1) Summarize the objective of the article.

2) What are the strengths/weaknesses of the article. Specifically describe the technological intervention and key findings. What are the key findings from the work?

3) Discuss the opportunities for technology to impact the main emphasis of the article(s). Be specific with your comments here. For example, what technologies were used? What are the key issues to be considered? etc.

400 A Community-Based Telehealth Programme for Elderly Low-Income African Americans Kathleen Buckley, Binh Tran*, Janice Agazio, Ellen Wuertz† School of Nursing and * Department of Biomedical Engineering, The Catholic University of America, Washington DC and † Austin Community College, Austin, Texas, USA. Correspondence and reprint requests: Kathleen M. Buckley, PhD, RN, Associate Professor, School of Nursing, The Catholic University of America, Washington, DC. E-mail: Buckleyk@cua.edu. © The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 ABSTRACT Objective: To evaluate a community health nursing initiated telehealth programme for elderly African American clients with hypertension and/or diabetes. Design: Quasi-experimental pre-test/post-test design. Setting: The study was community-based and carried out in a federally subsidised apartment complex for lower-income, older adults in Washington, DC. Methods: The study group consisted of 22 residents aged 65 years and older, who had previously received a diagnosis of diabetes and/or essential hypertension and were taking an anti-glycaemic and/or antihypertensive medication. Remote monitoring equipment and a video-phone operating over a standard telephone line were installed in their homes and they were trained in their use and operation. Residents performed daily monitoring of blood pressure and/or blood glucose using the equipment. At their regular primary care visits, diabetics also obtained their HbA1c (glycosylated haemoglobin) values as a measure of their blood glucose control over the past three months. The residents received weekly video visits from nurse educators. During these visits, they received education on the self-management of hypertension and/or diabetes and specific management advice based on their individual data. Before and after the 3 month pilot study the participants completed a questionnaire aimed at assessing their knowledge of diabetes and/or high blood pressure, self-efficacy for managing chronic disease, and perception of telehealth technology. Results: Nineteen of the 22 participants completed the study. There were a total of 172 virtual visits with an average of 9 videophone contacts per subject over the 3 month period. The results of the study demonstrated a trend in reduction of HbA1c for the residents with diabetes, but there was no significant improvement in HbA1c, blood glucose or blood pressure measurement. However, knowledge of diabetes and hypertension, self-efficacy and perception of telehealth significantly increased following the protocol. Conclusion: The outcomes of this project suggest that telehealth may have some value in community-based settings, but more research is needed to determine the appropriate target population, admission criteria, telehealth technology, and frequency and intensity of the intervention. A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 401 INTRODUCTION By 2030 it is expected that the number of Americans over the age of 65 years will have doubled to 72 million, and will make up 20% of the population1 . Unfortunately, with longevity there is a greater risk of developing chronic diseases that require healthcare. Concurrent with this aging phenomenon and an increased need for cost efficient healthcare, the United States is undergoing a significant rise in the use of healthcare technologies. These include telecommunication and remote monitoring equipment, which offer tremendous opportunities to support the geriatric population toward their preference to age and remain independent in their own homes2 . The growing needs of the elderly corresponding with the proliferation of recent home care technologies have given momentum to telehealth programmes. Telehealth allows clinicians to monitor their patients’ chronic conditions and to communicate with them at a distance through virtual visits3 . Some systems have the capability to monitor clinical data, such as vital signs, weight, blood oxygen saturation levels, blood glucose levels, heart and lung sounds, and electrocardiogram results, and then transfer them over either cable, wireless connections, or ordinary telephone lines to a secure website. If needed, healthcare providers are able to adjust their patients’ medications or treatments, and then continue to monitor their progress at home. Other telehealth systems