An audit of the Veterans Health Administration's 12-year-old Home Telehealth Program indicates the VHA has missed opportunities to enroll more veterans who could benefit most from the program - and could have delayed more expensive institutional care for some 59,000 veterans.
The report, issued on March 9 and analyzing the VHA's program in 2012 and 2013, found that the number of non-institutional care (NIC) veterans enrolled in the telehealth program grew by 13 percent in 2012, but declined by 4 percent in 2013. Conversely, in 2013, the number of veterans enrolled under chronic care management (CCM) guidelines jumped 51 percent, and those admitted under health promotion/disease prevention (HPDP) guidelines rose by 37 percent.
The audit faults a change in performance methodology adopted by the VHA in 2011, when the agency switched from measuring specific performance goals for each of the three categories to looking at the program by total number of patients enrolled in all categories. As a result, auditors found that the VHA's performance metrics in successive years featured more HPDP participants, who generally have less healthcare needs and don't need as much management from primary care physicians as the NIC patients.
In other words, according to the audit, once primary care physicians reached their performance targets by enrolling enough patients in the program, they stopped recommending patients for the program. And they reached those goals by enrolling more HPDP and CCM patients.
The "VHA was successful in reaching its new performance metric," the report concluded. "However, obtaining this goal did not result in more patients with the greatest medical needs receiving care under the program."
To be classified as an NIC patient, a veteran must meet at least one of the following criteria:
- Have one or more behavioral or cognitive problems;
- Have a life expectancy of six months or less;
- Have difficulty with three or more daily living activities, such as bathing, dressing and eating; and
- Have a combination of two or more of the following: 1) 75 years of age or older; 2) living alone; 3) visited a VHA clinic 12 or more times in the past 12 months; and 4) have difficulty with at least three instrumental activities of daily living, such as preparing meals, shopping and managing medications.
Veterans meeting CCM criteria can't qualify as NIC patients but have one or more chronic diseases; while those meeting HPDP criteria must meet six conditions, which include being at risk for developing a chronic disease or needing assistance in choosing and maintaining healthy behaviors.
According to the audit, the VHA estimated that about 205,000 veterans who met NIC criteria were eligible to participate in the telehealth program in FY2013, and that about 29 percent of them – or 59,000 veterans - could have avoided long-term institutional care by using the program.
Ironically, the audit found that NIC patients showed the best outcomes after being enrolled in the telehealth program, reducing their average bed days of care (BDOC) by 1.4 days over a six-month period (compared to 0.3 days and 0.4 days for CCM and HDPD patients, respectively). In addition, the audit found that NIC patients showed the best outcomes by reducing their inpatient stays.
Overall, the audit found that the telehealth program has improved clinical outcomes and expanded access to care for veterans while reducing treatment costs and complications. The program costs less than $2,400 per patient annually, compared to a $22,200 annual price tag for care management and in-home nursing care and a $92,300 annual bill for contract nursing home care. And while the program's budget has increased 124 percent from $85.2 million in 2009 to $190.3 million in 2013, the number of veterans enrolled in the program has jumped 115 percent, from 37,200 to 80,200.
According to the audit report, the VHA has accepted the report's conclusions and will work to identify NIC patients who could benefit from the telehealth program.
