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Der-Martirosian C, Yoo CK, Steers WN, Hou CG, Chu K, Ferguson J, Carter M, Heyworth L, Leung LB. Primary care team characteristics associated with video use: a retrospective national study at the Veterans Health Administration. BMC PRIMARY CARE 2024; 25:333. [PMID: 39244538 PMCID: PMC11380331 DOI: 10.1186/s12875-024-02565-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 08/05/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE To examine primary care (PC) team members' characteristics associated with video use at the Veterans Health Administration (VA). METHODS VA electronic data were used to identify PC team characteristics associated with any video-based PC visit, during the three-year study period (3/15/2019-3/15/2022). Multilevel mixed-effects logistic regression models on repeated yearly observations were used, adjusting for patient- and healthcare system-level characteristics, and study year. We included five PC team categories: 1.PC providers (PCP), which includes physicians, nurse practitioners, physician assistants, 2.Nurses (RN/LVN/LPN/other nurses), 3.Mental health (MH) specialists, 4.Social workers (SW), and 5.Clinical pharmacists (PharmD). POPULATION 54,494 PC care team members nationwide (61,728,154 PC visits; 4,916,960 patients), including 14,422 PCPs, 30,273 nurses, 2,721 MH specialists, 4,065 SWs, and 3,013 PharmDs. RESULTS The mean age was 46.1(SD = 11.3) years; 77.1% were women. Percent of video use among PC team members varied from 24 to 84%. In fully adjusted models, older clinicians were more likely to use video compared to the youngest age group (18-29 years old) (example: 50-59 age group: OR = 1.12,95%CI:1.07-1.18). Women were more likely to use video (OR = 1.18, 95%CI:1.14-1.22) compared to men. MH specialists (OR = 7.87,95%CI:7.32-8.46), PharmDs (OR = 1.16,95%CI:1.09-1.25), and SWs (OR = 1.51,95%CI:1.41-1.61) were more likely, whereas nurses (OR = 0.65,95%CI:0.62-0.67) were less likely to use video compared to PCPs. CONCLUSIONS This study highlights more video use among MH specialists, SWs, and PharmDs, and less video use among nurses compared to PCPs. Older and women clinicians, regardless of their role, used more video. This study helps to inform the care coordination of video-based delivery among interdisciplinary PC team members.
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Affiliation(s)
- Claudia Der-Martirosian
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA.
- Veterans Emergency Management Evaluation Center (VEMEC), Department of Veterans Affairs, North Hills, CA, USA.
| | - Caroline K Yoo
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - W Neil Steers
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center (VEMEC), Department of Veterans Affairs, North Hills, CA, USA
| | - Cynthia G Hou
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - Karen Chu
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center (VEMEC), Department of Veterans Affairs, North Hills, CA, USA
| | - Jacqueline Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA
| | - Maia Carter
- Office of Primary Care/Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Leonie Heyworth
- Office of Connected Care/Telehealth Services, Veterans Health Administration, Washington, DC, USA
- Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Lucinda B Leung
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Peracca SB, Lachica O, Lamkin RP, Jackson GL, Mohr DC, King HA, Whited JD, Fonseca AS, Morris IJ, Gifford AL, Weinstock MA, Oh DH. Implementation of Direct-to-Patient Mobile Teledermatology in VA. J Gen Intern Med 2024; 39:97-105. [PMID: 38252250 PMCID: PMC10937882 DOI: 10.1007/s11606-023-08480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/12/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION NCT03241589.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Olevie Lachica
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Rebecca P Lamkin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, 6301 Herndon Road, Durham, NC, 27713, USA
| | - John D Whited
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Duke University School of Medicine, 6301 Herndon Road, Durham, NC, 27713, USA
| | - Allene S Fonseca
- Department of Dermatology, Wayne State University, 18101 Oakwood Boulevard #402, Dearborn, MI, 48124, USA
| | - Isis J Morris
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA, 02130, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, 72 E Concord Street, Boston, MA, 02118, USA
| | - Martin A Weinstock
- Department of Dermatology and Epidemiology, Brown University, 593 Eddy Street, Providence, RI, 02903, USA
- Center for Dermatoepidemiology, Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA
| | - Dennis H Oh
- Dermatology Service (190), San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA, 94121, USA.
- Department of Dermatology, University of California San Francisco, 1701 Divisadero Street, San Francisco, CA, 94115, USA.
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O'Shea AMJ, Mulligan K, Carlson P, Haraldsson B, Augustine MR, Kaboli PJ, Shimada SL. Healthcare Utilization Differences Among Primary Care Patients Using Telemedicine in the Veterans Health Administration: a Retrospective Cohort Study. J Gen Intern Med 2024; 39:109-117. [PMID: 38252240 PMCID: PMC10937860 DOI: 10.1007/s11606-023-08472-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/10/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The COVID-19 pandemic encouraged telemedicine expansion. Research regarding follow-up healthcare utilization and primary care (PC) telemedicine is lacking. OBJECTIVE To evaluate whether healthcare utilization differed across PC populations using telemedicine. DESIGN Retrospective observational cohort study using administrative data from veterans with minimally one PC visit before the COVID-19 pandemic (March 1, 2019-February 28, 2020) and after in-person restrictions were lifted (October 1, 2020-September 30, 2021). PARTICIPANTS All veterans receiving VHA PC services during study period. MAIN MEASURES Veterans' exposure to telemedicine was categorized as (1) in-person only, (2) telephone telemedicine (≥ 1 telephone visit with or without in-person visits), or (3) video telemedicine (≥ 1 video visit with or without telephone and/or in-person visits). Healthcare utilization 7 days after index PC visit were compared. Generalized estimating equations estimated odds ratios for telephone or video telemedicine versus in-person only use adjusted for patient characteristics (e.g., age, gender, race, residential rurality, ethnicity), area deprivation index, comorbidity risk, and intermediate PC visits within the follow-up window. KEY RESULTS Over the 2-year study, 3.4 million veterans had 12.9 million PC visits, where 1.7 million (50.7%), 1.0 million (30.3%), and 649,936 (19.0%) veterans were categorized as in-person only, telephone telemedicine, or video telemedicine. Compared to in-person only users, video telemedicine users experienced higher rates per 1000 patients of emergent care (15.1 vs 11.2; p < 0.001) and inpatient admissions (4.2 vs 3.3; p < 0.001). In adjusted analyses, video versus in-person only users experienced greater odds of emergent care (OR [95% CI]:1.18 [1.16, 1.19]) inpatient (OR [95% CI]: 1.29 [1.25, 1.32]), and ambulatory care sensitive condition admission (OR [95% CI]: 1.30 [1.27, 1.34]). CONCLUSIONS Telemedicine potentially in combination with in-person care was associated with higher follow-up healthcare utilization rates compared to in-person only PC. Factors contributing to utilization differences between groups need further evaluation.
