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A Telerehabilitation Model for Victims of Polytrauma

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A Telerehabilitation Model for Victims of Polytrauma
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   Rehabilitation Nursing           Rehabilitation NURSING A Telerehabilitation Model for Victims of Polytrauma                                   The Low Activities of Daily Living Monitoring Program (LAMP) at the North Florida/South Georgia Veterans Health Sys-tem 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. service-members had died as a result of the U.S. engage-ments in Afghanistan and Iraq. More than 32,000 troops have been wounded, many sustaining multi-system 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 depres-sion. To help increase survival rates resulting from war-related multiple traumas and reduce the fre-quency 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 im-mediate 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 out-comes for this high-risk group requires aggressive individualized treatment, close follow-up, and con-tinuous reevaluation after hospital discharge (Bose & Tejwani, 2006). The best methods and models of such care have yet to be defined, however. This article pro-poses the use of telehealth as a key component in the long-term management of combat-wounded veterans who have experienced multisystem injuries. Telehealth Telehealth  is defined as the “use of electronic infor-mation 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). Special-ized 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         those with impairments and others for whom access is difficult          travel to increase access to healthcare services         -vention to manage and minimize the impact of chronic diseases and avoid emergency depart-ment (ED) visits and hospitalizations        -tic capabilities because patients must submit vital health information at regular intervals (i.e., daily, weekly) to allow for trend tracking        care coordination that unites physicians, nurses, rehabilitation specialists, psycholo-gists, and social workers with patients       increased adherence as patients receive feed- back regarding their medical conditions and KEY WORDS  home-based telehealth  polytrauma  telerehabilitation veteran care  216 Rehabilitation Nursing          A Telerehabilitation Model for Victims of Polytrauma can become actively involved in managing their care and treatment interventions. 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 trau-mas, places greater demands on the system for coor-dination 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 reg-istered 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 thera-pists, 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 (Ben-nett, Fosbinder, & Williams, 1997; Celler, Lovell, & Basilakis, 2003; Hooper, Yellowlees, Marwick, Cur-rie, & 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 servic-es including compensatory strategies, training and education, monitoring, and long-term care of people with disabilities (Office for the Advancement of Tele-health, 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 ill-ness (Burns, Crislip, Daviou, Temkin, & Vesmarovich, 1998; Cruise & Lee, 2005; Halamandaris, 2004; Win-ters, 2002). One example of a successful TRH program within the VHS is the Low Activities of Daily Liv-ing (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 help-ful 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 combina-tion with health monitoring technologies. OTs serve as CCs for veterans and work collaboratively with other healthcare providers such as nurses, rehabilita-tion 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 arthri-tis, diabetes, hypertension, stroke, and amputations. The LAMP team provides each patient with a compre-hensive assessment, including physical, functional, and cognitive measures, as well as a full home assessment focusing on accessibility and safety. Care plans for re-mote 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 messag-ing device, the Health Buddy (HB; Health Hero Net-work, 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 dis-ease and disability management model through the   Rehabilitation Nursing           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. Communica-tion technology provides LAMP CCs with the neces-sary 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 Afghani-stan, the VHS is challenged to care for a new genera-tion 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. Case History Mr. T. is a 40-year-old man who worked as a contrac-tor 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 result-ing 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 infec-tion. During this hospitalization, Mr. T. was assessed  by the chief of physical medicine and rehabilita-tion, 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 imple-ment 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 equip-ment was not being used because it was not prop-erly 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 modifi-cations 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 capabili-ties, the team determined that he would benefit from a small form factor desktop computer, wireless