A promise of telemedicine is to improve access to care. Part of this promise is to provide supplemental care or supportive care to patients with chronic illnesses. This supplemental care and supportive care takes the form of case management. The idea behind case management is establishing a relationship with a nurse, dietitian or other health professional who will make frequent contact with the patient to improve self-management techniques. Self-management techniques are the skills and knowledge to allow the patient to take informed actions in the care of his or her own illness. This chapter discusses issues that face primary care providers and nurse case managers in using telemedicine to improve patients’ self-management skills.

Team Approach
The majority of care in chronic illness is dependent on the patient. The patient is the one who must make daily choices to control his or her own condition. In the case of diabetes mellitus, it is the patient who must chose to make appropriate food choices, appropriate exercise choices, choose to do the fingerstick glucose readings, and take medication. For patients to make wise choices, they must understand the disease process and how their actions impact the disease. Patients also need to understand that they have the ability to make wise decisions. The case manager’s goal is to empower the patient to strive for decisions that are associated with better outcomes.

In the IDEATel project, the team is composed of the patient, the primary care provider (PCP), the nurse case manager, the dietitian, and the endocrinologist.

The nurse case manager, after obtaining a medical history, focuses on teaching the basics of diabetes pathophysiology; the importance of good control of glucose, lipids and blood pressure; correct methods to monitor glucose and blood pressure; ways to prevent complications; and if complications are suspected, when to get medical attention.

The dietitian provides education on appropriate dietary and exercise choices. The dietitian educates patients on good nutrition and helps patients work out an individualized meal plan.

The endocrinologist provides daily, individualized oversight of the recommendations that the case managers provide to the PCPs.

In our model, the PCPs are the final evaluators of the recommendations and decide which ones to implement. The PCP’s knowledge of the patient is more complete as they have done physical examinations and may have known the patient for years. The PCP writes the prescriptions. The team may help to help to titrate dosages, particularly of insulin, if so desired by the PCP.

Communication
Implicit in the team approach is the need for effective communication. The goal is to create documentation that is complete, but time efficient to record and read. We use electronic forms to improve clinical data capture and to present the data in a readable format. The development of these electronic forms is an ongoing process, shaped by feedback from case managers and PCPs. In our case management model the key lines of communication are between the nurse case managers and the patients, the nurse case managers and the PCPs, and between the patients and PCPs.

The nurse case managers and the patient communicate primarily by videoconferencing using the telemedicine equipment. During these video visits the nurse case managers obtain the history and provide education. The IDEATel electronic visit form is a template for the video visit interaction. During the visit, the nurse case managers use a document camera to display models or drawings to help illustrate their points. In addition to synchronous video connections, patients have access to a secure (encrypted) electronic messaging system, through which they can communicate with the nurse case managers in asynchronous fashion. Patients who are unaccustomed to messaging use the telephone to communicate brief or immediate concerns.

Within the diabetes center the nurse case managers, dietitian, and endocrinologist meet and review patient issues in order to formulate problem-solving strategies.

After review with the endocrinologist, the nurse case manager communicates with the PCP. Transmission of the electronic visit form by secure e-mail is the communication modality of choice. However, communication can occur as the PCP chooses, as a fax, secure electronic message, or telephone call. Hard copy of the communication is also sent through the surface mail as back up. Communication between the endocrinologist and PCP, in the form of a telephone call, can also occur, as necessary.

Finally, communication between the PCP and the patient is a critical step to improve patient outcomes. With improved self-management knowledge and skills, patients should be able to express themselves better, and their increased understanding should also improve communication during PCP office visits. The PCP’s directions can be further reinforced with subsequent telemedicine visits with the nurse case managers.

Consensus on Guidelines
For the team approach to be successful, a consensus on goals needs to be accepted. In diabetes management, many approaches, medication choices, dietary choices, and exercise programs are possible to meet desired goals. The approaches and goals may be individualized, but these must be communicated amongst the team.

The goals of our program include prevention of the short- and long-term complications of diabetes mellitus, hypertension and dyslipidemia. If complications are present, we aim to prevent progression of complications.

In the IDEATel project we are using the American Diabetes Association Clinical Practice Recommendations (http://care.diabetesjournals.org/content/vol25/suppl_1/) and the Veterans Health Administration Management of diabetes mellitus primary care core algorithm (http://www.va.gov/diabetes/) as guidelines. These references are evidence-based and considered cost-effective.

Educational Goals
The nurse case managers strive to improve diabetes self-management skills. The processes that the case managers use are modeled after the National Standards for Diabetes Self-Management Education (http://care.diabetesjournals.org/cgi/content/full/25/suppl_1/s140)
These areas include:
Good glucose and blood pressure self-monitoring
Disease process and treatment options
Nutritional management
Physical activity management
Preventing, detecting and treating acute complications
Preventing, detecting and treating chronic complications
Goal setting and problem solving
Psychosocial adjustment to daily life.

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