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Affiliation(s)
- Amy M J O'Shea
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA.
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA.
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA.
| | - Kailey Mulligan
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, 52241, USA
| | - Paige Carlson
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA
| | - Bjarni Haraldsson
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA
| | - Matthew R Augustine
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx, NY, USA
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter J Kaboli
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, 52246-2208, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA
| | - Stephanie L Shimada
- Center for Healthcare Organization and Implementation Research (CHOIR) at the Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Ritchey KC, Olney A, Chen S, Martinez E, Paulsen MR, Tunoa J, Powers JS. Implementation of a Multicomponent Otago-Based Virtual Fall Reduction, Education, and Exercise Program (MOVing FREEly) in Older Veterans. Geriatrics (Basel) 2023; 8:115. [PMID: 38132486 PMCID: PMC10742562 DOI: 10.3390/geriatrics8060115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/31/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE The COVID-19 pandemic limited access to community fall prevention programs, thus establishing the need for virtual interventions. Herein, we describe the feasibility, effectiveness, and acceptability of a virtual, multicomponent fall prevention program (MOVing FREEly). METHODS A team of clinical falls prevention experts developed a six-week multicomponent fall prevention exercise and education class for older community-dwelling adults at risk of falling. Feasibility was measured through class attendance; effectiveness was measured through changes in performance measures, self-report of falling risk, and concern about falling; acceptability was assessed through questionnaires completed immediately upon program completion and at a three-month follow up. RESULTS A total of 32 patients participated in the MOVing FREEly program. Attendance for education and exercise classes on average was greater than 80% with little attrition. Patient reported reduced concern of falling, improvement in the falls efficacy scale-international (FES-I) short form, and had statistically significant improvement in 30 s sit-to-stand and single-leg balance tests. The program was well received by participants, saving them significant time and costs of travel. CONCLUSIONS A virtual, multicomponent fall prevention program is feasible and acceptable and effective as reducing falling risk. Future studies can explore the ability of this program to reduce falling incident and injury.
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Affiliation(s)
- Katherine C. Ritchey
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; (S.C.); (E.M.); (M.R.P.); (J.T.)
- Division of Geriatrics and Gerontology, Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104, USA
| | - Amanda Olney
- Rehabilitation Care Services, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA;
| | - Sunny Chen
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; (S.C.); (E.M.); (M.R.P.); (J.T.)
| | - Erica Martinez
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; (S.C.); (E.M.); (M.R.P.); (J.T.)
| | - Michelle R. Paulsen
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; (S.C.); (E.M.); (M.R.P.); (J.T.)
| | - Jennifer Tunoa
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA; (S.C.); (E.M.); (M.R.P.); (J.T.)
| | - James S. Powers
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Health Care System, 1310 24th Avenue South Nashville, Nashville, TN 37212, USA;
- Division of Geriatrics, Vanderbilt School of Medicine, 2147 Belcourt Ave., Suite 100, Nashville, TN 37212, USA
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Mohr NM, Vakkalanka JP, Holcombe A, Carter KD, McCoy KD, Clark HM, Gutierrez J, Merchant KAS, Bailey GJ, Ward MM. Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality. J Gen Intern Med 2023; 38:3313-3320. [PMID: 37157039 PMCID: PMC10682298 DOI: 10.1007/s11606-023-08220-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes. OBJECTIVE To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM. DESIGN Comparative effectiveness matched cohort study. PATIENTS Veterans aged 65 years and older treated for CHF, COPD, or DM. MAIN MEASURES We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality. KEY RESULTS A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16). CONCLUSIONS The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Andrea Holcombe
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Kimberly D McCoy
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Heidi M Clark
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Jeydith Gutierrez
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - George J Bailey
- Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
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Lamkin RP, Peracca SB, Jackson GL, Hines AC, Gifford AL, Lachica O, Li D, Morris IJ, Paiva M, Weinstock MA, Oh DH. Using the RE-AIM framework to assess national teledermatology expansion. FRONTIERS IN HEALTH SERVICES 2023; 3:1217829. [PMID: 37936881 PMCID: PMC10627029 DOI: 10.3389/frhs.2023.1217829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/02/2023] [Indexed: 11/09/2023]
Abstract
Background Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics. Methods We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding. Findings Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period. Conclusions Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.
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Affiliation(s)
- Rebecca P. Lamkin
- Center for Healthcare Organizational and Implementation Research (CHOIR), VA Boston Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Boston, MA, United States
| | - Sara B. Peracca
- Dermatology Service, San Francisco VA Health Care System, San Francisco, CA, United States
| | - George L. Jackson
- Center of Innovation to Accelerate Discovery & Practice Transformation (ADAPT), Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
- Peter O'Donnell, Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Aliya C. Hines
- Department of Medicine, Division of Dermatology, John D. Dingell VA Medical Center, United States Department of Veterans Affairs, Detroit, MI, United States
- Department of Dermatology, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Allen L. Gifford
- Center for Healthcare Organizational and Implementation Research (CHOIR), VA Boston Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Boston, MA, United States
- Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- Department of Health, Law, Policy and Management, School of Public Health, Boston University, Boston, MA, United States
| | - Olevie Lachica
- Dermatology Service, San Francisco VA Health Care System, San Francisco, CA, United States
| | - Donglin Li
- Center for Healthcare Organizational and Implementation Research (CHOIR), VA Boston Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Boston, MA, United States
| | - Isis J. Morris
- Center of Innovation to Accelerate Discovery & Practice Transformation (ADAPT), Durham VA Health Care System, Veterans Health Administration, United States Department of Veterans Affairs, Durham, NC, United States
| | - Marcelo Paiva
- Center for Dermatology, Providence VA Medical Center, United States Department of Veterans Affairs, Providence, RI, United States
| | - Martin A. Weinstock
- Center for Dermatology, Providence VA Medical Center, United States Department of Veterans Affairs, Providence, RI, United States
- Department of Dermatology and Epidemiology, Brown University, Providence, RI, United States
- Office of Connected Care, Department of Veterans Affairs, Washington, DC, United States
| | - Dennis H. Oh
- Dermatology Service, San Francisco VA Health Care System, San Francisco, CA, United States
- Office of Connected Care, Department of Veterans Affairs, Washington, DC, United States
- Department of Dermatology, School of Medicine, University of California San Francisco, San Francisco, CA, United States
