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A Telerehabilitation Model for Victims of Polytrauma
The Low Activities of Daily Living Monitoring Program (LAMP) at the North Florida/South Georgia Veterans Health System is a telerehabilitation program that promotes independence for veterans experiencing difficulties with activities of daily living by focusing on a combination of care coordination, assistive technology/adaptive equipment, and home environmental modifications. Initially designed to serve elders at risk of institutionalization, LAMP now is being adapted to the needs of veterans living with the effects of multisystem polytrauma. This article provides an overview of telehealth, explains the LAMP model, and presents a case history of a veteran who sustained complete tetraplegia and traumatic transfemoral amputation as the result of a blast injury and who lives successfully at home with the support of LAMP. A recent cost analysis of LAMP patients compared to a matched cohort receiving standard care also is presented. The LAMP model shows promise as a method for home-based management of combat-wounded veterans who experience multisystem polytrauma.
As of June 2008, more than 4,600 U.S. servicemembers had died as a result of the U.S. engagements in Afghanistan and Iraq. More than 32,000 troops have been wounded, many sustaining multisystem polytrauma (U.S. Department of Defense, 2008). Conditions rehabilitation nurses commonly encounter include, but are not limited to, traumatic brain injury; traumatic amputation and peripheral nerve injury in upper or lower limbs; maxillofacial trauma; auditory and visual impairment; spinal cord injury; and psychological disorders such as posttraumatic stress disorder, anxiety, and depression. To help increase survival rates resulting from war-related multiple traumas and reduce the frequency of penetrating injuries to the head and vital organs, the U.S. military has mandated the use of Kevlar helmets and body armor. Advances in emergency medical treatment combined with improvements in body armor have increased the survival rate of polytrauma patients who otherwise would have died from these injuries. Unfortunately, such protective covering offers limited protection against nonpenetrating injuries from blasts and high-impact falls (Okie, 2005).
Most of the polytrauma literature focuses on immediate medical and surgical treatments to reduce field mortality and morbidity. However, survivors and their families face lifetimes of challenges related to living with the consequences of these injuries. It generally is recognized that achieving optimal outcomes for this high-risk group requires aggressive individualized treatment, close follow-up, and continuous reevaluation after hospital discharge (Bose & Tejwani, 2006). The best methods and models of such care have yet to be defined, however. This article proposes the use of telehealth as a key component in the long-term management of combat-wounded veterans who have experienced multisystem injuries.
Telehealth is defined as the “use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration” (Office for the Advancement of Telehealth, 2002, p. 1). Specialized medical devices, videoconferencing, computer networking, and software management systems allow for the evaluation, diagnosis, and treatment of patients in various locations, including the home environment. Medical applications of telehealth are numerous. The main objectives include
Telehealth Applications Within the Veterans Health System
The U.S. Department of Veterans Affairs (VA) is responsible for operating nationwide programs for healthcare, financial assistance, and burial benefits to veterans and their families. The most visible of the VA system services is health care. The Veterans Health System (VHS) is the largest integrated healthcare system in the United States, providing a multitude of services to more than 5.5 million veterans in fiscal year 2006 (U.S. Department of Veterans Affairs, 2007).
The complexity of our veterans’ healthcare needs, especially veterans with multiple injuries and traumas, places greater demands on the system for coordination of care. In the past, care or case management was defined by an episode of care, either in a clinic or hospital, typically with a set number of follow-up phone calls after a patient’s discharge. Today the VHS care coordination model combines the role of a care coordinator (CC) with home telehealth technologies to allow for consistent follow-up that transcends clinical programs and physical settings. CCs usually are registered nurses, nurse practitioners, or occupational therapists (OTs) who serve as key team members, communicating information on a veteran’s response to at-home clinical treatment to facility-based therapists, specialists, and primary care providers via the VA’s computerized medical record system (Meyer, Kobb, & Ryan, 2002). Telehealth models that combine care coordination with communication technology offer a way to decrease healthcare costs and increase patient satisfaction and have been shown to be an important component in managing illnesses (Bennett, Fosbinder, & Williams, 1997; Celler, Lovell, & Basilakis, 2003; Hooper, Yellowlees, Marwick, Currie, & Bidstrup, 2001; Joseph, 2006; Kobb, Hoffman, Lodge, & Kline, 2003; Noel, Vogel, Erdos, Cornwall, & Levin, 2004).
