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Service Delivery Innovation Profile

Care Coordinators Remotely Monitor Chronically Ill Veterans via Messaging Device, Leading to Lower Inpatient Utilization and Costs

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As part of the Care Coordination/Home Telehealth Program at the Veterans Health Administration, care coordinators remotely monitor veterans with chronic conditions such as diabetes, high blood pressure, and other physical or mental health problems via a messaging device that poses daily disease-specific and general health-related questions. The system transmits patient responses that are then available for review using software that organizes the data and highlights out-of-range values. The system allows care coordinators to quickly pinpoint health issues and respond accordingly, either by contacting the patient (to offer care instructions and/or self-care education) or his or her physician or directing the patient to emergency services. The program significantly reduced hospital admissions, inpatient days, and comparative care costs, and generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospital admissions and bed days; comparisons of annual, per-patient program costs to those of other VHA programs serving similar patients; and post-enrollment patient satisfaction scores.
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Developing Organizations

Veterans Health Administration
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Date First Implemented

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Patient Population

Vulnerable Populations > Military/dependents/veteransend pp

Problem Addressed

If not monitored closely, chronically ill individuals—such as those with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and hypertension—may develop complications that lead to the need for expensive inpatient and/or long-term care. Although ongoing monitoring of these individuals, especially older ones, may prevent some of these complications, relatively few health systems have the capacity to provide such services.
  • Cycle of hospitalizations: Many patients with chronic illnesses require frequent hospitalizations to deal with exacerbations or complications associated with their condition(s). For example, almost one-third of hospitalized CHF patients require readmission within 30 days of discharge.1 Admissions and readmissions occur for a number of reasons, such as deficiencies in patient self-care and lack of appropriate followup after discharge.2
  • Especially for older individuals: The Veterans Health Administration (VHA) estimates that its population of patients aged 85 years and older will have more than tripled between 2000 and 2012 (when it will reach 1.4 million).3 Many of these elderly individuals suffer from multiple chronic conditions, and they frequently have a strong preference to remain in their homes.
  • Leading to significant clinical and economic burden: Chronic illnesses are associated with high health care utilization and costs. For example, CHF is the leading cause of hospitalization among older patients, accounting for an estimated $29.6 billion in costs in 2006.2
  • Unrealized benefits of monitoring: Ongoing monitoring of chronically ill individuals, especially older ones, can help to prevent many exacerbations and complications, thus reducing care costs and allowing them to remain in their homes. Yet, relatively few health systems have the capacity to provide chronically ill individuals with such ongoing monitoring. The VHA, for example, has identified an urgent need to increase the capacity of its noninstitutional care services to support chronically ill patients.3

What They Did

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Description of the Innovative Activity