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Shoemaker HE, Thorpe A, Stevens V, Butler JM, Drews FA, Burpo N, Scherer LD, Fagerlin A. Telehealth Use During the COVID-19 Pandemic Among Veterans and Nonveterans: Web-Based Survey Study. JMIR Form Res 2023; 7:e42217. [PMID: 37527547 PMCID: PMC10494868 DOI: 10.2196/42217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/15/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND In the first year of the COVID-19 pandemic, studies reported delays in health care usage due to safety concerns. Delays in care may result in increased morbidity and mortality from otherwise treatable conditions. Telehealth provides a safe alternative for patients to receive care when other circumstances make in-person care unavailable or unsafe, but information on patient experiences is limited. Understanding which people are more or less likely to use telehealth and their experiences can help tailor outreach efforts to maximize the impact of telehealth. OBJECTIVE This study aims to examine the characteristics of telehealth users and nonusers and their reported experiences among veteran and nonveteran respondents. METHODS A nationwide web-based survey of current behaviors and health care experiences was conducted in December 2020-March 2021. The survey consisted of 3 waves, and the first wave is assessed here. Respondents included US adults participating in Qualtrics web-based panels. Primary outcomes were self-reported telehealth use and number of telehealth visits. The analysis used a 2-part regression model examining the association between telehealth use and the number of visits with respondent characteristics. RESULTS There were 2085 participants in the first wave, and 898 (43.1%) reported using telehealth since the pandemic began. Most veterans who used telehealth reported much or somewhat preferring an in-person visit (336/474, 70.9%), while slightly less than half of nonveterans (189/424, 44.6%) reported this preference. While there was no significant difference between veteran and nonveteran likelihood of using telehealth (odds ratio [OR] 1.33, 95% CI 0.97-1.82), veterans were likely to have more visits when they did use it (incidence rate ratio [IRR] 1.49, 95% CI 1.07-2.07). Individuals were less likely to use telehealth and reported fewer visits if they were 55 years and older (OR 0.39, 95% CI 0.25-0.62 for ages 55-64 years; IRR 0.43, 95% CI 0.28-0.66) or lived in a small city (OR 0.63, 95% CI 0.43-0.92; IRR 0.71, 95% CI 0.51-0.99). Receiving health care partly or primarily at the Veterans Health Administration (VA) was associated with telehealth use (primarily VA: OR 3.25, 95% CI 2.20-4.81; equal mix: OR 2.18, 95% CI 1.40-3.39) and more telehealth visits (primarily VA: IRR 1.5, 95% CI 1.10-2.04; equal mix: IRR 1.57, 95% CI 1.11-2.24). CONCLUSIONS Telehealth will likely continue to be an important source of health care for patients, especially following situations like the COVID-19 pandemic. Some groups who may benefit from telehealth are still underserved. Telehealth services and outreach should be improved to provide accessible care for all.
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Affiliation(s)
- Holly E Shoemaker
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, United States
| | - Alistair Thorpe
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Vanessa Stevens
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, United States
- Department of Internal Medicine, Division of Epidemiology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jorie M Butler
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, United States
- Geriatrics Research, Education, and Clinical Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Frank A Drews
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, United States
- Department of Psychology, College of Social and Behavioral Science, University of Utah, Salt Lake City, UT, United States
| | - Nicole Burpo
- Research Operations, American Heart Association, Dallas, TX, United States
| | - Laura D Scherer
- University of Colorado School of Medicine, Aurora, CO, United States
- VA Denver Center for Innovation, Denver, CO, United States
| | - Angela Fagerlin
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, United States
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Wells SY, Morland LA, Hurst S, Jackson GL, Kehle-Forbes SM, Jaime K, Aarons GA. Veterans' reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination. Psychol Serv 2023; 20:483-495. [PMID: 36326662 PMCID: PMC10154431 DOI: 10.1037/ser0000714] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Premature dropout from posttraumatic stress disorder treatment (PTSD) hinders treatment response. Studies have primarily used quantitative methodology to identify factors that contribute to Veterans' premature dropout, which has yielded mixed results. Qualitative methods provide rich data and generate additional hypotheses about why Veterans discontinue PTSD treatment. This study aimed to understand Veterans' reasons for dropping out of prolonged exposure therapy (PE) and to examine if there are differences in reasons for dropout between three delivery modalities: in-home, in-person (IHIP), office-based telehealth (OBT), or home-based telehealth (HBT). Twenty-two Veterans who dropped out of PE from a parent randomized clinical trial participated in individual qualitative interviews about potential contextual and individual factors related to discontinuation. Team-based coding was used to conduct open and focused coding. Themes were generated that described factors that influenced Veterans' dropout from PE and constant comparison was used to explore differences in reasons between the three modalities. Most Veterans had multiple reasons for dropping out and reasons were similar across delivery modalities with few differences. Practical barriers (e.g., scheduling difficulties), attitudes toward mental health providers and therapy (e.g., stigma), psychological and physical health factors (e.g., perceived worsening of symptoms, pain), and the therapeutic context (e.g., disliking aspects of PE) contributed to Veterans' decisions to drop out from PE. Veterans in OBT reported more types of practical barriers than Veterans in HBT and IHIP. These findings can help generate hypotheses about interventions that may promote engagement and future studies should continue to study how to reduce dropout. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | - Samantha Hurst
- Department of Family Medicine & Public Health, University of California, San Diego
| | - George L Jackson
- Durham Veterans Affairs Medical Center, Center of Innovation to Accelerate Discovery and Practice Transformation
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O'Shea AMJ, Howren MB, Mulligan K, Haraldsson B, Shahnazi A, Kaboli PJ. Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic. J Gen Intern Med 2023:10.1007/s11606-023-08120-8. [PMID: 37340258 DOI: 10.1007/s11606-023-08120-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. OBJECTIVE To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. DESIGN Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. PARTICIPANTS All veterans receiving VHA MH services during study period. MAIN MEASURES MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. KEY RESULTS Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45-1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90-0.94; P < 0.001). CONCLUSIONS This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.
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Affiliation(s)
- Amy M J O'Shea
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City VA Healthcare System, Iowa City, IA, USA.
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - M Bryant Howren
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
- Florida Blue Center for Rural Health Research & Policy, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Kailey Mulligan
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Bjarni Haraldsson
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City VA Healthcare System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
| | - Ariana Shahnazi
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
| | - Peter J Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City VA Healthcare System, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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10
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Dryden EM, Kennedy MA, Conti J, Boudreau JH, Anwar CP, Nearing K, Pimentel CB, Hung WW, Moo LR. Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers. Health Serv Res 2023; 58 Suppl 1:26-35. [PMID: 36054487 PMCID: PMC9843069 DOI: 10.1111/1475-6773.14055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value. DATA SOURCES In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits. STUDY DESIGN A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges. DATA COLLECTION We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach. PRINCIPAL FINDINGS Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity). CONCLUSIONS Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.