An emerging application of telehealth, known as telerehabilitation (TRH), can play a key role in the polytrauma care system by strengthening the long-term management of patients with multiple traumas and related impairments and medical concerns. TRH involves the remote delivery of rehabilitation services including compensatory strategies, training and education, monitoring, and long-term care of people with disabilities (Office for the Advancement of Telehealth, 2002). The focus of TRH is to increase access to rehabilitation services and to allow veterans to achieve and maintain safe and independent lives in their own homes. TRH has the potential to manage multiple components of health, including functional independence, self-care, and self-management of illness (Burns, Crislip, Daviou, Temkin, & Vesmarovich, 1998; Cruise & Lee, 2005; Halamandaris, 2004; Winters, 2002). One example of a successful TRH program within the VHS is the Low Activities of Daily Living (ADL) Monitoring Program (LAMP; Bendixen, Horn, & Levy, 2007). LAMP is based on preliminary work conducted by Mann and colleagues (Mann, Hurren, Tomita, & Charvat, 1995; Mann, Marchant, Tomita, Fraas, & Stanton, 2001; Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999), which showed that functional decline may be attenuated by providing assistive technology/adaptive equipment (AT/AE). Other studies also have demonstrated that the use of AT/AE within the home environment can be helpful for people with disabilities (Berry & Ignash, 2003; Gitlin, Winter, Dennis, Corcoran, Schinfeld, & Hauck, 2006; Verbrugge & Sevak, 2002).
The VHS LAMP is a TRH program that targets veterans with functional deficits and chronic illnesses who are at risk for multiple VA hospital and nursing home bed days of care (BDOC). LAMP was designed to promote independence and self-management of illness and disability and to reduce healthcare costs through the use of home-based services in combination with health monitoring technologies. OTs serve as CCs for veterans and work collaboratively with other healthcare providers such as nurses, rehabilitation specialists, and clinicians and with families and caregivers. LAMP interventions range from installing AT/AE and modifications in the home environment to providing daily therapeutic regimens and ongoing support for self-care needs. LAMP staff also provides hands-on and remote training in the use of AT/AE.
The LAMP target population includes veterans with multiple comorbidities and impairments such as arthritis, diabetes, hypertension, stroke, and amputations. The LAMP team provides each patient with a comprehensive assessment, including physical, functional, and cognitive measures, as well as a full home assessment focusing on accessibility and safety. Care plans for remote monitoring are developed based on information obtained from these assessments. Two communication systems are used for LAMP remote monitoring: a basic computer with Internet capability and a home messaging device, the Health Buddy (HB; Health Hero Network, Inc., Redwood City, CA). The computer provides two-way free-text communication between the CC and the patient. For patients who are not computer literate, the HB is less complex and easier to use and serves as an interface between patients at home and CCs located at the VA. Home-based daily remote monitoring through the computer or HB comprises a multicomponent disease and disability management model through the review of personal health dialogues. Health-specific education is provided based on individual needs. Patient adherence to medication and treatment plans also is addressed. Maintaining daily contact with TRH patients allows for comprehensive patient-provider communication and follow-up support. LAMP daily self-care reports include information on falls, ADLs, and mobility throughout the home environment, as well as a patient’s ability to go outside of the home and participate in leisure and social activities. Communication technology provides LAMP CCs with the necessary information to monitor health status and self-care parameters and provide immediate intervention and ongoing care management through the VA.
As a result of recent conflicts in Iraq and Afghanistan, the VHS is challenged to care for a new generation of war-injured veterans. One of the ways VHS is responding to this need is to apply the LAMP model to veterans with multisystem injuries who require complex medical and rehabilitation management.
