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IMPROVING HEALTH CARE TO VETERANS – Using a Patient-centered medical home model of care to affect a change in health care results

Bischoff, Martin B., Cantor. Jeffrey A. – Lead investigators

 
BACKGROUND

  The Veterans Foundation of America (VFA) a 501(c)3 organization focused on improving the lives of Veterans (EIN# 26-2759619), was awarded a grant (DFHS16IVH021 (1)) from the New Jersey Department of Health (DOH)  with the goal of Improving Health care to Veterans.  The VFA teamed up with Gladius Health as an implementation partner to execute this grant. The VFA applied for this grant with the intent of demonstrating that positive outcomes can be achieved with a low cost Patient Centered Medical Home (PCMH) approach, using veterans as Healthcare coordinators and wellness coaches and consequently significantly improve veteran’s health in the state of New Jersey.
 
   The current standard of care that has been initiated by the Veterans Health Administration is the PACT Team model or Patient Aligned Care Team. Although we were not granted access to the VHA electronic medical records (EMR) system, we used the frequency of interaction with patients as our standard of care cohort.
                                                                                                                 
   The impact of chronic illness is dramatic. By 2020, 157 million Americans will be diagnosed with a chronic illness and 87 million Americans will be diagnosed with multiple illnesses or comorbidities. Inadequate health literacy coupled with a lack of understanding of how to reach their health care goals results in ineffective care. The hypothesis that we aimed to prove is the assignement of a wellness coach that coordinates care for/with the patient, acting as a so called “personal trainer” for health care would have a more profound impact on improving health literacy and showing an improvement on health care goals.


   Patients were assigned a Wellness Coach (WC) that ensured that the interventions required to follow prescribed behavior modification and treatment regimens that would have an impact on both primary and secondary endpoints of the study. Wellness Coaches and care coordinators focus on improving health care costs and outcomes while providing 360 degree care for patients. The WCs are focused on patients bridging health care provider (HCP) and Integrated Delivery Networks, with the ultimate goal of improving outcomes and ensuring a pay-for-performance mindset. WCs act in a manner similar to that of a Personal Trainer that ensures motivation, knowledge and regularity are integrated.


STUDY DESIGN

   The VFA was awarded approximately $38,000 to test the WC model.  These monies allowed for a relatively modest study population of 25 veterans and 1 WC. There were six primary endpoints for the study:  

Weight Reduction
Blood glucose reduction
Systolic & Diastolic Blood Pressure reduction
Smoking cessation or reduction of tobacco consumption
Exercise increase
Patient Satisfaction

Five secondary endpoints were also included in the study:

Health Literacy
Alcohol consumption
Number of healthy meals consumed
Number of sad days
Medication compliance                                         

   The 25 patient study group was drawn from local Veteran Support Organizations (VSO) such as the Veterans of Foreign Wars (VFW), Disabled American Veterans (DAV), and the American Legion.  The original intent was to draw these patients from the Veterans Administration (VA), however, as this study could not be approved by the VA IRB, and since we are not employees of the VHA, this was not possible.  As such, patients were drawn throughout several counties in New Jersey, with an age range from twenty-six to seventy-one years old. There were twenty-four male patients and one female patient all of whom were non-hispanic and white. We tried to recruit a diverse group of patients across different ethnicities and races, but due to our timeline to completion, we were not able to recruit patients from these other groups. Patients fell across a wide range of socioeconomic status and all patients were employed.

Patients were then stratified into 3 cohorts:  

A -   Received weekly WC visits 
B -   Received monthly WC visits
C -   Received monthly phone calls in lieu of onsite visits (standard of  care)                                                                                      
  Patients were enrolled in the study and followed for six months.  Each patient received an initial physician visit to establish baseline data and then a physician visit at study end.  Each patient also received a stipend for participation. The WC is a trained Combat Life Saver (CLS), which is a military first aid certification, and was a certified Emergency Medical Technician (EMT) in the state of New Jersey.  He also received disease specific training for the purpose of this study.  We wanted to also show that having a wellness coach that was also a veteran would have an impact on addressing some of the issues common to his fellow veterans and could better relate to the patients needs. Having a veteran serve as a wellness coach also helped in the ability to motivate fellow veterans. Overwhelmingly, all patients preferred to have a veteran serve as their wellness coach.

   The WC met with all of the enrolled patients as prescribed by the cohort they were randomized into. The WC would spend approximately 1 hour with the patient per visit, going over medical terminology, explaining the importance of medication compliance, going over exercise routines that are in line with each patients capabilities, review the importance of reducing both alcohol & tobacco consumption and reducing risky behavior, coordinate care with family members, reinforce the patient’s health care goals, review of healthy lifestyles and healthy eating, discuss additional ways of coping with stress and feeling blue, and motivating the patients to lose weight and get fit.

Data compiled over the six months are summarized in table 1.  

RESULTS

Table 1 – Summary of Results




 








Definitions

Weight Reduction – Average of lbs lost from the start to the end of the study
Blood Glucose – Average reduction of mg/dl
Systolic Blood Pressure – Average reduction of mm Hg
Diastolic Blood Pressure – Average reduction of mm Hg
Smoking Cessation – Tobacco consumption at the start and end of the study
Exercise – Hours of exercise/week added from the start to the end of the study
Patient Satisfaction – Change of rating of patient satisfaction on a 10 scale at the start and end of the study
Health Literacy – Change in rating of health literacy on a 10 scale as defined by what the patient understands about their health care goals, medical terminology, and treatment protocols at the start and end of the study
Alcohol Consumption – Reduction of alcohol consumed as defined as drinks/day
Healthy Meals – Change in the number of healthy meals consumed in a 30 day period
Sad Days – Change in the number of reported sad or blue days/month at the start and the end of the program
Medication Compliance – A survey question on a 10 scale that assessed how compliant the patient was at taking their medication at the start and end of the study.

CONCLUSION
      
 These data are statistically significant across all endpoints in clearly demonstrating the value of intense intervention. This 6 month study utilizing a WC to improve outcomes demonstrated positive results.  Cohort A which received the most intense interaction, one visit per week had the greatest overall improvement in both primary and secondary endpoints. Cohort B which received only one visit per month, nonetheless, demonstrated significant improvement as well, though not as great as Cohort A. The final Cohort, C, which received the current standard of care of only phone call follow-up showed the least overall improvement in outcomes.  Numerous healthcare systems are in the process of attempting to define optimal and cost effective patient care when released back to the community.  Anecdotal evidence suggests that email, texts and regular mail are ineffective.  Other models employ Nurse Practitioners or Physician Assistants as Wellness Coaches.  While perhaps effective, this is extremely expensive and they may not be versed in the language, culture or neighborhoods of the patients. This study demonstrates the effectiveness of employing a trained veteran as a wellness coach to help improve outcomes for other veterans in a cost effective manner. A larger study should be conducted to verify these results and to perhaps more importantly extrapolate this data to population groups outside the veteran community.

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