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Affiliation(s)
- Eileen M. Dryden
- Center for Healthcare Organization and Implementation ResearchDepartment of Veterans Affairs (VA) Bedford Healthcare SystemBedfordMassachusettsUSA
| | - Meaghan A. Kennedy
- New England Geriatric Research, Education, and Clinical CenterVA Bedford Healthcare SystemBedfordMassachusettsUSA,Department of Family MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - Jennifer Conti
- Center for Healthcare Organization and Implementation ResearchDepartment of Veterans Affairs (VA) Bedford Healthcare SystemBedfordMassachusettsUSA
| | - Jacqueline H. Boudreau
- Center for Healthcare Organization and Implementation ResearchDepartment of Veterans Affairs (VA) Bedford Healthcare SystemBedfordMassachusettsUSA
| | - Chitra P. Anwar
- Center for Healthcare Organization and Implementation ResearchDepartment of Veterans Affairs (VA) Bedford Healthcare SystemBedfordMassachusettsUSA
| | - Kathryn Nearing
- Eastern Colorado VA Geriatric Research Education and Clinical CenterAuroraColoradoUSA,Division of Geriatric MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Camilla B. Pimentel
- Center for Healthcare Organization and Implementation ResearchDepartment of Veterans Affairs (VA) Bedford Healthcare SystemBedfordMassachusettsUSA,New England Geriatric Research, Education, and Clinical CenterVA Bedford Healthcare SystemBedfordMassachusettsUSA,Department of Public Health, Zuckerberg College of Health SciencesUniversity of Massachusetts LowellLowellMassachusettsUSA
| | - William W. Hung
- Bronx Geriatric Research Education and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA,Department of Geriatrics and Palliative MedicineIcahn School of MedicineNew York CityNew YorkUSA
| | - Lauren R. Moo
- New England Geriatric Research, Education, and Clinical CenterVA Bedford Healthcare SystemBedfordMassachusettsUSA,Department of NeurologyHarvard Medical SchoolBostonMassachusettsUSA
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11
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Sistad RE, Enggasser J, Livingston NA, Brief D. Comparing substance use treatment initiation and retention between telehealth delivered during COVID-19 and in-person treatment pre-COVID-19. Am J Addict 2023; 32:301-308. [PMID: 36645267 DOI: 10.1111/ajad.13385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/19/2022] [Accepted: 12/24/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES A large portion of veterans referred to substance use disorder (SUD) treatment do not attend their first appointment or leave treatment prematurely. Telehealth options may increase access to care and treatment attendance. This study compared treatment initiation and retention between in-person treatment pre-COVID-19 and telehealth treatment during COVID-19 in a VA hospital outpatient alcohol and drug treatment clinic. METHODS Electronic health record data were collected on 373 veterans out of 481 referrals. Mixed logistic and negative binomial regression models were used for estimating the effect of treatment modality on treatment initiation and retention, respectively. RESULTS The odds of initiating treatment were 2.6 times greater when referred to a telehealth appointment during COVID-19 compared to an in-person appointment pre-COVID-19. Months retained in treatment postinitiation was similar between treatment modalities. Each month in treatment corresponded to a subsequently lower rate of treatment session attendance and by the fourth month, the average number of sessions attended was significantly lower for those receiving in-person treatment compared to those receiving telehealth treatment. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The odds of initiating SUD treatment and rate of treatment attendance over time was greater for services delivered via telehealth during COVID-19 compared to in-person pre-COVID-19. Extending telehealth services as an option for individual and group SUD treatment may promote treatment initiation and potentially higher rate of attendance over time. This study provides additional evidence for the feasibility and utility of rapidly expanding telehealth for veterans seeking outpatient substance use treatment.
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Affiliation(s)
- Rebecca E Sistad
- U.S. Department of Veteran Affairs, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, Boston, USA
| | - Justin Enggasser
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, Boston, USA.,Pear Therapeutics, Boston, Massachusetts, USA
| | - Nicholas A Livingston
- U.S. Department of Veteran Affairs, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, Boston, USA.,Behavioral Science Division, National Center for PTSD, Massachusetts, Boston, USA
| | - Deborah Brief
- U.S. Department of Veteran Affairs, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, Boston, USA
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Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic. BMC PRIMARY CARE 2022; 23:155. [PMID: 35717159 PMCID: PMC9206131 DOI: 10.1186/s12875-022-01738-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/17/2022] [Indexed: 01/19/2023]
Abstract
Abstract
Background
At the onset of COVID-19, there was a rapid expansion of telehealth (video/telephone) visits to maintain delivery of primary care (PC) services at the Veterans Health Administration (VA). This study examines patient, provider, and site-level characteristics of any virtual and video-based care in PC.
Methods
Interrupted time series (ITS) design was conducted using VA administrative/clinical, electronic healthcare data, 12-months before and 12-months after COVID-19 onset (set at March 2020) at the VA Greater Los Angeles Healthcare System (GLA), between 2019 and 2021. Patients with at least one visit to a VA PC clinic at GLA (n = 547,730 visits) were included in the analysis. The two main outcomes for this study were 1) any telehealth (versus in-person), as well as 2) video-based care (versus telephone). For the ITS analysis, segmented logistic regression on repeated monthly observations of any telehealth and video-based care was used.
Results
Percent telehealth and video use increased from 13.9 to 63.1%, and 0.3 to 11.3%, respectively, before to after COVID-19 onset. According to adjusted percentages, GLA community-based clinics (37.7%, versus 29.8% in hospital-based clinics, p < .001), social workers/pharmacists/dietitians (53.7%, versus 34.0% for PC clinicians, p < .001), and minority groups, non-Hispanic African Americans (36.3%) and Hispanics (34.4%, versus 35.3% for Whites, p < .001) were more likely to use telephone than video. Conversely, mental health providers (43.3%) compared to PC clinicians (15.3%), and women (for all age groups, except 75+) compared to men, were more likely to use video than telephone (all p’s < .001).
Conclusions
Since telehealth care provision is likely to continue after COVID-19, additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) versus video-based care (e.g., integrated mental health visits). Additionally, it is important to understand how all clinics can systematically increase access to both telephone- and video-based PC services, while ensuring equitable care for all patient populations.