The VHA Care Coordination/Home Telehealth program employs care coordinators to remotely monitor veterans with chronic conditions on a daily basis. Each day, patients respond to disease-specific and general health-related questions posed by a home messaging device; the system transmits responses that are available for review by the care coordinator using software that organizes the data and highlights out-of-range values. This allows care coordinators to quickly pinpoint health issues and respond accordingly, either by contacting the patient or his or her physician or directing the patient to emergency services. Key elements of the program include the following:
  • Enrollment: Physicians refer patients to the program who require noninstitutional care for chronic conditions, such as diabetes, CHF, hypertension, COPD, posttraumatic stress disorder, depression, and/or other physical or mental health issues. To date, more than 48,000 veterans across the country are enrolled, roughly two-thirds of whom have multiple conditions. Enrollees include some of the 2 to 3 percent of veterans who collectively account for 30 percent or more of VHA costs, along with others who often require urgent admission to the hospital or who visit clinics frequently. Patients enroll voluntarily and remain in the program as long as necessary to meet their unique needs. Some stay for only a few months, while others remain in the program for the rest of their lives.
  • Care coordinator assessment: A care coordinator (usually a nurse or social worker) performs a formal intake assessment on each patient, with assessments being repeated as necessary but at least every 6 months. The assessment process includes the following:
    • Full review of medical history: The care coordinator conducts a full review of the patient's medical history, psychosocial needs, caregiver support, medications, and activities of daily living.
    • Confirmation of program appropriateness: The care coordinator uses locally developed enrollment criteria to confirm that this program can best meet the patient's needs (as opposed to other VHA programs, such as home health or nursing home placement).
    • Assignment to care category: The assessment determines the appropriate category of care for the patient based on the complexity of his or her needs. The program offers various types of support, including noninstitutional care (for those with highly complex care needs), chronic care management (for more functional patients with chronic diseases), acute care management (for those requiring relatively short-term support), and health promotion/disease prevention for patients such as those whose primary need is for weight management. Patients may be reassigned to different care categories during subsequent assessments (which, as noted, occur at least every 6 months).
    • Development of care plan: The care coordinator develops a care plan for the patient based on his or her chronic condition(s) and medical complexity and identifies specific indicators to be monitored from home using the home telehealth device. As with the care category assignment, the plan can be reviewed and modified during each subsequent assessment.
  • Response to daily questions via messaging device: The care coordinator provides the patient with a messaging device to be connected to a telephone line in the home and trains the patient and/or the caregiver to use it. Training may occur in person (during a clinic visit) or over the telephone (if the device has been mailed). Each day, the patient accesses the device to read and respond to a series of questions regarding his/her medical condition(s). Questions relate to general well-being, symptoms, knowledge, activities of daily living, and caregiver support. As appropriate, the questions also ask about key clinical indicators relevant to the patient's underlying health condition(s), such as vital signs, blood glucose measurement, and/or weight. In some cases, these values are uploaded directly by wired or wireless connection of the measurement device to the messaging device; in other cases, the patient may enter the values from the measurement device into the messaging device. These clinical indicators have been drawn from a variety of standards of practice such as the national practice guidelines developed by VHA and the Department of Defense.
  • Ongoing monitoring by care coordinator: The care coordinator automatically receives an organized summary of patient responses each day via computer. The system provides color-coded alerts when indicators fall outside of the range that has been established for that patient, thus helping the coordinator identify and triage patient needs. The coordinator responds to these needs based on his or her professional expertise, providing active care management and self-management education to the patient, communicating with the patient’s physician when necessary, and/or directing the patient to contact emergency services. Although virtually all care coordinator services are provided by telephone, patients may also see the care coordinator when they have other appointments scheduled with their physicians or for other services. When interacting with patients, the care coordinator uses the VHA’s electronic health record (EHR) system to access data from any VHA site in the country and document treatment planning and patient interactions.
  • Caregiver support: Because patients with significant challenges often rely on a caregiver, the care coordinator may use several screening tools to assess caregiver stress levels on an ongoing basis and then initiate supportive activities when appropriate. This might take the form of referral for social work services through the VHA or for community-based resources such as support groups or Meals on Wheels.

Context of the Innovation

The VHA, a large integrated health system housed within the U.S. Department of Veterans Affairs, provides health care services to approximately 5.6 million veterans each year (out of the roughly 7.6 million veterans enrolled in the VHA). The impetus for this program came from two administrators in Veterans Integrated Service Network (VISN) 8, a VHA administrative region in Florida that serves a large number of veterans, many of whom have multiple and complex chronic conditions. These administrators became concerned about the need to expand service capacity for the growing number of older veterans in the region with chronic conditions and long-term care needs.

Did It Work?

