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Service Delivery Innovation Profile

Daily Remote Monitoring and As-Needed Nurse Contacts Reduce Unexpected Clinic Visits, Hospitalizations for Chemotherapy Patients


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Snapshot

Summary

The Department of Veteran Affairs and National Cancer Institute developed a telehealth-enabled program for cancer patients undergoing chemotherapy. Patients answer simple questions each day about symptoms using a touchpad device that transmits the information to a nurse care coordinator, including color-coded alerts for patients experiencing problems. The nurse proactively contacts patients with unusual and/or severe symptoms, providing additional support, education, referrals, or other services as needed. A matched case-control study found that the program increased access to telephone-based support, significantly reduced unexpected use of hospital and clinic services, and resulted in fewer missed chemotherapy treatments in the hospital.1

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key measures of planned and unplanned hospital and clinic use between program participants and a matched control group of similar patients.
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Developing Organizations

Department of Veteran Affairs Care Coordination/Home-Telehealth Program; National Cancer Institute
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Use By Other Organizations

The program is available throughout the entire VA system; no information exists on what other VA sites currently use it.

Date First Implemented

2003
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Patient Population

The pilot study included predominantly male cancer patients (95 percent), with the average age being 63.5 years. Roughly one-half of patients (48 percent) had lung cancer.end pp

Problem Addressed

Cancer patients undergoing chemotherapy often experience symptoms that can have a significant negative impact on quality of life and lead to the need for physician and/or hospital care. Although strategies exist to help manage these symptoms, most patients remain unaware of them, in part because providers view uncontrolled symptoms as normal and unavoidable.
  • Common chemotherapy-related symptoms: Cancer patients undergoing chemotherapy routinely suffer from pain, nausea, dizziness, fatigue, shortness of breath, emotional distress, dehydration, and functional impairment.1
  • Lack of knowledge in managing symptoms: Many patients do not know and/or forget how to manage these symptoms, and/or lack knowledge about when such symptoms require immediate attention.
  • Leading to need for physician, hospital care: Left unaddressed, these symptoms often require additional treatment, including cancer-related outpatient and inpatient visits. For example, dehydration and/or nausea can lead to the need for emergency department (ED) and/or inpatient care, shortness of breath often requires a workup to rule out pneumonia, and vomiting or blood in the stool may necessitate a visit to the primary care physician or hospital. In many instances, the presence of complications (e.g., infections) prevents patients from undergoing routine inpatient and outpatient chemotherapy treatments.
  • Unrealized benefits of proactive symptom management: Appropriate symptom management has the potential to prevent complications and the associated need for unplanned physician and/or hospital visits,2 but many providers see these uncontrolled symptoms as normal and thus do not proactively address them.

What They Did

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Description of the Innovative Activity

The Department of Veteran Affairs (VA) telehealth-enabled program for cancer patients undergoing chemotherapy includes two core elements. Each day, patients answer simple questions about symptoms using a touchpad device that transmits the information to a nurse care coordinator, including color-coded alerts for patients experiencing problems. The nurse proactively contacts patients with unusual and/or severe symptoms, providing additional support, education, referrals, and other services as needed. The goal is to proactively monitor and regulate symptoms, thus reducing the need for unexpected clinic, ED, and hospital care. Key elements are described below:
  • In-home training on telehealth device: As necessary, the care coordinator (a nurse with expertise in oncology) visits the homes of participating patients to set up the telehealth device and provide instructions on using it. Because the device is relatively simple to operate (requiring patients to answer questions via a touchpad), some patients who were being seen in the oncology clinic and/or had adequate caregiver support at home did not require home visits.
  • Daily questions on symptoms: Each day, the patient answers questions about five common chemotherapy-related symptoms, including pain, fatigue, nausea, functional limitations, and emotional distress. The device is programmed to ask additional questions depending on the patient's answers—for example, if the patient indicates severe pain, the device probes for more information on the location, duration, and intensity of the pain.
  • Transmitting information, alerts to care coordinator: All patient answers are transmitted by the device via a toll-free telephone number to a secure Web site behind the VA firewall. The care coordinator can then access this password-protected Web site to review the data. The device is embedded with an algorithm that translates the information submitted into a color code, with green indicating that everything is normal, yellow indicating potential problems, and red indicating significant issues that require immediate attention. Typically, the presence of particular symptoms and/or the surpassing of an agreed-on symptom threshold will generate a red or yellow alert.
  • Care coordinator intervention: The care coordinator immediately calls the patient whenever a red alert is issued and will frequently call those patients with yellow alerts as well. The care coordinator uses his or her judgment to resolve the patient's problems. Examples of interventions include making a timely referral to the clinic, reinforcing symptom-based education, offering encouragement and reassurance, or arranging for needed medications. For example, a patient at risk for dehydration due to nausea will be instructed on strategies for managing the nausea and encouraged to intake fluids to prevent dehydration.
  • Interaction with provider team: The care coordinator routinely inputs relevant information from the patient's responses to the daily questions into an electronic medical record (EMR) system. This information can be accessed by any VA provider involved in the patient's care. When necessary, the nurse may also call or e-mail the patient's physician or staff at the VA chemotherapy clinic.