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13
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Getting Connected: a Retrospective Cohort Investigation of Video-to-Home Telehealth for Mental Health Care Utilization Among Women Veterans. J Gen Intern Med 2022; 37:778-785. [PMID: 36042096 PMCID: PMC9427431 DOI: 10.1007/s11606-022-07594-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Increasingly, women are serving in the military and seeking care at the Veterans Health Administration (VHA). Women veterans face unique challenges and barriers in seeking mental health (MH) care within VHA. VA Video Connect (VVC), which facilitates video-based teleconferencing between patients and providers, can reduce barriers while maintaining clinical effectiveness. OBJECTIVE Primary aims were to examine gender differences in VVC use, describe changes in VVC use over time (including pre-COVID and 6 months following the beginning of COVID), and determine whether changes over time differed by gender. DESIGN A retrospective cohort investigation of video-to-home telehealth for MH care utilization among veterans having at least 1 MH visit from October 2019 to September 2020. PARTICIPANTS Veterans (236,268 women; 1,318,024 men). INTERVENTIONS (IF APPLICABLE) VVC involves face-to-face, synchronous, video-based teleconferencing between patients and providers, enabling care at home or another private location. MAIN MEASURES Percentage of MH encounters delivered via VA Video Connect. KEY RESULTS Women veterans were more likely than men to have at least 1 VVC encounter and had a greater percentage of MH care delivered via VVC in FY20. There was an increase in the percentage of MH encounters that were VVC over FY20, and this increase was greater for women than men. Women veterans who were younger than 55 (compared to those 55 and older), lived in urban areas (compared to those in rural areas), or were Asian (compared to other races) had a greater percentage of MH encounters that were VVC since the start of the pandemic, controlling for the mean percentage of VVC MH encounters in the 6 months pre-pandemic. CONCLUSIONS VVC use for MH care is greater in women veterans compared to male veterans and may reduce gender-specific access barriers. Future research and VVC implementation efforts should emphasize maximizing patient choice and satisfaction.
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Hohman JA, Martinez KA, Anand A, Rood M, Martyn T, Rose S, Rothberg MB. Use of Direct-to-Consumer Telemedicine to Access Mental Health Services. J Gen Intern Med 2022; 37:2759-2767. [PMID: 35091925 PMCID: PMC8799413 DOI: 10.1007/s11606-021-07326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare. OBJECTIVE To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare. DESIGN Retrospective cross-sectional study. SETTING Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018. PARTICIPANTS Patients and physicians. MAIN MEASURES Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression. KEY RESULTS We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits). CONCLUSIONS As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.
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Affiliation(s)
- Jessica A Hohman
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA. .,Cleveland Clinic Community Care, Cleveland, OH, USA.
| | - Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA
| | - Amit Anand
- Cleveland Clinic Center for Behavioral Health, Cleveland, OH, USA
| | - Mark Rood
- Cleveland Clinic Community Care, Cleveland, OH, USA
| | - Trejeeve Martyn
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Susannah Rose
- Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, Cleveland, OH, USA.,Cleveland Clinic Community Care, Cleveland, OH, USA
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Gately ME, Quach ED, Shirk SD, Trudeau SA. Understanding Variation in Adoption of Video Telehealth and Implications for Health Care Systems. MEDICAL RESEARCH ARCHIVES 2022; 10:10.18103/mra.v10i5.2751. [PMID: 36405543 PMCID: PMC9670247 DOI: 10.18103/mra.v10i5.2751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Telehealth has rapidly expanded since COVID-19. Veterans Health Administration (VHA), the largest integrated health care system in the United States, was well-positioned to incorporate telehealth across specialties due to existing policies and infrastructure. OBJECTIVES The objective of this study is to investigate predictors of occupational therapy (OT) practitioners' adoption of video telehealth. METHODS This study presents data from a convenience sample of VHA occupational therapy (OT) practitioners administered pre-pandemic, in fall 2019. Survey development was guided by the Promoting Action on Research Implementation in Health Services framework, and gathered clinician attitudes, experiences, and perspectives about video telehealth to deliver OT services. Items included telehealth usage, perceived effectiveness of specific OT interventions, and perceptions about evidence. Our outcome variable denoted practitioners' level of adoption of video telehealth: telehealth users (adopters), non-users who want to use telehealth (potential adopters and reference group), and non-users who do not want to use telehealth (non-adopters). In multiple multinomial logistic regressions, we tested whether level of adoption was associated with years of VHA work experience and perceived strength of evidence. RESULTS Of approximately 1455 eligible practitioners, 305 VHA occupational therapy practitioners participated in the survey (21% response rate). One hundred and twenty-five (41%) reported using video telehealth, whereas 180 (59%) reported not using video telehealth. Among non-users, 107 (59%) indicated willingness to adopt telehealth whereas 73 (41%) were not willing. More VHA work experience predicted higher odds of being an adopter than a potential adopter; perceptions of stronger evidence regarding video telehealth predicted higher odds of being a potential adopter than a non-adopter. CONCLUSION Clinician beliefs and years of experience exerted an influence on clinicians' use or willingness to use video telehealth. Efforts to enhance adoption of video telehealth should address clinicians' beliefs regarding the innovative nature of and organizational resources necessary to foster utilization.
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Affiliation(s)
- Megan E Gately
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System Bedford, MA
| | - Emma D Quach
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System Bedford, MA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Department of Gerontology, University of Massachusetts Boston
| | - Steven D Shirk
- VA Bedford Healthcare System, Bedford, MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Scott A Trudeau
- Geriatric Research Education and Clinical Center, VA Bedford Healthcare System Bedford, MA
- American Occupational Therapy Association, Bethesda, MD
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Vakkalanka JP, Lund BC, Ward MM, Arndt S, Field RW, Charlton M, Carnahan RM. Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans. J Gen Intern Med 2022; 37:1610-1618. [PMID: 34159547 PMCID: PMC8219175 DOI: 10.1007/s11606-021-06969-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment. METHODS A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year. RESULTS Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65). CONCLUSIONS As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - R William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
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17
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Zaccari B, Loftis JM, Haywood T, Hubbard K, Clark J, Kelly UA. Synchronous Telehealth Yoga and Cognitive Processing Group Therapies for Women Veterans with Posttraumatic Stress Disorder: A Multisite Randomized Controlled Trial Adapted for COVID-19. Telemed J E Health 2022; 28:10.1089/tmj.2021.0612. [PMID: 35357957 PMCID: PMC9519809 DOI: 10.1089/tmj.2021.0612] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Providing care over telehealth grew slowly until the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, providing mental health care was readily adapted to virtual means; however, clinical trial research is nascent in adapting methods and procedures to the virtual world. Methods: We present protocol modifications to pivot a multisite randomized controlled trial study, conducted at Southeastern and Pacific Northwestern Veterans Affairs Health Care Systems, from being conducted in-person to virtually, following the onset of the COVID-19 pandemic. We measured outcomes of posttraumatic stress disorder (PTSD) symptoms and psychophysiological markers of stress among female Veterans with PTSD secondary to military sexual trauma. We collected qualitative data about provider and participant experiences with telehealth. Results: Across sites, 200 participants were consented (48 virtually), 132 were randomized (28 to virtual groups), and 117 completed data collection and treatment (69 completed all or some data collection or treatment virtually). Conclusions: The pivots made for this study were in response to the COVID-19 pandemic and offer innovative procedures leveraging technology and contributing to the broader landscape of conducting research virtually. Clinical Trials Number: NCT02640690.