consist of two-way interactive sound and image communications. These allow healthcare providers to conduct ‘face-toface visits’ and monitor their patients’ progress without their patients ever leaving home, thereby saving time and resources. As the geriatric population increases, telehealth technology offers the potential to enhance the independence of the elderly by promoting health through distant patient monitoring, education, and counselling. Research has shown that telehealth improves clinical outcomes and helps patients gain control over a variety of chronic illnesses, such as diabetes, hypertension, chronic heart failure, spinal cord injury, and chronic wounds4–8 . Several studies have found telehealth interventions to be particularly effective in improving outcomes for diabetic patients through educational, monitoring and motivational activities8,9 . In a randomised controlled study of 174 elderly, diabetic home health patients, the results showed that patients receiving the telehomecare intervention in comparison to usual care were more likely to be discharged earlier from homecare services as well as have a decreased likelihood of admission to a hospital or skilled nursing facility10 . Another randomised controlled trial, known as the Informatics for Diabetes Education and Telemedicine (IDEATel) project, compared telemedicine case management to usual care for 1,665 elderly patients with diabetes living in New York State8 . The researchers found a greater improvement in glycaemic control, blood pressure, and LDL (Low Density Lipoprotein) cholesterol levels in the telemedicine group as compared to the usual care group at one-year follow-up. Buckley, Tran, Agazio & Wuertz 402 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 Patients with hypertension have also benefited from telehealth interventions. The monitoring and transmission of blood pressures have been used not only in the diagnosis of hypertension, but also in their treatment, resulting in significant reductions in blood pressures as compared to patients receiving usual care11,12 . In one randomised controlled trial, 387 African Americans with hypertension were recruited from the Detroit community to receive either nurse-managed home blood pressure telemonitoring (TM) or enhanced usual care (UC) 4 . The TM group monitored their blood pressure three times a day, and also received weekly educational telephone counselling about their blood pressure in relation to their target goal, medication compliance, and lifestyle modification. Although both groups experienced decreases in systolic and diastolic blood pressures, the TM group showed a significantly greater reduction in systolic blood pressure over a 12-month period of time. In addition to improving medical outcomes, telehealth has been found to enhance psychosocial outcomes. It has been suggested that telehealth empowers patients, who may be socially isolated, by connecting them to supportive providers13 . It has also been suggested that even in the absence of a clinician, telehealth may promote self-responsibility through patients self-monitoring their clinical data. In the IDEATel trial for elderly patients with diabetes, it was found that diabetes self-efficacy scores were significantly improved for the group receiving telehealth intervention as compared to usual care14 . The researchers suggest that greater self-efficacy leads to improved diabetes self-management, reduced health risks, and better general health. Whereas most telehealth programmes have been established by primary care providers or home care nursing agencies to monitor and communicate with their patients, few have been initiated by community health nurses, who have traditionally worked with clients in their own environment emphasising self-care. Telehealth would seem to be a natural medium for such nurses to assist individuals, families and communities to actively develop and exercise their autonomy in health matters. The purpose of this pilot investigation was to evaluate a community health nursing initiated telehealth programme for elderly African American clients with hypertension and/or diabetes. Since this type of intervention has not been reported as being used before with this type of population in a community-based setting, the focus of the study was more to assess the feasibility rather than an evaluation of the intervention. Our hypothesis was that when comparing post to pre-intervention there would be an improvement in glycosylated haemoglobin (HbA1c) and monthly mean blood glucose for the residents with diabetes, and in monthly mean blood pressure measurements for those with hypertension. Additional outcomes of the study were to evaluate the effect of telehealth upon the residents’: 1) knowledge