Telemonitoring in Rural Elder Nutrition Centers: Demonstration Project of Hypertension Management (District of Columbia)

Project Final Report (PDF, 697.08 KB)

Project Details - Ended

Project Categories

Summary:

This project, the Technologies for Enhancing Access to health Management (TEAhM) project, was a pilot study which implemented and evaluated telehealth kiosks in community-based senior centers. The project team was composed of a partnership between researchers from LeadingAge, Wright State University, Healthanywhere, and four senior centers in rural Ohio. Comparisons were made between seniors with hypertension who  used the kiosk over ten months, and those hypertensive seniors who did not. Two of the senior centers served as intervention sites, while the other two served as controls. A total of 113 seniors were enrolled in the project, 41 of whom used the kiosk. The main objectives of the project were to:

  • Determine proof-of-concept for a system in which telehealth monitors can be utilized to manage blood pressure in a community setting that targets high risk elders.
  • Compare blood pressure control in a telehealth group to blood pressure control in a control (non-telehealth) group.

Blood pressure data from the kiosks was transmitted to a central server monitored by study nurses.  Data was entered into an electronic health record with an alert system: nurses were alerted by e-mail if study patients' blood pressures reached a certain threshold as defined by the patient's primary care physician.

The project was effective at creating alerts in response to elevated blood pressure so that those results could be managed immediately.  The team found it challenging to connect with the seniors’ primary care physicians to obtain blood pressure referral protocols and felt that overcoming this challenge in the future would be important to ensure success of this type of project. Of note, a post-study physician survey revealed that while physicians see the value in this type of service, many of the physicians were unaware that they had patients involved in the study. 

The directors at the two senior centers with the kiosks felt that study participants valued the kiosks and thought that the use of the technology itself was easier than it had been expected to be.  They also felt that the use of telehealth services at senior centers was a natural extension of existing programming in their communities.  Staff reported that they saw clear value in the program, and felt that senior centers were a good venue for this technology. 

Study participants noted value in the kiosks, but expressed frustration over the number of follow-up calls they received in response to the study nurses receiving blood pressure alerts.  The vast majority of participants, 95 percent, reported that they were "very comfortable" with the use of the kiosk. 

The project was able to show that this type of technology is well accepted by both seniors and senior center staff.  Further study could more directly involve primary care practices, building on TEAhM.  Such a project could help to improve connections between community-based senior centers routinely used by seniors and the physicians that care for them.

Telemonitoring in Rural Elder Nutrition Centers: Demonstration Project of Hypertension Management - 2011

Summary Highlights

Summary: Despite extensive public and professional education and the availability of efficacious treatments, hypertension remains the most common and strongest risk factor for cardiovascular disease in North America. Hypertension is present in more than 70 percent of Americans aged 80 and older, and it is the single most important risk factor for stroke. Improved approaches to patient self-management are increasingly viewed as an integral part of the health care process, and offer particular promise for conditions such as hypertension. Telehealth may provide a novel approach to enhancing the ability of older adults to manage hypertension and other chronic conditions, especially if this technology is delivered in community-based settings that are easily accessed by seniors.

This project is one of the Agency for Healthcare Research and Quality (AHRQ)-sponsored Accelerating Change and Transformation in Organizations and Networks (ACTION) projects designed to promote innovation in health care delivery by accelerating the diffusion of research into practice. Under the leadership of Dr. Helaine Resnick, this demonstration project was conducted by a partnership consisting of researchers from LeadingAge and Wright State University; Healthanywhere, a telehealth technology company; and four senior centers in Ohio. The study was designed to explore the feasibility of installing telehealth kiosks in community-based senior centers and using telehealth technology to manage blood pressure (BP) in a setting that targets high-risk elderly patients. Study participants included hypertensive adults who received nutrition assistance at one of the four senior centers involved in the project. Two of the centers installed telehealth kiosks that allowed participants to conduct self-monitoring of their BP any time they use the center. Two sites did not have kiosks and served as control facilities. Blood pressure data from telehealth stations at the intervention centers were streamed to a secure central server managed by a telehealth vendor and monitored by study nurses. Data was collected on hypertension baseline and endpoints such as physician visits and medication titrations, with a focus on comparisons between participants at intervention and control facilities.

The results of this pilot study are the first step in determining the promise of further research in this area.

Project Objectives:

  • Determine proof-of-concept for a system in which telehealth monitors can be utilized to manage BP in a community setting that targets high-risk elders. (Achieved)
  • Compare BP control in a telehealth group to BP control in a control (non-telehealth) group. (Achieved)

2011 Activities: Enrollment and participant followup were completed in 2010; the focus of activity in 2011 was on data analysis and development of the final report. The project was completed in April and a final report was delivered to the AHRQ in June.

Impact and Findings: Study participants were highly compliant with use of the technology, but use dropped off somewhat over the 10 months of followup. Ninety-five percent of participants reported being "very comfortable" with use of the telehealth kiosk at the end of the study, and senior center directors reported overall satisfaction on the part of their clients and their staff with the kiosk. Many participants commented on the convenience of having the equipment set up at the senior center because they were there on a regular basis for activities. Thus, participation and ongoing BP measurements did not impose any added burden on seniors beyond the time involved in taking the measurements. Center directors also reported that at the completion of the project, they felt that the telehealth device was easy for seniors to use and that staff were seldom tapped for questions or assistance.