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Affiliation(s)
- Belle Zaccari
- Department of Mental Health and Clinical Neurosciences, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Department of Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer M. Loftis
- Department of Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, Oregon, USA
| | - Terri Haywood
- Departments of Research and Development, Atlanta VA Health Care System, Decatur, Georgia, USA
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA
| | | | - Jennifer Clark
- Primary Care; Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Ursula Ann Kelly
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA
- Nursing and Patient Care Services; Atlanta VA Health Care System, Decatur, Georgia, USA
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18
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Palo A, D'Souza JM. The impact of COVID-19 on the treatment of obsessive-compulsive disorder. Bull Menninger Clin 2022; 86:35-47. [PMID: 35258344 DOI: 10.1521/bumc.2022.86.1.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.
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Affiliation(s)
- Amanda Palo
- Assistant professor in the Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Johann M D'Souza
- Practicum student at Baylor College of Medicine and a graduate student in the Department of Psychology at the University of Houston, Houston, Texas
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19
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Wray C, Tang J, Byers A, Keyhani S. Digital Health Skillsets and Digital Preparedness: Comparison of Veterans Health Administration Users and Other Veterans Nationally. JMIR Form Res 2022; 6:e32764. [PMID: 35089147 PMCID: PMC8838565 DOI: 10.2196/32764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background As health care systems shift to greater use of telemedicine and digital tools, an individual’s digital health literacy has become an important skillset. The Veterans Health Administration (VA) has invested resources in providing digital health care; however, to date, no study has compared the digital health skills and preparedness of veterans receiving care in the VA to veterans receiving care outside the VA. Objective The goal of the research was to describe digital health skills and preparedness among veterans who receive care within and outside the VA health care system and examine whether receiving care in the VA is associated with digital preparedness (reporting more than 2 digital health skills) after accounting for demographic and social risk factors. Methods We used cross-sectional data from the 2016-2018 National Health Interview Survey to identify veterans (aged over 18 years) who obtain health care either within or outside the VA health care system. We used multivariable logistic regression models to examine the association of sociodemographic (age, sex, race, ethnicity), social risk factors (economic instability, disadvantaged neighborhood, low educational attainment, and social isolation), and health care delivery location (VA and non-VA) with digital preparedness. Results Those who received health care within the VA health care system (n=3188) were younger (age 18-49 years: 33.3% [95% CI 30.7-36.0] vs 24.2% [95% CI 21.9-26.5], P<.01), were more often female (34.7% [95% CI 32.0-37.3] vs 6.6% [95% CI 5.5-7.6], P<.01) and identified as Black (13.1% [95% CI 11.2-15.0] vs 10.2% [95% CI 8.7-11.8], P<.01), and reported greater economic instability (8.3% [95% CI 6.9-9.8] vs 5.5% [95% CI 4.6-6.5], P<.01) and social isolation (42.6% [95% CI 40.3-44.9] vs 35.4% [95% CI 33.4-37.5], P<.01) compared to veterans who received care outside the VA (n=3393). Veterans who obtained care within the VA reported more digital health skills than those who obtained care outside the VA, endorsing greater rates of looking up health information on the internet (51.8% [95% CI 49.2-54.4] vs 45.0% [95% CI 42.6-47.3], P<.01), filling a prescription using the internet (16.2% [95% CI 14.5-18.0] vs 11.3% [95% CI 9.6-13.0], P<.01), scheduling a health care appointment on the internet (14.1% [95% CI 12.4-15.8] vs 11.6% [95% CI 10.1-13.1], P=.02), and communicating with a health care provider by email (18.0% [95% CI 16.1-19.8] vs 13.3% [95% CI 11.6-14.9], P<.01). Following adjustment for sociodemographic and social risk factors, receiving health care from the VA was the only characteristic associated with higher odds (adjusted odds ratio [aOR] 1.36, 95% CI 1.12-1.65) of being digitally prepared. Conclusions Despite these demographic disadvantages to digital uptake, veterans who receive care in the VA reported more digital health skills and appear more digitally prepared than veterans who do not receive care within the VA, suggesting a positive, system-level influence on this cohort.
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Affiliation(s)
- Charlie Wray
- Section of Hospital Medicine, San Francisco Department of Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Janet Tang
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Amy Byers
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Division of Mental Health Services, San Francisco Department of Veterans Affairs Medical Center, San Francisco, CA, United States.,Department of Psychiatry and Behavioral Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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20
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Anderson E, Dvorin K, Etingen B, Barker AM, Rai Z, Herbst A, Mozer R, Kingston RP, Bokhour B. Lessons Learned From VHA's Rapid Implementation of Virtual Whole Health Peer-Led Groups During the COVID-19 Pandemic: Staff Perspectives. Glob Adv Health Med 2022; 11:21649561211064244. [PMID: 35106189 PMCID: PMC8795823 DOI: 10.1177/21649561211064244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session "Taking Charge of My Life and Health" (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups. OBJECTIVE We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually. METHODS We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts. RESULTS Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans' reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group's role as an antidote to isolation during the COVID-19 pandemic. CONCLUSION Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems.
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Affiliation(s)
- Ekaterina Anderson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital, Hines, IL, USA
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Zenith Rai
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Abigail Herbst
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Reagan Mozer
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | - Rodger P. Kingston
- Veteran Engagement in Research Group, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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21
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Abstract
The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.