of diabetes and/or high blood pressure, 2) self-efficacy for managing chronic disease, and 3) perception of telehealth technology. A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 403 METHODS Setting and Participants As part of a community housing redevelopment project, The Catholic University of America (CUA) partnered with the Community Preservation and Development Corporation (CPDC), a nonprofit affordable housing developer, to initiate a community-based telehealth programme in which residents were enrolled in a 3-month telemonitoring study. The programme was carried out at Edgewood Terrace, a federally subsidised apartment complex for lower-income, older adults in Washington, DC. Study enrolment began in August 2006 and was completed in July 2007. Residents aged 65 years and older, who had previously received a diagnosis of diabetes and/or essential hypertension and were taking an anti-glycaemic and/or antihypertensive medication, were chosen as the target group. The reason for targeting this group was based upon a prior study by the research team of 85 senior residents in the apartment complex. Diabetes and hypertension were found to have the highest prevalence of chronic diseases among the residents15 .The residents also had to have a landline telephone in their apartment. Research participants were recruited through community presentations, flyers posted in the building, and direct questioning from support services staff located in the building regarding their interest. Residents with severe visual or hearing impairments, cognitive impairment, a psychiatric illness not controlled with medication, and a history of illicit drug use or heavy alcohol consumption were excluded. Eligible subjects were identified by a community health nurse working in the housing project, and a non-random purposive sample of 22 participants were chosen for the study. Procedure After referral, subjects were asked by telephone to participate in the study. Upon agreement to participate, one of two registered nurses trained in diabetes and hypertension management and a biomedical engineer scheduled a home visit. During this initial visit, the nurse explained the research study, and obtained informed consent as approved by the CUA Institutional Review Board (IRB). The subjects completed: (a) a demographic form, (b) a diabetes and/or high blood pressure knowledge test, depending upon their diagnoses, (c) the Telemedicine Perception Questionnaire (TMPQ),16 and (d) the Chronic Disease Self-efficacy Scale17 .The subjects were given a patient education packet with materials from the Diabetes and Cardiovascular Disease Toolkit18 . The materials included logs for the subject to record their blood pressures and/or blood glucose, which they were encouraged to bring to their primary care provider visits. The materials also contained a Food and Activity Tracker record for the subjects to monitor their dietary intake and activity levels and to be used for counselling18 . The biomedical engineer installed the remote monitoring equipment and videophone, both operating over a standard telephone line. The primary equipment was a Medstar Unit by Cybernet Medical Inc. (Ann Arbor, Michigan), a telecom- Buckley, Tran, Agazio & Wuertz 404 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 munications box that connected commercial off-the-shelf and FDA (Food and Drug Administration) approved monitoring peripherals to the phone line for direct upload to a remote secure, encrypted server. Depending on the chronic condition of the participant, health monitoring peripherals consisted of a One-Touch Ultra Glucometer (LifeScan, Inc.), and an A&D UC 767 digital blood pressure cuff (A&D Medical, Inc). The participants with diabetes also received glucose test strips for the glucometer. The equipment was programmed to detect and send any new values automatically to the remote server, but the data could also be sent immediately by using a one-button press operation on the Medstar Unit. Once uploaded, the encrypted data were accessible by the nurse using the Internet via Cybernet Medical’s proprietary electronic medical record (EMR) system. Access to the site was password protected. Virtual visits or two-way interactive video between the nurse and participant, were conducted using the TeleVYou500SP videophone by Wind Currents Technology Inc. (Woodstock, New York). Video was transmitted at up to 33.6 kilobytes per second (kbps) and between 5–15 frames per second (fps) and could be adjusted depending on the desired video quality. The default setting was for medium quality images which transmitted at approximately 8–10 fps. The video quality was adequate for the purposes of medication instruction and education about diabetes and hypertension. During