RESNA 27th International Annual Confence
Home Monitoring for Veteran's with Low ADL Performance
The Low ADL Monitoring Program (LAMP) is a Department of Veteran Affairs VISN 8 Community Care Coordination Service (CCCS) clinical demonstration project designed to promote independence and reduce health related costs to Veterans with Activities of Daily Living (ADL) dependence. LAMP services are home-based, utilize a combination of traditional and advanced technologies, and promote independence and the maintenance of skills necessary to remain living at home. A key aspect of LAMP is care coordination, and LAMP staff work collaboratively with primary care providers (PCP) and clinicians to reduce complications, hospitalizations, and unscheduled clinic and emergency room visits.
telerehabilitation, remote monitoring, technology, Veterans
Research has demonstrated that individuals with decreased functional status are at a high risk for institutionalization or other health care utilization because of the negative impact of low functional ability on well-being, attitude, and other co-morbidities. Decreased functional status can make self-management of other chronic conditions difficult at best and this places these individuals at risk for health care crises. Telerehabilitation is emerging as a new and effective use of communications technology in the management of such patients with chronic illnesses and disabilities through monitoring, training, and therapeutic interventions (1).
Through the use of communications technology, patients are able to become actively involved in the process of managing their care and treatment interventions. The use of innovative technology to monitor and assist patients in their homes allows care providers to reach out to individuals who may be isolated and have difficulty accessing medical services due to their remote location. The integration of care coordination and high technology for home monitoring provides for improved patient compliance, improved service delivery to the home, early intervention of medical complications that may go unreported, and the avoidance of unnecessary emergency room and clinic visits.
The success of telerehabilitation and telemedicine in general may ultimately depend on the efficient and innovative use of high technology capabilities (2). LAMP services effectively utilize care coordination and the very latest available technology to enable safe and independent living, enhance quality of life, increase access to services, and reduce health-related costs to functionally impaired Veterans.
The target population for the Low ADL Monitoring Program (LAMP) includes Veterans who require personal assistance with at least two basic activities of daily living (ADLs), such as eating, bathing, grooming, dressing, toileting, transferring, and mobility. By targeting this at risk population, it is anticipated that the provision of compensatory strategies and home monitoring through communications technology will demonstrate a increase in safety and independence within the home, an increase in quality of life, an increase in patient compliance, and a reduction in institutional care and other health care utilization.
LAMP uses a battery of instruments to measure multiple dimensions including instruments developed by other investigators, and instruments developed to meet the unique requirements of this study. All data is collected face-to face in study participants' homes by occupational therapist interviewers. Interview time averages about 2.5 to 4 hours. Appointments are scheduled at times convenient for study participants to ensure that they are rested, comfortable, and do not feel rushed.
Three instruments are used to measure functional and cognitive status: the Instrumental Activities of Daily Living (IADL) section of the Older American Resources/Services Procedures, the Sickness Impact Profile (SIP), and the Functional Independence Measure (FIM). These instruments are moderately correlated with each other and there is some overlap in content such as mobility. However, there are substantial differences in these measures, conceptual and structural. The Mini Mental State Examination (MMSE), as well as the FIM cognitive, are utilized for mental status measurements. The Jette Functional Status Index-Modified measures pain on a scale from 1-4. Also utilized is the Veteran's SF-36 & Health Behaviors for quality of life, a leisure performance measure, and the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST).
Following functional and home assessments, occupational therapists write treatment plans and make recommendations for assistive technology/adaptive equipment (AT/AE), and determine environmental interventions that will maintain or improve the Veteran's function, address safety, independence, and quality of life. Occupational therapists also initiate referrals for additional services, as appropriate. AT/AE is provided free-of-charge to the participants and is purchased through the appropriate VA providers. Once the devices are obtained, the therapist delivers them to the patient, and provides training for each device provided. Patient needs determine how many visits are required.
LAMP services include either weekly phone contact for home monitoring, a combination of phone and daily computer, internet-based communication (including audio and video), daily communication through the Health Buddy, or the use of Smart Phone technology. Personalized daily dialogue forms are provided to Veterans with computers or Smart Phones. Through communications technology, the LAMP Care Coordinator is able to monitor daily self-care needs, identify if a home health care visit is needed, suggest self-administered self-care alternatives (remotely whenever possible), provide information and training to enhance daily functional performance, and maintain close contact between the Veteran and the primary care provider.
The follow is basic demographic information on the research sample for year 1 (n=80). Subjects range in age from 51 to 89 years of age, with a mean of 73.95 years. A majority of the subjects are male (94.8%) and white (89.8%), with just over 28 percent widowed. Over 29 percent have completed high school, and although income levels varied, approximately 20 percent of the sample have incomes under $10,000 per year. Information on measures of health, functional and psychosocial status for year 1 include an average of 6.0 visits to their primary care provider at the VA, and 1.63 days hospitalized. They are taking on average 12.25 medications, and have a mean of 15.17 chronic diseases or conditions. On average study participants are 33.85 percent physically disabled (Sickness Impact Profile score). Participants scored a mean of 8 out of 14 for Instrumental Activities of Daily Living (IADLS), and 93.98 out of 126 on the Functional Independence Measure (FIM). Subjects' mean Mini Mental Status Examination (MMSE) score is 25.48; 24 is typically the cutoff point for separating samples into cognitively / non-cognitively impaired.
Initial assessments began in February, 2003 and to date, LAMP has 80 Veterans enrolled. Thirty-six Veterans are currently utilizing computers for remote monitoring, while 30 are using the Health Buddy, 6 are using Smart Phone applications, and 8 are being remotely monitored via telephone. Outcome measures include initial and follow-up functional assessments, AT/AE patient utilization and satisfaction, quality of life measures, overall patient satisfaction, provider satisfaction, patient compliance with preventive health and practice guidelines, and overall cost and measured use of the VA services. Follow up assessments will begin at end of year 1 (February 2004) to determine the success of the telerehabilitation project.
LAMP services are based on the experience of a major 3-year National Institute on Disability and Rehabilitation Research (NIDRR) funded study, where frail elders were monitored for self-care needs using computers with video-teleconferencing capability (3). The information obtained through LAMP could yield valuable information for clinicians and policy makers in regards to service delivery, provision of assistive technology, and home modifications. Through the promotion of independence and home monitoring, institutional care and other health care utilization may be reduced, in turn reducing overall health related costs.
This two-year demonstration project was funded by the Department of Veteran Affairs VISN 8 Community Care Coordination Service (CCCS).
Roxanna M. Bendixen, MHS, OTR/L,
Rehabilitation Science Doctoral Program,
University of Florida
College of Health Professions,
PO Box 100164,
Gainesville,
FL 32610.
Telephone number 352-273-6043.