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Affiliation(s)
- Amanda Palo
- Assistant professor in the Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Johann M D'Souza
- Practicum student at Baylor College of Medicine and a graduate student in the Department of Psychology at the University of Houston, Houston, Texas
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22
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Thomas AM, Baker JW, Hoffmann TJ, Lamb K. Clinical pharmacy specialists providing consistent comprehensive medication management with increased efficiency through telemedicine during the COVID19 pandemic. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021; 4:934-938. [PMID: 34518814 PMCID: PMC8426730 DOI: 10.1002/jac5.1494] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/09/2021] [Accepted: 02/16/2021] [Indexed: 12/02/2022]
Abstract
INTRODUCTION The Veterans Affairs (VA) has been at the forefront of harnessing the skills of clinical pharmacy specialists (CPS) in patient-aligned care teams (PACT) to improve patient care outcomes and create access for veterans. With the unfortunate arrival of Coronavirus disease 2019 (COVID19), PACT CPS were duty-bound to expand telehealth services at an accelerated rate. The purpose of this quality improvement analysis is to compare CPS efficiency as well as some objective patient metrics to assess for a change in the quality of care. This is the first study to compare the efficiency and quality of care by CPS in the VA pre-COVID19 and during the COVID19 pandemic. METHODS This is a retrospective review of PACT CPS comprehensive medication management from 3/10/19 to 11/30/19 and 3/10/20 to 11/30/20. Data points focused on clinic encounters, patient accountability to appointments, disease state expansion, and markers of disease-state management. Given diabetes and hypertension are the main disease states managed by most PACT CPS', the study evaluated changes in hemoglobin A1c (HbA1c) and blood pressure (BP) between the two cohorts as well. Data were analyzed using GraphPad Software or Microsoft Excel. A student T-test was used for continuous data and Chi-squared or Fishers Exact for nominal data. RESULTS The total number of PACT CPS encounters increased 32% in 2020, and the number of unique patients increased by 12%. There were a statistically significant increase in telephone and direct-to-consumer (DCT) video visits. The rates of no shows and cancellations significantly decreased between 2019 and 2020. There was no difference in the average change in HbA1c or average blood pressure between the two study groups. CONCLUSIONS When PACT CPS services transitioned from primarily face-to-face visits to all virtual care, the consistency of care improved, and the quality of care was not compromised.
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Affiliation(s)
- Ashley M. Thomas
- Tennessee Valley Healthcare System, Veterans Affairs Alvin C. York CampusMurfreesboroTennesseeUSA
| | - Jennifer W. Baker
- Tennessee Valley Healthcare System, Veterans Affairs Alvin C. York CampusMurfreesboroTennesseeUSA
| | - Terry J. Hoffmann
- Tennessee Valley Healthcare System, Veterans Affairs Alvin C. York CampusMurfreesboroTennesseeUSA
| | - Kristen Lamb
- Tennessee Valley Healthcare System, Veterans Affairs Alvin C. York CampusMurfreesboroTennesseeUSA
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23
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Finley BA, Palitsky R, Charteris E, Pacheco C, Kapoor D. Outpatient telecardiology perceptions among rural, suburban, and urban veterans utilizing in-person cardiology versus telecardiology services: A mixed methods analysis. J Rural Health 2021; 37:812-820. [PMID: 34002404 DOI: 10.1111/jrh.12586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To better understand opportunities and barriers to implementation and adoption, this mixed-methods study qualitatively examined attitudes toward telecardiology services among veterans who use in-person (IP) outpatient cardiology service versus those using telecardiology (TC) outpatient services. METHODS Free-text responses were collected from N = 179 veterans enrolled in Veteran Health Administration (VHA) IP or TC services in 3 rural-serving, outpatient telehealth clinics and 1 large, metropolitan outpatient center. Mixed-method analyses of responses included thematic analysis, followed by comparison of code categories and themes between IP and TC groups. FINDINGS Fifteen thematic coding categories were identified, which comprised 4 valence categories (favorable or unfavorable attitudes toward TC and IP), as well as themes pertaining to obstacles and opportunities for TC implementation. Overall, veterans enrolled in TC held more favorable attitudes toward TC than those enrolled in IP. Veteran responses included structural concerns (eg, time demands, access, and travel), as well as humanistic qualities (rapport, competence, and face-to-face contact). Differences were observed between the responses of veterans who reported dwelling in urban, suburban, and rural communities, with rural-identifying veterans generally holding more favorable attitudes toward TC than suburban-identifying veterans. CONCLUSIONS TC users had overwhelmingly positive perceptions of TC. Conversely, unfavorable attitudes from IP patients toward TC did not appear to be borne out in the responses of TC users. On the contrary, TC users' responses may indicate opportunities for allaying the concerns of TC-naïve veterans. This suggests promise for developing tailored education to dispel barriers for TC service implementation.
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Affiliation(s)
- Brooke A Finley
- College of Nursing, The University of Arizona, Tucson, Arizona, USA
| | - Roman Palitsky
- Department of Psychiatry and Human Behavior, Brown University, Providence, Rhode Island, USA
| | - Elaine Charteris
- Cardiology Department, Southern Arizona Veterans Administration Healthcare System (SAVAHCS), Tucson, Arizona, USA
| | - Christy Pacheco
- College of Nursing, The University of Arizona, Tucson, Arizona, USA
| | - Divya Kapoor
- Cardiology Department, John Cochran VA Medical Center, St. Louis, Missouri, USA.,Washington University School of Medicine, St. Louis, Missouri, USA
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24
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Matsumoto RA, England BR, Mastarone G, Richards JS, Chang E, Wood PR, Barton JL. Rheumatology Clinicians' Perceptions of Telerheumatology Within the Veterans Health Administration: A National Survey Study. Mil Med 2021; 185:e2082-e2087. [PMID: 32789463 DOI: 10.1093/milmed/usaa203] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The Department of Veterans Affairs Veterans Health Administration (VA) Strategic Plan (Fiscal Year 2018-2024) identified four priorities for care including easy access, timely and integrated care, accountability, and modernization, all of which can be directly or indirectly impacted by telemedicine technologies. These strategic goals, coupled with an anticipated rheumatology workforce shortage, has created a need for additional care delivery methods such as clinical video telehealth application to rheumatology (ie, telerheumatology). Rheumatology clinician perceptions of clinical usefulness telerheumatology have received limited attention in the past. The present study aimed to evaluate rheumatologists' perceptions of and experiences with telemedicine, generally, and telerheumatology, specifically, within the VA. MATERIALS AND METHODS A 38-item survey based on an existing telehealth providers' satisfaction survey was developed by two VA rheumatologists with experience in telemedicine as well as a social scientist experienced in survey development and user experience through an iterative process. Questions probed VA rheumatology clinician satisfaction with training and information technology (IT) supports, as well as barriers to using telemedicine. Additionally, clinician perceptions of the impact and usefulness of and appropriate clinical contexts for telerheumatology were evaluated. The survey was disseminated online via VA REDCap to members of the VA Rheumatology Consortium (VARC) through a LISTSERV. The study protocol was approved by the host institution IRB through expedited review. Survey responses were analyzed using descriptive statistics. RESULTS Forty-five anonymous responses (20% response rate) were collected. Of those who responded, 47% were female, 98% were between 35 and 64 years old, 71% reported working at an academic center, and the majority was physician-level practitioners (98%). Respondents generally considered themselves to be tech savvy (58%). Thirty-six percent of the sample reported past experience with telemedicine, and, of those, 29% reported experience with telerheumatology specifically. Clinicians identified the greatest barrier to effective telerheumatology as the inability to perform a physical exam (71%) but agreed that telerheumatology is vital to increasing access to care (59%) and quality of care (40%) in the VA. Overall, regardless of experience with telemedicine, respondents reported that telerheumatology was more helpful for management of rheumatologic conditions rather than initial diagnosis. CONCLUSIONS While the majority of rheumatology clinicians did not report past experience with telerheumatology, they agreed that it has potential to further the VA mission of improved access and quality of care. Rheumatology clinicians felt the suitability of telerheumatology is dependent on the phase of care. As remote care technologies continue to be rapidly adopted into clinic, clinician perceptions of and experiences with telemedicine will need to be addressed in order to maintain high-quality and clinician- and patient-centric care within VA rheumatology.
