A Longitudinal Telephony and Multiple Disease Management System To Improve Ambulatory Care

Patients with chronic medical conditions consume the majority of medical resources, with those having multiple complex chronic diseases consuming more than others. Particularly vulnerable is the subset of patients who have had frequent hospitalizations and emergency department (ED) visits, both markers of disease severity and liability, inadequate health care delivery, patient self-care failure, and other personal, social, medical, and health care system inadequacies. Improving methods of clinical management in this group may improve quality of care and reduce costs.

This project assessed the effectiveness of the Telephone-Linked Care for Complex Patients (TLC-C) automated telephony system to reduce preventable hospitalizations and improve quality of life in patients who have multiple chronic diseases. TLC-C is a modification of the Telephone-Linked Care (TLC) system which was previously shown to be effective in disease control and the frequency of acute clinical events and urgent or emergent health care episodes. TCL-C monitors patients between their ambulatory care visits, detects and notifies clinicians about important clinical events, and promotes patient self-care.

The specific aims of this project were to:

• Modify the TLC so that it contains additional content that addresses the needs of patients with multiple chronic diseases who transition to ambulatory care from acute care settings.
• Evaluate this modified TLC system in urban ambulatory care practices that serve a vulnerable patient population.
• Assess outcomes of patients in these practices who use the TLC-C system.
• Present a realistic and effective plan for sustaining TLC-C in the general internal medicine practices at Boston Medical Center.

A 6-month randomized controlled trial of TLC-C versus usual care was conducted. In addition, patient’s views and physician’s impressions were qualitatively evaluated. The primary outcomes were unplanned hospitalizations and ED visits; secondary outcomes were patient quality of life, satisfaction, and ambulatory appointment show-rates. The study initially encountered low recruitment and made several methodology changes to increase recruitment, including expanding inclusion criteria to include subjects with only one chronic disease. While TLC-C utilization improved, not all intervention group participants used the system as suggested by the study protocol.

The research did not show improvements in any of the primary or secondary outcomes. Previous research of the TLC technology had shown positive results and impressive utilization rates of the system. The authors concluded that understanding the reasons for the divergence in research in TLC versus TLC-C is important and will affect the design of systems like TLC-C in the future.