Aging veterans with multiple chronic diseases are particularly vulnerable to adverse outcomes when transitioning to a different healthcare provider or facility. Transferring to other facilities or to home is especially difficult when care is complicated by a co-existing mental health or social issue like homelessness or poverty. Technology can be used to assist patient transitions and track the quality of care.
A research study currently underway is examining the utilization of connected care technologies when virtual nurses assist veterans. The study https://clinicaltrials.gov/ct2/show/NCT02632552 with approximately 600 participants, is examining the use of a virtual nurse.to assist when veterans are transitioned from the hospital to the home.
The virtual nurse is a computer program designed to simulate a discharge nurse. During the inpatient stay, the virtual nurse appears on a computer touch screen and educates veterans with CHF or COPD on the important components of a care transition as well as how to send and receive text messages on their mobile phones.
Following discharge to home, the virtual nurse continues to coach veterans and their family members. Post discharge access to care will be done through a two way computer complete with a text messaging system.
In addition, another study will be conducted to determine if diabetics can receive better care using technology. Currently, over three million veterans have adopted the VA patient portal “My HealtheVet”. However, actual use of the portal varies considerably and there is little data on how the portal features can best improve patient outcomes.
VA researchers are working to define effective portal use by using clinical and administrative data, coding secure messages, developing patient surveys, and doing in-depth interviews with veterans who have extensive portal experience.
Lessons learned from this study will be used to refine an intervention to support effective use of portal features for chronic disease management. Researchers have chosen to anchor their investigation to a particular disease area involving type 2 diabetes.