Mr. T. is a 40-year-old man who worked as a contractor for a local builder. He joined the Naval Reserves 2 months before September 11, 2001, and was called to active duty in March 2004. In May 2004, Mr. T. sustained a C3-C4 spinal cord injury with a resulting American Spinal Injury Association complete tetraplegia and left transfemoral amputation after a mortar attack in Iraq. He was airlifted to Germany for emergent care and stabilization, transported to Bethesda Naval Hospital, and transferred to the Tampa, FL, VA Spinal Cord Injury (SCI) Center in June 2004. After a lengthy hospitalization, which included extensive inpatient rehabilitation, he was discharged to his rural Florida home in May 2005. Upon discharge, he was enrolled in VA home-based primary care and referred to home-health nursing, a home-health aide, rehabilitation therapy, and respite services. Mr. T.’s medical issues were managed in his home until July 2005, when he was admitted to a medical intensive care unit secondary to generalized malaise, chest congestion, and a urinary tract infection. During this hospitalization, Mr. T. was assessed by the chief of physical medicine and rehabilitation, who determined that he would benefit from a variety of rehabilitation interventions including changing his power wheelchair joystick, providing electrical stimulation to his left hand to stimulate recovery, ordering further evaluation of his neck and back pain, trying various pain management techniques, and increasing computer access in his home. Mr. T. was referred to LAMP to help implement this care plan through remote monitoring and care coordination. He was discharged home in mid July and enrolled in LAMP 5 days later.
The LAMP initial assessment determined that although Mr. T. had several services in place and a variety of adaptive equipment, much of the equipment was not being used because it was not properly adapted to his needs, the family was not fully trained on its use, or it was not properly set up within the home. Mr. T. needed a cup holder for his power wheelchair, for example, long straws, and modifications to his seating and positioning in his power wheelchair to decrease his pain level and increase his independence in operating the device. Although some computer equipment was provided, it was not being used because it had never been installed, and no instruction on its home use had been provided to the patient or his family. After the LAMP team surveyed Mr. T.’s home and his needs and capabilities, the team determined that he would benefit from a small form factor desktop computer, wireless network adaptors, a Web router/wireless access point, a Web camera, and a tablet PC mounted to his power wheelchair (all provided by the North Florida/South Georgia Veterans Health System), which eventually would be used with his environmental control unit. These devices would allow staff to remotely monitor Mr. T. in LAMP via a personal computer. LAMP staff installed the equipment and followed up with the Tampa VA SCI Center and its vocational rehabilitation case manager to discuss the adaptive equipment previously ordered by its staff, which included voice recognition software and head mouse (for hands-free access). Mr. T. and his wife were trained on all equipment, and LAMP staff worked with the Gainesville VA outpatient occupational therapist/certified hand therapist to coordinate real-time TRH using Web cameras located in Mr. T.’s home and the OT clinic. This allowed Mr. T. to complete an electrical stimulation trial delivered by an instrumented wrist orthosis (H200, Bioness Inc, Santa Clarita, CA) to encourage recovery of hand function while in the comfort of his own home (unfortunately this intervention did not result in significant recovery).
LAMP staff provided suggestions regarding the construction of a new home for Mr. T. to ensure maximum accessibility and independence. As part of his ongoing care, Mr. T. and his wife answered a series of questions regarding his health and functional status via the computer. The questions were developed to match his current health concerns and had preset options as answers. There also were opportunities to share information in a free-text format. Mr. T. or his wife completed the LAMP survey daily using his personal computer, which communicates with the desktop computers of CCs in Gainesville. The CCs can respond quickly to concerns and notify Mr. T.’s VA primary care provider, nurse, and other clinicians as appropriate. Issues requiring notification include the need for prescription refills; adapting Mr. T.’s power wheelchair secondary to pain, skin breakdown, and positioning concerns; medical interventions related to ongoing pain issues; replacing adaptive equipment that has worn out or broken; and providing new equipment as indicated, such as a ceiling-track lift system to assist with transfers in his new home. LAMP also continued to coordinate with Mr. T.’s home health therapists to ensure that his ongoing therapy and equipment needs were met. LAMP also helped to establish in-home respite care, and continues to help coordinate hospital-based respite care as needed.
As a result, although Mr. T. continues to require total assistance with all basic ADLs and instrumental ADLs, he has been able to reside at home with his family rather than having to move into a long-term care facility.
LAMP Cost Analysis
A recent study (Bendixen, 2007) examined healthcare costs using retrospective data from 115 veterans enrolled for at least 1 year in LAMP and compared them to costs accrued by a matched comparison group. The comparison group was matched based on geographic location, age, marital status, chronic illnesses, and number of hospital BDOCs during the 12-month prestudy period. Healthcare costs included expenditures for hospital BDOC, clinic visits, ED fees, and nursing home care units at 12 months before and 12 months after interventions. Total summed actual costs and itemization of costs for LAMP and the matched comparison group are presented in Tables 1 and 2. The tables compare 1-year preenrollment costs to 1-year postenrollment costs.