the initial home visits, the participants were trained in the use and operation of the equipment. All subjects were instructed to measure their blood pressure and/or blood glucose daily in the morning prior to taking any medications, and to record the readings in a log. At the completion of the visit, the nurse scheduled a time within the week to conduct the first telehealth visit using the videophone. With the subject’s permission, the nurse contacted the subject’s primary care provider to inform him/her of the subject’s participation in the research study. The subjects participated in the study for a period of 3-months with daily monitoring of blood pressure and/or blood glucose using the equipment. At their regular primary care visits, the subjects with diabetes also obtained their HbA1c values as a measure of their blood glucose control over the past three months. The last value obtained prior to enrolment in the study was compared to the most recent one taken upon completion of the study. The goal for managing diabetes was to reduce or maintain blood glucose, as measured by HbA1c, at less than 7%. The target mean monthly blood pressures was 135/85 mm Hg, as blood pressures measured at home and above this level are regarded as hypertensive19 . The residents received weekly video visits from the nurse educators. The video visits generally lasted between 20 and 60 minutes with an average of 30 minutes depending upon the needs of the client. During these visits, the client received education on the self-management of hypertension and/or diabetes, and, if needed, a refresher on use of the telehealth equipment. The nurses discussed with the clients any changes in their health status, and the most recent trends of their monitored data. The nurses also focused on diet, weight control, and medication adherence. As A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 405 part of a general health promotion educational programme, the subjects were also counselled on general self-care, smoking cessation and stress reduction, following an assessment of their stage of readiness for change. At the end of the research study, the subject’s nurse made a final home visit. The subject was again asked to complete the same series of questionnaires and surveys as done on the initial home visit. The telehealth equipment was then removed from the home. Data Analysis The demographic data collected were analysed using descriptive statistics. The questionnaires were scored and examined pre versus post study. Each subject served as his/her own control, and the monitoring data from the first month was compared to the last month for analyses of means and variances. Paired sample t test with the SPSS statistical software (SPSS Inc. Chicago, Illinois) were used for analyses of the pre- and post-diabetes and high blood pressure knowledge tests, TMPQ, and Chronic Disease Self-Efficacy Scale. RESULTS Of the 22 residents recruited, one withdrew prior to completion of the study and two more were discontinued from the study because of noncompliance with taking the measurements. A total of 19 African American residents (11 males and 8 females) completed the study. The mean age was 70.8 (SD = 4.7) with a range of 65 to 81 years. The mean number of years of education was 11.3 (SD = 2.4). More than 79% of the subjects were single, widowed or divorced, and lived alone. All of the Table 1. Hemoglobin A1c comparisons for subjects with diabetes (n = 10) Subject # Pre-study Post-study 1 13.5 7.4 2 7.5 6.8 3 5.9 5.0 4 6.0 6.3 5 8.6 7.7 6 7.2 6.4 7 6.7 6.4 8 7.4 6.3 9 9.7 8.4 10 6.8 6.5 Mean ± SD 7.93 ± 2.27 6.72 ± 0.93a a p ≥ .05 between measurement points Buckley, Tran, Agazio & Wuertz 406 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 subjects were diagnosed with hypertension, and 10 of the 19 subjects also had type 2 diabetes. The 19 subjects who completed the study had a total of 172 virtual visits. The subjects were contacted by videophone an average of 9.05 times (range 6–12) over the 3 month period. Prior to the telehealth intervention, 6 of the 10 participants had an HbA1c greater than 7%. After the intervention protocol, this number was reduced by 50%. All but one participant demonstrated a reduction in HbA1c (see Table 1). Although a paired t test did not demonstrate a significant reduction based on α = 0.05 level of significance, the figures did show a trend toward reduction (t = 2.15, p = 0.06). Mean blood glucose (MBG) values were also calculated for each month (see Table 2). Percent changes between each month were compared using paired sample t-tests. There was a significant reduction in MBG from month 1 to month 2 (t = –2.326, p = 0.045); however, no significant differences were found between month 1 and 3 (t = 