Study nurses reported a high degree of satisfaction with the technology, but indicated that having access to the health care portal on a mobile device would have been a good addition to the technology platform. Nurses reported the ability to provide quick and effective nursing interventions in response to elevated blood pressure readings but expressed that greater access to participants' physicians would have helped study nurses utilize the technology more effectively. Based on these findings, future research might explore how to move the nurse monitoring aspect of the project into the primary care setting or integrate it into the senior center's stream of services allowing direct communication with the primary physicians' office. Although an office-based approach to nurse management was beyond the scope of this project, this project highlights the potential additional benefits that could be realized by incorporating nurse-mediated management in the office setting. However, financing is one of the major barriers inhibiting the proliferation of this type of technology. Therefore, incorporating nurse-mediated management in the office setting would not be feasible unless it was covered by Medicare or other health insurance plans.

Future research on the efficacy and cost-effectiveness of this telehealth approach for chronic disease management could provide evidence supporting the adoption of this approach into regional or national networks of senior centers. Studies could also focus on operational and logistical issues associated with building bridges between physicians who care for seniors and senior centers that are routinely utilized by these individuals. This line of investigation would significantly contribute to advancing community-based, communication-focused technologies for this vulnerable population.

Target Population: Elderly*, Hypertension, Low SES/Low Income*, Rural Health*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patientcentered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Telemonitoring in Rural Elder Nutrition Centers: Demonstration Project of Hypertension Management - 2010

Summary Highlights



Target Population: Elderly*, Hypertension, Low SES/Low Income*, Rural Health*

Summary: With the aging of the U.S. population, increased attention is being given to delivering health and related services to older persons in the community and to how new technologies can facilitate delivery and receipt of services that were once available only in traditional ambulatory care settings. There is a vast network of organizations that provide nutrition and other health promotion, disease prevention, and social services to low-income elders, many of whom live in rural areas. Harnessing the networks and infrastructures of senior centers may be a particularly efficient means of using technology to reach many vulnerable elders.

The primary objective of the study is to evaluate the feasibility of using telehealth technology to manage blood pressure (BP) in a community setting that targets high-risk elderly patients. A secondary objective is to compare BP control in a telehealth group to a control group. The study is being conducted among hypertensive adults who receive nutrition assistance at one of four senior centers in Ohio. Two of the centers have installed telehealth kiosks that allow participants to conduct self-monitoring of their BP any time they use the center; the two sites that do not have kiosks serve as the control facilities. Data are being collected on hypertension baseline and endpoints such as physician visits and medication titrations, with a focus on comparisons between participants at intervention and control facilities.

This study will help determine whether integrating the networks and infrastructures of both federally and privately-funded senior centers is an efficient way to reach vulnerable elders. The results of this study will be the first step in determining the promise of further research in this area.

Project Objectives:
  • Determine proof-of-concept for a system in which telehealth monitors can be utilized to manage BP in a community setting that targets high risk elders. (Ongoing)
  • Compare BP control in a telehealth group to BP control in a control (non-telehealth) group. (Ongoing)

2010 Activities: Participant recruitment and enrollment was completed in 2010, with the last participant followup contact completed in November. In addition, data were collected from a physician survey among 11 respondents. Two interim reports were developed, in March and August 2010 respectively, on the implementation and assessment of telehealth BP stations. A paper titled, “Impact of blood pressure telemonitoring on hypertension outcomes: a literature review” was published in the Journal of Telemedicine and e-Health in September 2010. There were also multiple presentations of preliminary findings at several national meetings in 2010, including: 1) an introduction of the project to the American Association of Homes and Services for the Aging (AASHA) 2010 Future of Aging Services Conference and Leadership Summit in Washington D.C. in February; 2) a presentation of the literature review, study design, and preliminary data to the Long Term and Post Acute Care Supportive Services conference in Baltimore, MD in May; and 3) a presentation of the literature review and lessons learned to AASHA’s Annual Meeting in Los Angeles, CA in November.

Preliminary Impact and Findings: During initial enrollment it became apparent that recruiting intervention participants was more difficult than anticipated. A lower-than-expected number of participants identified themselves as having hypertension, a finding that posed challenges to enrollment efforts. However, since this is a pilot study and not aimed at formal hypothesis testing, no statistical issues dealing with power are anticipated as these methodological issues are not inherent to the study design. An additional observation made was unreliable Internet connectivity at one of the intervention sites, a finding that has important implications for the broader application of this work in the future.

Observations in the earlier phases of the study point to the many preliminary findings, including:

  • Challenges exist in obtaining service and maintaining continuity from local Internet services providers, therefore Internet connectivity at senior centers is not always ideal. Because telehealth is predicated on reliable Internet connectivity, this issue is one that will need to be examined very carefully in the evaluation of this project.
  • Proper selection of BP cuff size and proper placement of BP cuff may require extra instruction to ensure correctness and consistency. Participants may benefit from being given a reminder card with easy-to-follow instructions. This important consideration has a direct impact on BP measurement, which in turn, has implications for how individuals’ BP will be managed.
  • Participants may have increased BP scores when starting to use the machine due to anxiety over use of the kiosk. Evidence that “white coat hypertension” is present in telehealth is important to consider when reviewing initial and preliminary readings from seniors who are new to this technology.
  • Participants have more experience with automatic BP machines at baseline than expected with more than 99 prior uses. Even in relatively rural areas, exposure to automated BP devices at home, in pharmacies, and in supermarkets is relatively high, a factor that may help ease the transition into use of this technology in the setting of telehealth.

As of December 2010, data collection is complete and analysis is well underway. Findings from the analysis will be available in 2011.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

Communication-Focused Technologies: Technologies for Enhancing Access to Health Management - Final Report

Citation:
Resnick HE, Alwan M. Communication-Focused Technologies: Technologies for Enhancing Access to Health Management - Final Report. (Prepared by LeadingAge under Contract No. 290-06-0024-2.) AHRQ Publication No. 11-0066-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2011. (PDF, 697.08 KB)
Principal Investigator: 
Document Type: 
Research Method: 
Population: 
Medical Condition: 
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.