Context of the Innovation

This program was the result of an interagency grant between the National Cancer Institute (NCI) and the VA central office. The cancer telehealth program is run out of the VA's Care Coordination/Home-Telehealth Program, part of the VA Office of Care Coordination; the program was implemented at a VA site in Gainesville, FL, that has a large outpatient chemotherapy clinic and hospital. The program was developed after NCI officials learned of the VA's success in using home telehealth to monitor patients with chronic conditions such as heart failure, diabetes, and hypertension. NCI leaders became intrigued by the idea of applying the concept to cancer, which is increasingly considered a chronic disease where patients routinely live for long periods of time. The program also fit in well with the recommendations of the Institute of Medicine's 2001 Crossing the Quality Chasm Report,3 which highlighted the failure of the U.S. health care system to effectively manage important symptoms of chronic disease, including pain and fatigue.

Did It Work?

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Results

A matched case-control study that included 43 program participants and 82 control group patients found that the program increased access to telephone-based support, significantly reduced unexpected use of hospital and clinic services, and resulted in fewer missed chemotherapy treatments in the hospital.1
  • Enhanced access to telephone-based support: During the 6-month trial, each participating patient received an average of seven calls, while control group patients had less than one interaction (0.7), typically the result of calling a 24-hour phone advice line.
  • Less unexpected service use: Comparisons of utilization between participants and the control group show that the program significantly reduced unplanned chemotherapy-related hospitalizations (57 percent) and bed days (51 percent), unplanned clinic visits (97 percent), preventable all-cause bed days (50 percent), and admissions (49 percent; this finding approached but did not reach statistical significance). The program did not have a significant impact on ED visits.
  • Fewer planned clinic visits: Program participants had 64 percent fewer planned, cancer-related clinic visits than did control group patients. This finding may be due to more frequent interactions with the care coordinator, which helped prevent the need to travel long distances for followup care through the provision of self-management advice and/or the arranging of medications or other needed services over the phone.
  • Fewer missed chemotherapy treatments: Participants had more than twice the number of planned, chemotherapy-related hospitalizations than did control group patients. This finding supports the hypothesis that the program helped prevent complications or symptoms that often force patients to postpone scheduled treatments.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key measures of planned and unplanned hospital and clinic use between program participants and a matched control group of similar patients.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Briefing clinic providers: To secure buy-in and support, a team of individuals familiar with care coordination gave a presentation to chemotherapy clinic providers about the proposed program, inviting input and advice on its development.
  • Training care coordinators: The care coordinator received brief training on the telehealth device, including how to access information transmitted from the device and how to interpret the color codes. Because the nurse already had extensive experience in oncology and in using the VA's EMR, little additional training was needed.

Resources Used and Skills Needed

  • Staffing: One part-time care coordinator handled the 43 participating patients during the 6-month trial. As noted, the nurse had extensive experience in oncology.
  • Costs: Data on development, equipment, and operating costs for the program are not available.
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Funding Sources

Department of Veterans Affairs; National Cancer Institute
The pilot study was funded by a $111,000 grant from NCI. These funds covered research-related costs during the pilot study. The VA pays for program-related equipment, staff, and other ongoing operating expenses.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Involve physicians upfront: Physicians should be briefed and invited to provide input on the program during the development phase, as their support is critical to success.
  • Consider appropriate frequency of monitoring: Daily monitoring can take up a significant amount of the care coordinator's time. Less frequent monitoring—two to four times a week—may be possible.
  • Make device easy to use: Patients will not use the device if it is difficult to do so. Ease-of-use led to very high compliance rates during the pilot study.
  • Leverage the EMR: This program would be difficult to operate without an EMR, which allows for easy communication across providers.
  • Use experienced oncology nurse: The care coordinator should have extensive experience in caring for cancer patients.

Sustaining This Innovation

  • Communicate appropriately with physicians: A careful balance must be struck when communicating with physicians about patients. Physicians want to be promptly informed about clinically important problems, issues, or complications that arise, but do not want to be overwhelmed with information about minor, clinically irrelevant issues.

Use By Other Organizations

The program is available throughout the entire VA system; no information exists on what other VA sites currently use it.

More Information

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Contact the Innovator

Neale R. Chumbler, PhD
Research Scientist and Associate Director
VA HSR&D Center of Excellence on Implementing Evidence-based Practice
Roudebush VAMC
Professor, Department of Sociology
Indiana University School of Liberal Arts at Indiana University-Purdue University Indianapolis
1481 West Tenth Street, 11-H
Indianapolis, IN 46202
E-mail: Neale.Chumbler@va.gov

Innovator Disclosures

Dr. Chumbler has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Chumbler NR, Kobb R, Harris L, et al. Healthcare utilization among veterans undergoing chemotherapy: the impact of a cancer care coordination/home-telehealth program. J Ambulatory Care Manage. 2007;30(4):308-17. [PubMed]

Footnotes

1 Cooley ME, Short TH, Moriarty HJ. Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer. Psychooncology. 2003;12(7):694-708. [PubMed].
2 Hewitt M, Greenfield S, Stovall E, editors. From cancer patient to cancer survivor: lost in transition. Washington, DC: National Academy Press; 2006.
3 Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
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Original publication: July 20, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 28, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.