Based on this analysis, total costs for hospital BDOC for both cohorts decreased in the year following enrollment. For the LAMP group, nursing home BDOC decreased approximately 50% during the postenrollment year compared to a decrease of 9% for the matched cohort. Itemized costs revealed that LAMP participants experienced a considerable increase in clinic visits postintervention. This significant increase in CC-initiated clinic visits has been observed in other VA home telehealth studies (Chumbler et al., 2005; Kobb et al., 2003). In comparison, clinic visits and costs for the matched cohort decreased during the poststudy period.
In this short-term (12 months) comparison of LAMP with standard care, inpatient costs were reduced (both inpatient BDOC and nursing home care for both groups). Although LAMP’s inpatient BDOC and nursing home care unit costs notably decreased before and after enrollment, the increase in clinic costs increased LAMP’s overall postenrollment costs. This suggests that LAMP increased home independence, but at a financial cost compared to standard care in the short term. It is important to note that a primary focus of telehealth is to increase access to care; as a result, much of the increase in clinic visits was a result of LAMP enrollment. Although cost savings had been hypothesized due to the complex illnesses of the veteran enrollees, frequent follow-up clinic visits were scheduled to ensure there was no decline in condition and to check on the progress of interventions and treatments. Longer observation periods would allow time to weigh the impact of the increase in care- and health-related cost effects provided by the TRH program. Recent studies have shown that clinic visits have declined within the second year of a telehealth intervention (Barnett et al., 2006). Moreover, Jennett and colleagues (2005) reported that institutions should not expect short-term results in cost savings and should move away from cost-benefit analysis in telehealth and instead view telehealth as a long-term venture with patient use as a measure of success. Success also may be measured by an increase in clinic visits as patients receive access to the intense care their illnesses require.
The costs and benefits of a LAMP approach for veterans with multisystem injuries or polytraumas are not yet known. Although the complexity of care required by many of these veterans seems ideally suited for a care coordination and home-based TRH intervention, the approach may need to be broadened to include an interdisciplinary team of CCs. The CCs in the current LAMP program are OTs who focus on independence and functionality, adaptive measures in the home, and home safety. The OTs monitor medical and primary care needs and remain in close contact with facility-based providers if a medical emergency occurs. An expanded interdisciplinary model, including OTs, advanced practice rehabilitation registered nurses, and social workers may prove a better approach to addressing the complex, long-term rehabilitation, medical, and social needs of veterans with polytrauma. To provide compassionate and fiscally responsible care to wounded veterans, future research should test different home-based TRH models to determine which models best meet the needs of returning veterans. Future research also should use a randomized controlled trial design that follows the intervention and comparison groups for more than 12 months and collects information to identify CC-initiated outpatient visits.
The authors gratefully acknowledge the veterans and their families who took part in this study. The opinions contained in this paper are those of the authors and do not necessarily reflect those of the U.S. Department of Veterans Affairs. This material is the result of work supported with resources and the use of facilities at the United States Department of Veterans Affairs, Health Services Research & Development/Rehabilitation Research & Development, and the North Florida/South Georgia Veterans Health System.
About the Authors
Roxanna M. Bendixen, PhD OTR/L, is research assistant professor in the College of Public Health & Health Performance, department of occupational therapy, at the University of Florida in Gainesville, FL. Address correspondence to her at firstname.lastname@example.org.
Charles Levy, MD, is chief of physical medicine and rehabilitation at North Florida/South Georgia Veterans Health System in Gainesville, FL.
Barbara J. Lutz, PhD RN CRRN, is assistant professor in the College of Nursing at the University of Florida.
Kathleen R. Horn, MS OTR/L, is lead care coordinator of the Low ADL Monitoring Program (LAMP) at North Florida/South Georgia Veterans Health System in Gainesville, FL.
Kim Chronister, MHS OTR/L, is a care coordinator of the Low ADL Monitoring Program (LAMP) at North Florida/South Georgia Veterans Health System in Gainesville, FL.
William C. Mann, PhD OTR, is a distinguished professor and chair of the department of occupational therapy and director of the Center for Telehealth at the University of Florida, Gainesville, FL.
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