Virtually Healthy: Chronic Disease Management in the Home

Abstract

Beginning in April 2000, eight clinical demonstration projects were funded for 2 years within the Sunshine Network of the Veterans Health Administration (VHA) to test disease management principles, the care coordinator role, and the effective use of technology to maintain veterans in their homes. Five of these projects focused on complex medical/chronic disease populations. Seven hundred and ninety-one veterans were recruited in these five projects and enrolled in the Community Care Coordination Service (CCCS). The program was conceptualized around and designed by network field staff as an "aging in place" model. The purpose behind the integration of the care coordinator role with technology was to improve health status, increase program efficiency, and decrease resource utilization. Evaluation results to date have shown a 40% reduction in emergency room visits, 63% reduction in hospital admissions, 60% reduction in hospital bed days of care, 64% reduction in VHA nursing home admissions, and 88% reduction in nursing home bed days of care. All Performance Improvement outcomes reached or exceeded the targeted goals, and a functional assessment revealed five significant improvements out of 10 domains of the SF 36V.