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The program significantly reduced hospital admissions, inpatient days, and care costs and generated high levels of patient satisfaction.
  • Fewer admissions and inpatient days: An analysis of 17,025 program participants found that inpatient admissions fell by 19.7 percent during the 6 months after enrollment (as compared with admissions during the year before participating in the program). The same analysis found that inpatient days fell by 25.3 percent, well above the 4.6 percent reduction in all VHA patients.
  • Lower costs: The program costs much less than other VHA programs serving similar patients. The telehealth program costs an average of $1,600 per patient each year, compared with annual per-patient costs of $13,121 for VHA's home-based primary care service and $77,745 for VHA's nursing home care.
  • High patient satisfaction: Program participants have a mean satisfaction score of 86 percent (with 100 percent signifying total satisfaction) with the program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of hospital admissions and bed days; comparisons of annual, per-patient program costs to those of other VHA programs serving similar patients; and post-enrollment patient satisfaction scores.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Pilot program: The VISN 8 region piloted the program between 2000 and 2003.
  • Steering committee planning: A multidisciplinary steering committee made up of representatives from geriatrics, nursing, and extended care from the VHA central office and VISN 8 examined the pilot experience and planned the expansion of the program to other VHA regions.
  • Establishment of telehealth office: The VHA established a central office (known as the Office of Telehealth Services) to oversee the national rollout and sustainment of the program. This office is a part of the VHA's Office of Patient Care Services and ensures communication and collaboration with other health care programs within the VHA.
  • Obtaining technology: The VHA solicited proposals from and signed national contracts with selected technology vendors for home-based telehealth messaging technologies. The devices are similar, although some features vary among vendors.
  • Standardized care coordinator training: The program established a national training center in Lake City, FL, to provide standardized training to care coordinators. The curriculum includes at least 12 hours of online education and 2 to 4 weeks of precepted training at a local VHA institution. Approximately 5,000 care coordinators have been trained to date.
  • Ongoing expansion: The program continues to expand, with plans to increase in census by 50 percent in each of the next 2 years. This will help it meet the expanding need as the number of veteran patients aged 85 years or more that VHA treats is set to triple by 2011 compared with 2000.3

Resources Used and Skills Needed

  • Staffing: VHA currently employs approximately 450 care coordinators, with each handling a caseload of roughly 90 to 125 patients, depending on a number of variables.
  • Costs: As noted, the annual, per-patient cost of the program is roughly $1,600. This figure includes care coordinator time, expenses related to technology and equipment, and overhead. Due to the VHA's buying power, equipment costs may be higher for other organizations adopting this program.
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Funding Sources

Veterans Health Administration
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Adoption Considerations

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Getting Started with This Innovation

  • Use systems approach: Integrate the program into existing medical and behavioral health services, as the use of existing resources helps keep program costs low.
  • Select vendors carefully: Programs that rely on technologies such as home telehealth devices from any individual vendor could become unsustainable due to advances in technology or vendors going out of business. Consequently, the initial selection of a vendor should be based on the organization's track record, years in operation, and ability to adapt to new technological developments/requirements.
  • Provide thorough training: Care coordinator training should be formalized and standardized to ensure that the program offers consistently high-quality services. This training should focus on the case management component of the role as well as use of the technology.
  • Leverage the EHR: Care coordinators need to have access to the EHR, thus ensuring that decisionmaking and treatment provision can be based on complete patient data and that all indicators and interventions can be reviewed by physicians, other involved hospital staff, and other providers as appropriate.
  • Plan for sustainability from the beginning: If possible, set up a funding stream to ensure the long-term viability of the program. For example, the VHA has evolved to incorporate home telehealth into the ongoing funding stream in addition to use of time-limited funding.

Sustaining This Innovation

  • Focus on the patient: Successful outcomes depend on the ability to meet individual patient needs. Care coordinators should identify and address these needs while also encouraging patient self-management, as this approach will ultimately serve the patient best and help to reduce utilization.
  • Elicit ongoing feedback from coordinators: Although the basic concept of monitoring home-based patients seems fairly straightforward, the details related to how patients use the technology and how care coordinators communicate with those patients can be complicated. Care coordinators can provide valuable "on-the-ground" feedback as to how well the program is working and often may be able to offer potential solutions to identified problems.
  • Develop a formal quality management process: The VHA uses a uniform quality management process for Care Coordination Home Telehealth that includes established standards that apply to all programs, called Conditions of Participation, and regular reviews and site visits for all telehealth programs.

More Information

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Contact the Innovator

Linda Foster
Lead Quality Manager
Office of Telehealth Services
Department of Veterans Affairs

Innovator Disclosures

Ms. Foster has not indicated whether she 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

United States Department of Veterans Affairs. Care Coordination/Home Telehealth. Available at:

Darkins A, Ryan P, Kobb R, et al. 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. Telemed J E Health. 2008;14(10):1118-26. [PubMed]


1 Landro L. Keeping patients from landing back in the hospital. The Wall Street Journal. December 12, 2007. Available at:
2 Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation. October 2007. Available at:
3 Darkins A, Ryan P, Kobb R, et al. 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. Telemed J E Health. 2008;14(10):1118-26. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 02, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 07, 2013.
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.

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