as a novel venue for delivery of telehealth to seniors. Our work strongly suggests that if made widely available, this technology will be embraced by both seniors and senior center staff. Based on these findings, the next logical step is to explore how to link the nurse monitoring aspect to primary care and integrate it into the senior center's stream of services in coordination with the primary physician's office. Although an office-based approach to nurse management was beyond the scope of the TEAhM pilot, exploration of how office-based nurse management could be incorporated into senior center–based telehealth would be valuable if this line of investigation were to be sustainable in the future. However, this approach would only make sense from a financing point of view if the intervention was covered by Medicare or other health insurance. Although there is no doubt that financing is one of the major barriers inhibiting the proliferation of telehealth technology, new integrated, medical home, accountable care and other pay-for-performance models that will be implemented and demonstrated under the Affordable Care Act may be much more conducive to the integration of this type of intervention into primary care practice in the future.

Although the investigative team found that the telehealth technology offered several clear benefits to community-dwelling seniors, others were identified as warranting attention in the future. Two such areas were ensuring proper BP cuff placement and maximizing long-term compliance with use of the technology. Participants did not always use the appropriately sized BP cuff size, and instructions about proper cuff placement were not consistently followed. Examples of incorrect cuff placement included placing the cuff on the elbow and applying the cuff over bulky clothes. Although proper cuff placement was demonstrated to participants during training and illustrated placement instructions were posted on the kiosks, participants needed additional reminders to follow these instructions and periodic supervision to ensure that proper placement was consistent. Long-term compliance with kiosk use is also an issue that warrants discussion. Although early use of the kiosk was very favorable and peaked at more than 80%, use dropped off considerably during follow-up, an observation that has been reported previously. ³ In some cases, TEAhM participants had to wait in line to use the telehealth kiosk, and some found this waiting time to be inconvenient and chose not to use the kiosk during those visits. There were also instances where participants who were first in line to use the kiosk suggested to others behind them that the device was not operating properly (potentially out of privacy concerns), thereby reducing device use. A sign-up list to use the device, a private alcove for the kiosk, and/or enhanced training on use of the equipment might help promote long-term compliance in future studies. Regardless of the cause of noncompliance, analysis of compliance data clearly showed that efforts are needed to ensure continued use of this technology following the initial “honeymoon” period.

The potential for scaling-up of a successful telehealth program in the senior center setting is substantial: There is a network of approximately 4,000 Title III nutrition centers across the nation. ¹⁸ Supplementing this vast, Federally supported network, is an even larger network of privately funded centers providing similar community-based nutrition and support services. ^19,20 In collaboration with local PCPs, these centers have the potential to form the backbone of a novel telehealth network promoting community-based chronic care management on a regional or national scale.

A TEAhM strength was that study activities did not represent a major departure from routine job-related activities for senior center staff. Indeed, the centers involved in TEAhM as well as many others provide health education and supplementary programs related to common chronic conditions including hypertension, a programmatic feature that made the telehealth intervention consistent with their broader mission. When center directors were asked about issues associated with how the costs of this type of program could be covered, the greatest concern on their part involved start-up costs, including equipment and ongoing Internet costs. Directors felt that if a telehealth program was set up as was done in TEAhM, senior center staff time could be covered because the majority of work was done by clinical personnel, with only minimal guidance to participants and support from center staff. One of the directors explained that she would be more than willing to use her center to permanently set up this type of program but that she would not be able to cover the cost of equipment installation or maintenance, concerns that point back to critical issues associated with financing novel programs.

A future study that is powered to evaluate the efficacy and cost-effectiveness of this community-based telehealth approach for chronic disease management could provide evidence supporting the adoption of this approach into regional or national networks of senior centers. Such a study could involve identifying primary care practices and/or home health agencies that would be willing to collaborate with senior centers on a definitive telehealth study that builds on TEAhM. The study could also focus on operational and logistical issues associated with building the bridges between clinicians who care for seniors and community-based senior centers that are routinely utilized by these individuals. This line of investigation would make a significant contribution toward advancing community-based, communication-focused technologies for high-risk seniors.