Promoting Self-Care with Telehomecare: Impact on Outcome

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Elders with heart failure have the highest rehospitalization rate of all adult patient groups, with estimated annual total direct health care expenditures exceeding $24 billion.1 Self-care ability has been strongly associated with improvements in both patient and cost outcomes for this population. Telehomecare is an advanced technology designed to enhance self-care for patients with complex care needs. This communication and clinical information system enables patients to become active partners in their own care by providing the tools essential for self-monitoring and early symptom recognition. Despite telehomecare's potential to enhance patients' self-care in a cost-effective manner, few studies have evaluated its efficacy. Reported studies were conducted prior to the introduction of Medicare's prospective payment system for home care and evaluated the use of telehomecare in addition to traditional home visits. None examined patients' involvement in decision-making regarding the use of such technology in meeting their health care needs. Available data suggest that telehomecare may improve self-care and enhance outcomes for elders with heart failure but major gaps in knowledge exist regarding the clinical and cost effectiveness of this technology when decisions regarding its use are negotiated with patients and when it substitutes for traditional nurse visits under the recently introduced changes in the financing of home health care. The proposed randomized clinical trial is designed to address these knowledge gaps. The purpose of the proposed study is to compare the effects of a telehomecare intervention (N=108) that substitutes for some standard home care services and is designed to enhance self-care and improve outcomes for elders following hospital discharge for heart failure with the effects of standard home care services alone (N=108). Patient and cost outcomes will include: self-care, health care resource utilization, health status, quality of life, satisfaction, access to care and cost effectiveness. Data analysis will include mixed model ANOVA for continuous variables, non-parametric analogues of ANOVA for ordinal variables, Fisher's exact for discrete endpoints, survival analysis for time to first readmission, and methods by Lin and colleagues for estimating treatment costs with incomplete follow-up. Findings will help guide optimal use of telehomecare in promoting self-care in the growing population of chronically ill elders whose conditions are characterized by high morbidity, complex therapies and poor quality and cost outcomes.