net-work 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 rehabilita-tion 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 equip-ment, 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 stimula-tion 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 maxi-mum accessibility and independence. As part of his ongoing care, Mr. T. and his wife answered a series of questions regarding his health and functional sta-tus 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  218 Rehabilitation Nursing          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 equip-ment 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 fol-lowing 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 consider-able increase in clinic visits postintervention. This significant increase in CC-initiated clinic visits has  been observed in other VA home telehealth stud-ies (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 re-duced (both inpatient BDOC and nursing home care A Telerehabilitation Model for Victims of Polytrauma Table 2. Healthcare Expenditures for Matched Comparison Group ( N   = 115) 1-Year Prestudy Period and 1-Year Poststudy Period  Preenrollment Cost Days/Visit Postenrollment Cost Days/VisitDifference in Costs Pre- and PostenrollmentDifference in Days per Visit Pre- and Postenrollment Bed Days of Care $1,231,656 1,443 $553,924 699 -$677,732 -744Clinic $642,052 3,088 $862,510 2,931 +$220,458 -157Emergency Department $16,908 76 $12,826 72 -$4,082 -4Nursing Home Care Units $164,668 404 $149,198 400 -$15,470 -4Total Costs $2,055,283.60 $1,578,459.30 -$476,824.30 Table 1. Healthcare Expenditures for Low Activities of Daily Living Monitoring Program (LAMP) Participants ( N   = 115) at 1 Year Preenrollment and 1 Year Postenrollment  Preenrollment Cost Days/Visit Postenrollment Cost Days/VisitDifference in Costs Pre- and PostenrollmentDifference in Days per Visit Pre- and Postenrollment Bed Days of Care $1,494,483 1,449 $690,215 623 -$804,268 -826Clinic $1,162,211 4,561 $2,053,015 8,728 +$890,814 +4,167Emergency Department $23,842 116 $24,257 108 +$415 -8Nursing Home Care Units $84,177 214 $44,763 98 -$42,414 -116Total Costs $2,767,712.90 $2,812,250.50 -$44,537.60   Rehabilitation Nursing           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 re-sult of LAMP enrollment. Although cost savings had  been hypothesized due to the complex illnesses of the veteran enrollees, frequent follow-up clinic vis-its were scheduled to ensure there was no decline in condition and to check on the progress of interven-tions 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. Suc-cess also may be measured by an increase in clinic visits as patients receive access to the intense care their illnesses require. Conclusion 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 ide-ally 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 pro-viders 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 address-ing the complex, long-term rehabilitation, medical, and social needs of veterans with polytrauma. To provide compassionate and fiscally respon-sible 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. Acknowledgment 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 & Devel-opment, 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 Perfor-mance, department of occupational therapy, at the University of Florida in Gainesville, FL. Address correspondence to her at rbendixe@phhp.ufl.edu.Charles Levy, MD, is chief of physical medicine and reha-bilitation 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 direc-tor of the Center for Telehealth at the University of Florida, Gainesville, FL. References Barnett, T. E., Chumbler, N. R., Vogel, W. B., Beyth, R. J., Qin, H., & Kobb, R. (2006). The effectiveness of a care coordina-tion home telehealth program for veterans with diabetes mellitus: A 2-year follow-up.  American Journal of Managed Care, 12 (8), 467–474.Bendixen, R. (2007). Assessment of a telerehabilitation pro-gram for veterans with chronic illnesses. Unpublished manuscript, University of Florida at Gainesville. Bendixen, R., Horn, K., & Levy, C. (2007). Using telerehabilitation to support elders with chronic illness in their homes. Topics in Geriatric Rehabilitation, 23 (1), 47–52.Bennett, P. J., Fosbinder, D., & Williams, M. (1997). Care coordination in an academic medical center. Nursing Case  Management, 2 (2), 75–82.Berry, B. E., & Ignash, S. (2003). Assistive technology: Providing independence for individuals with disabilities. Rehabilitation Nursing, 28 (1), 6–14.Bose, D., & Tejwani, N. C. (2006). Evolving trends in the care of polytrauma patients. Injury, 37,  20–28.Burns, R. B., Crislip, D., Daviou, P., Temkin, A., & Vesmarovich, S. (1998). Using telerehabilitation to support assistive technology.  Assistive Technology, 10,  126–133.Celler, B. G., Lovell, N. H., & Basilakis, J. (2003). Using infor-mation technology to improve the management of chronic disease.  Medical Journal of Australia, 179 (5),   242–246.Chumbler, N. R., Vogel, W. B., Garel, M., Qin, H., Kobb, R., & Ryan, P. (2005). Health services utilization of a care coordination/home-telehealth program for veterans with diabetes: A matched-cohort study.  Journal of Ambulatory Care Management, 28 (3), 230–240.
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