1.597; p = 0.145) and month 2 and 3 (t = 0.267; p = 0.796). Monthly mean systolic (MSBP) and (MDBP) diastolic blood pressure readings were also calculated for each month. Both MSBP and MDBP demonstrated small improvements from month 1 to month 3 (see Table 3). However, there were no significant differences between the measurement intervals using a paired sample t test. Table 2. Blood glucose (BG) trends by month (n = 10) Minimum Maximum Mean Std. Deviation BG Month 1 101.29 159.84 128.96 18.11 BG Month 2 97.60 141.32 116.71a 13.51 BG Month 3 93.46 231.62 131.71 38.28 ap = 0.045 Table 3. Systolic (SBP) and diastolic (DBP) blood pressure trends for subjects (n = 19)a Minimum Maximum Mean ± SD SBP Month 1 116.4 191.1 144.69 ± 19.66 SBP Month 2 118.5 178.0 144.28 ± 17.70 SBP Month 3 116.3 168.4 141.89 ± 14.75 DBP Month 1 65.6 104.2 82.14 ± 10.82 DBP Month 2 67.96 101.4 81.63 ± 9.84 DBP Month 3 65.7 92.13 79.94 ± 8.25 a p ≥ .05 between measurement points A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 407 Data on the residents’ knowledge of diabetes and/or hypertension was collected on admission and at 3 months at the end of the intervention. The residents’ knowledge was measured by two separate 10-item tests for hypertension and/or diabetes (as appropriate to their diagnoses). The quiz questions for diabetes were derived from materials available through the National Council on Aging (NCOA) Center for Healthy Aging 20 , and those for high blood pressure from American Heart Association educational materials21 . Content validity was assessed through expert review. Reliability was assessed using the Kuder-Richardson (KR21) coefficient and found to be 0.63 for the hypertension knowledge test. However, because of the smaller number of participants with diabetes (n = 10), it was not possible to accurately calculate the Kuder-Richardson coefficient due to the decreased variance. Paired sample t tests were used to determine if there were differences before and after the intervention. For the diabetic participants, there was a significant improvement in pre and post knowledge (t = 3.25, p = 0.010). The hypertensive participants also showed a significant increase in their knowledge (t = 5.57, p = 0.000). The Chronic Disease Self-Efficacy inventory is a 33-item questionnaire using a 10-point Likert scale, and designed to measure perceived self-efficacy to self-manage chronic illness17 . Measures of self-efficacy included regularity of exercise, support from others, need to communicate with their physician, and management of disease and symptoms. Previous studies have noted high reliability coefficients and established validity for the instrument17 . For this study, the Cronbach’s α for this sample was 0.94 for pretest and 0.95 for post-test scores. The mean at baseline was 7.7 and at three months increased to 8.25 (t = 2.29, p = 0.034), indicating that the participants demonstrated an improvement in self-efficacy toward managing their chronic illness. The Telemedicine Perception Questionnaire (TMPQ) is a 17-item instrument using a 5-point Likert scale that was designed to assess patients’ impressions of the advantages and disadvantages of home-based telehealth. Demiris and colleagues found the instrument to have excellent reliability (Cronbach’s alpha of 0.8) and evidence of construct validity in the TeleHomeCare project with the University of Minnesota16 . For this study, Cronbach’s alpha for the pretest was 0.79 and for the post-test was 0.90. Higher scores indicated a more positive perception of telehealth. The mean scores for the post-test were significantly higher than the pretest scores (68.0 versus 62.6, respectively, t = 3.24; p < 0.05), indicating that subjects developed a more positive perception of telehealth after using the technology. DISCUSSION Any generalisations from this pilot telehealth study must be made cautiously due to the small sample size and short data collection period. However, some trends toward improvement were noted in HbA1c and initially in the blood glucose measurements. There may have been a possibility of Type II error (i.e. a false negative) Buckley, Tran, Agazio & Wuertz 408 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 as the sample may not have been large enough to detect a significant difference, when in fact, in a larger sample, there may have been significant percent changes in HbA1c and/or blood glucose between baseline and other measurement points. No significant improvement in blood pressures was demonstrated over the course of the study. If viewed from a medical model of chronic illness perspective rather than a focus on health promotion, the population selected for this study may not have been appropriate for the interventions selected. The fact that many of the residents with diabetes were relatively well managed prior to enrolment in the study with a mean HbA1c of 7.93 ± 2.27% may explain, in part, why no significant differences were found in mean glucose and HbA1c between month 1 and month 3. Further, 31.6% of the participant’s individual mean systolic blood pressure and 68.4% of the mean diastolic blood pressure were well controlled (<135/85) during month 1, such that significant changes would not have been expected. In relation to the goal of improvement in clinical outcomes, it may have been more beneficial and cost-effective to offer telehealth monitoring to residents with more unstable chronic illnesses. In a similar vein, if the primary objective of the programme was to improve clinical outcomes, the use of daily home blood glucose and blood pressure monitoring with weekly videophone visits by a nurse educator may have been an excessive intervention for this stable population with diabetes type 2 and/or with blood pressures relatively under control. There is much debate about the effectiveness of self-monitoring blood glucose (SMBG) for patients with non-insulin treated type 2 diabetes, and the recommendations for use and frequency of SMBG varies among practitioners22–24 . A decrease in frequency or a less invasive form of monitoring may have been more appropriate for some of the participants in this study. An alternative in-home messaging system that has been used successfully for veterans with chronic diseases is the Health Buddy developed by the Health Hero Network (Mountain View, California).25 This device measures patients’ knowledge, symptoms and behaviours through a series of questions in the format of asynchronous text messaging with a care coordinator who follows-up on all out-of-bounds alerts to provide “just-in-time” care. On the other hand, if the primary objective of the telehealth intervention was health promotion in terms of enhancing the knowledge base about chronic illness among elderly residents living with hypertension and diabetes in a community setting, the findings in this study related to the residents’ improvement in knowledge are encouraging. The videophone appears to have potential in the delivery of health education. However, simply knowing what to do to manage a chronic illness does not mean that health behaviours will occur. Actual performance of an activity is influenced by self-efficacy, the confidence in one’s ability to carry out and maintain the behaviours that produce the desired health outcome26 . The improved perceived self-efficacy in this study is also promising, since it is a variable that has been demonstrated in previous studies of patients with chronic illnesses to be associated with A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 409 improved health behaviours or health status outcomes27–29 . It has been proposed that telehealth advances clients’ skills and knowledge in managing chronic disease, promotes accountability for healthcare, and identifies early complications, which improves their confidence in taking charge of their own health30 . The participants’ improved satisfaction with telehealth in this study is consistent with other studies that have reported positive outcomes in patient satisfaction with telehealth31–33 . Previous reports of telehealth provided via videophones support this method of communication between the patient and clinician as allowing for bonding, caring, establishment of rapport and trust, and the ability for the participants to pick up verbal and nonverbal cues through a “social presence” or “telepresence”34–37 . In other studies, clients have reported convenience, an increased sense of security, and a greater sense of control and empowerment as additional benefits of using telehealth34,36,38 . It is important to acknowledge several limitations in the study. The primary limitations were the small sample size and the shortened length of the intervention. Given a larger, more diverse population with longer follow-up, the potential for Type II error would be reduced and may show significant changes in clinical parameters. Second, because of the quasi-experimental pretest–post-test design, it is possible that the results obtained were not caused by the telehealth intervention but influenced by other factors. A third concern is that all of the participants were volunteers. Thus, the effect of the intervention can only be extrapolated to residents willing to take part in the use of telehealth technologies. However, there is evidence that this may be a notable percentage of the elderly population with chronic illnesses15,39 . Because the programme was initiated by community nurses and not by the subjects’ primary care providers, it was not known how much trust the provider had in the readings that were provided. Without their integration into the programme, there were limitations as to the usefulness of the data in modifying treatment of the participants’ chronic illness. In another nurse-managed telehealth programme for hypertensive patients, only about half of the physicians reported using the telehealth reports to make changes in antihypertensive medications4 . Although it may require additional time and energy, it is essential that future programmes consider the most optimal means of incorporating primary care providers in order to get the maximum benefits from the readings obtained. The study has provided some insight into how to best enable the elderly in the community, who are living longer, to maintain their independence and strong self-efficacy in the management of chronic illnesses. The answer may be a greater reliance on the use of emerging technologies, such as telehealth, in elderly housing communities. For the geriatric population with chronic illnesses, telehealth may be an effective strategy for them to maintain independence, some control over their health conditions, and an overall improvement in their health status. This study shows some promise for telehealth for elderly residents with diabetes in that there was a trend toward reduction in HbA1c values. However, the clinical outcomes of Buckley, Tran, Agazio & Wuertz 410 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 this project suggests that before telehealth is considered as an option in communitybased settings, more research is needed to determine the appropriate target population, admission criteria, telehealth technology, and frequency and intensity of the intervention. The improvements in the residents’ knowledge and self-efficacy of chronic illness are encouraging, and suggests that health education and counselling through telehealth technologies, such as the videophone, may be beneficial for health promotional activities. The lack of inclusion in this study of primary care providers or advanced practice nurse case managers who could make changes to the treatment plan by protocol, was also problematic. It is essential that if clinical data is going to be collected via telehealth monitoring, that there is a system in place to modify the treatment plan as needed, or it is less likely that there will be an improvement in chronic disease outcomes. ACKNOWLEDGMENT This study was funded by the Department of Commerce’s Technology Opportunities Program grant #11-60-04008. We thank the residents of Edgewood Terrace who volunteered for this research study. REFERENCES 1 He W, Sengupta M, Velkoff VA, DeBarros KA. US Census Bureau, Current Population Reports, 65+ in the United States: 2005. Washington, DC: US Government Printing Office, 2005, pp. 23–209. 2 Institute of Electrical and Electronic Engineers Board of Directors. Position. Addressing the healthcare needs of our aging population with technology. Author, Washington, DC, 2005. http://www.ieeeusa.org/policy/positions/healthcareneeds.html. 3 Center for Aging Services Technologies. The use of innovative and emerging technologies to help meet the healthcare and quality of life needs of an aging population. Washington, DC: American Association of Homes and Services for the Aging, 2005. 4 Artinian NT, Flack JM, Nordstrom CK, Hockman EM, Washington GM, Jen KC, et al. Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nurs Res 2007; 56: 312–22. 5 Bondmass MD. Improving outcomes for African Americans with chronic heart failure: A comparison of two home care management delivery methods. Home Healthcare Manag Pract 2007; 20: 8–20. 6 Johnson-Mekota JL, Maas M, Buresh KA, Gardner SE, Frantz RA, Specht JKP, et al. A nursing application of telecommunications: Measurement of satisfaction for patients and providers. J Geron Nurs; 2001; 27: 28–33. 7 Phillips VL, Vesmarovich S, Hauber R, Wiggers E, Egner A. Telehealth: Reaching out to newly injured spinal cord patients. Public Health Rep 2001; 116: 94–102. 8 Shea S, Weinstock RS, Starren J, Teresi J, Palmas W, Field L, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus. J Am Med Inform Assoc 2006; 13: 40–51. A Community-Based Telehealth Programme The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 411 9 Izquierdo RE, Knudson PE, Meyer S, Kearns J, Ploutz-Snyder R, Weinstock RS. A comparison of diabetes education administered through telemedicine versus in person. Diab Care 2003; 26: 1002–7. 10 Dansky K, Bowles K, Palmer L. Clinical outcomes of telehomecare for diabetic patients. J Inf Technol Healthc 2003;1:61–74. 11 Rogers MAM, Buchan DA, Small D, Stewart CM, Krenzer BE. Telemedicine improves diagnosis of essential hypertension compared with usual care. J Telemed Telecare 2002: 8: 344–9. 12 Rogers MAM, Small D, Buchan DA, Butch CA, Stewart CM, Krenzer BE, et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. Ann Intern Med 2001; 134: 1024–32. 13 Dansky K, Bowles K, Palmer L. How telehomecare affects patients. Caring 1999; 18: 10–14. 14 Trief PM, Teresi JA, Izquierdo R, Morin PC, Goland R, Field L, et al. Psychosocial outcomes of telemedicine case management for elderly patients with diabetes: The randomized IDEATel trial. Diab Care 2007; 30: 1266–68. 15 Bertera EM, Tran BQ, Wuertz EM, Bonner A. A study of the receptivity to telecare technology in a community-based elderly minority population. J Telemed Telecare 2007; 13: 327–32. 16 Demiris G, Speedie S, Finkelstein S. A questionnaire for the assessment of patients’ impressions of the risks and benefits of home telecare. J Telemed Telecare 2000; 6: 278–84. 17 Lorig K, Stewart A, Ritter P, González V, Laurent D, Lynch J. Outcome Measures for Health Education and Other Healthcare Interventions. Thousand Oaks, CA: Sage Publications, 1996. 18 American Diabetes Association, American College of Cardiology, & Preventive Cardiovascular Nurses Association. Diabetes and cardiovascular disease toolkit. Author: Washington, DC, 2006. http://www.acc.org/education/Outreach/diabetes/diabetes.htm. 19 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42: 1206–52. 20 National Council on Aging (NCOA) Center for Healthy Aging. NCOA Center for Healthy Aging Model Health Programs Toolkits: Healthy Changes, 2004. Retrieved July 9, 2008 from http://www.healthyagingprograms.org/resources/MP_HealthyChanges.pdf. 21 American Heart Association. Test your high blood pressure IQ with this quiz, 2006. Author: Dallas, TX. http://www.americanheart.org/presenter.jhtml?identifier=3021399. 22 Welschen LMC, Bloemendal E, Nijpels G, Dekker JM, Heine RJ, Stalman WAB, Bouter LM. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin (Review). The Cochrane Collaboration 2008; 1–28. 23 Austin MM, Haas L, Johnson T, Parkin CG, Parkin CL, Spollett G, Volpone MT. Self-monitoring of blood glucose: Benefits and utilizatio. The Diabetes EDUCATOR 2006; 32: 835–47. 24 McAndrew L, Schneider SH, Burns E, Leventhal H. Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature. The Diabetes EDUCATOR 2007; 33: 991–1011. 25 Barnett RE, Chumbler NR, Vogel WB, Beyth RJ, Ryan P, Figueroa S. The cost–utility of a care coordination/home telehealth programme for veterans with diabetes. J Telemed Telecare 2007; 13: 318–21. 26 Bandura A. Self-efficacy: The Exercise of Control. New York: W. H. Freeman, 1997. 27 Lorig KR, Ritter PL, Jacquez A. Outcomes of border health Spanish/English chronic disease self-management programs. Diabetes Educ 2005; 31: 401–9. Buckley, Tran, Agazio & Wuertz 412 The Journal on Information Technology in Healthcare 2008; 6(6): 400–412 28 Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic disease self-management: A randomized trial. Med Care 2006; 44: 964–71. 29 Lorig KR, Sobel DS, Ritter PL, Laurent DD, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract 2001; 4: 256–62. 30 Po YM. Telemedicine to improve patients’ self-efficacy in managing diabetes. J Telemed Telecare 2000; 6: 263–7. 31 Finkelstein SM, Speedie SM, Demiris G, Veen M, Lundgren JM, Potthoff S. Telehomecare: Quality, Perception, Satisfaction. Telemed J E Health 2004; 10: 122–8. 32 Guillén S, Arredondo MT, Traver V, Valero MA, Martin S, Traganitis A, et al. User satisfaction with home telecare based on broadband communication. J Telemed Telecare 2002; 8: 81–90. 33 Buckley KM, Tran BQ, Prandoni CM. Receptiveness, use and acceptance of telehealth by caregivers of stroke patients in the home. OJIN 9(3). http://www.nursingworld. org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/ Volume92004/No3Sept04/ArticlePreviousTopic/TelehealthforStrokePatients.aspx. 34 Bowles KH, Dansky KH. Teaching self-management of diabetes via telehomecare. Home Healthc Nurse 2002; 20: 36–42. 35 Buckwalter KC, Davis LL, Wakefield BJ, Kienzle MG, Murray MA. Telehealth for elders and their caregivers in rural communities. Fam Community Health 2002; 25: 31–40. 36 Dimmick SL, Burgiss SG, Robbins S, Black D, Jarnagin B, Anders M. Outcomes of an integrated telehealth network demonstration project. Telemed J E Health 2003; 9: 13–23. 37 Wright LK, Bennet G, Gramling L. Telecommunication interventions for caregivers of elders with dementia. ANS Adv Nurs Sci 1998; 20: 76–88. 38 Johnston B, Wheeler L, Deuser J, Sousa KH. Outcomes of the Kaiser Permanente tele-home health research project. Arch Fam Med 2000; 9: 40–5. 39 Center for Aging Services Technologies. “Baby boomer” interest in the use of technology for the delivery of aging services and healthcare. Washington, DC: American Association of Homes and Services for the Aging, 2005a.