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Affiliation(s)
- Rachel A Matsumoto
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care System & University of Nebraska Medical Center, Omaha, NE
| | - Ginnifer Mastarone
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239
- Department of Communication, College of Liberal Arts & Sciences, Portland State University, 1825 SW Broadway, Portland, OR 97201
| | - J Steuart Richards
- Pittsburgh VA Medical Center & University of Pittsburgh, University Drive C, Pittsburgh, PA 15213
| | - Elizabeth Chang
- Phoenix VA Health Care System, 650 E Indian School Rd., Phoenix, AZ 85012
| | - Patrick R Wood
- Rocky Mountain Regional VA Medical Center & University of Colorado School of Medicine, 1700 N Wheeling St., Aurora, CO 80045
| | - Jennifer L Barton
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd., Portland, OR 97239
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
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25
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Peracca SB, Fonseca A, Hines A, King HA, Grenga AM, Jackson GL, Whited JD, Chapman JG, Lamkin R, Mohr DC, Gifford A, Weinstock MA, Oh DH. Implementation of Mobile Teledermatology: Challenges and Opportunities. Telemed J E Health 2021; 27:1416-1422. [PMID: 33691074 DOI: 10.1089/tmj.2020.0500] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA
| | - Allene Fonseca
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Aliya Hines
- VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea M Grenga
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John D Whited
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Rebecca Lamkin
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Allen Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Dennis H Oh
- Dermatology Service, San Francisco VA Health Care System, San Francisco, California, USA.,Department of Dermatology, University of California at San Francisco, San Francisco, California, USA
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James HM, Papoutsi C, Wherton J, Greenhalgh T, Shaw SE. Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework. J Med Internet Res 2021; 23:e23775. [PMID: 33434141 PMCID: PMC7837451 DOI: 10.2196/23775] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/27/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained. OBJECTIVE This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice. METHODS We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time. RESULTS We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption. CONCLUSIONS There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.
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Affiliation(s)
- Hannah M James
- Department of Knowledge Integration, University of Waterloo, Waterloo, ON, Canada
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Talley RM, Brunette MF, Adler DA, Dixon LB, Berlant J, Erlich MD, Goldman B, First MB, Koh S, Oslin DW, Siris SG. Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19. J Nerv Ment Dis 2021; 209:49-53. [PMID: 33003053 DOI: 10.1097/nmd.0000000000001254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.
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Affiliation(s)
| | | | | | | | | | | | - Beth Goldman
- Group for Advancement of Psychiatry, New York, New York
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Hastings SN, Mahanna EP, Berkowitz TSZ, Smith VA, Choate AL, Hughes JM, Pavon J, Robinson K, Hendrix C, Van Houtven C, Gentry P, Rose C, Plassman BL, Potter G, Oddone E. Video-Enhanced Care Management for Medically Complex Older Adults with Cognitive Impairment. J Am Geriatr Soc 2021; 69:77-84. [PMID: 32966603 PMCID: PMC8579876 DOI: 10.1111/jgs.16819] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This pilot study assessed feasibility of video-enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery. DESIGN Pilot randomized controlled trial. SETTING Durham Veterans Affairs Health Care System. PARTICIPANTS Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20-31) and their care partners. INTERVENTION The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone. MEASUREMENTS Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability. RESULTS Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm. CONCLUSION Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.
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Affiliation(s)
- Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth P. Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ashley L. Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Jaime M. Hughes
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Juliessa Pavon
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
| | - Katina Robinson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Cristina Hendrix
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
- ∥ Duke University School of Nursing, Durham, North Carolina
| | - Courtney Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela Gentry
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia Rose
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Brenda L. Plassman
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina
- ** Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina
| | - Guy Potter
- ** Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina
| | - Eugene Oddone
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Dittman JM, Tse W, Amendola MF. Optimizing Peripandemic Care for Veteran Major Non-Traumatic Lower Extremity Amputees: A Proposal Informed by a National Retrospective Descriptive Analysis of COVID-19 Risk Factor Prevalence. Mil Med 2020; 185:e2124-e2130. [PMID: 32601682 PMCID: PMC7337786 DOI: 10.1093/milmed/usaa180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation. MATERIALS AND METHODS The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999-2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age > 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort. RESULTS VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P < .0001) and nearly all patients were male (99%). At least one ECDC-RF comorbidity was present in 25,526 (88.7%) of BKA and 17,558 (82.4%) of AKA patients (P < .0001). AA BKA patients were significantly more likely than non-AA BKA patients to present with at least one ECDC-RF comorbidity (P = .01). CONCLUSIONS According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.
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Affiliation(s)
- James M Dittman
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 23298
| | - Wayne Tse
- Department of Surgery, Central Virginia Veterans Affairs Health Care System, Richmond, VA 23249
| | - Michael F Amendola
- Department of Surgery, Central Virginia Veterans Affairs Health Care System, Richmond, VA 23249
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Biddell CB, Spees LP, Mayer DK, Wheeler SB, Trogdon JG, Rotter J, Birken SA. Developing personalized survivorship care pathways in the United States: Existing resources and remaining challenges. Cancer 2020; 127:997-1004. [PMID: 33259060 DOI: 10.1002/cncr.33355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.,School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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31
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Muir SD, de Boer K, Nedeljkovic M, Meyer D. Barriers and facilitators of videoconferencing psychotherapy implementation in veteran mental health care environments: a systematic review. BMC Health Serv Res 2020; 20:999. [PMID: 33131495 PMCID: PMC7603749 DOI: 10.1186/s12913-020-05858-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whilst treatment for mental health issues has traditionally been conducted in-person, advances in technology has seen a recent growth in the use of online video therapy services to help overcome access-to-care barriers faced by those living in rural locations and those unable to travel. These barriers are particularly apparent in the case of veteran populations, which is the focus of this review. Whilst the research investigating the efficacy of online video therapy to treat mental health issues among veterans is promising, widespread adoption and utilisation of this modality remains low with efforts often failing to progress past the pilot phase to implementation. This review focuses on the implementation of online video therapy in veteran mental health care settings and aims to identify the potential barriers and facilitators relevant to implementing the modality in military organisations. METHODS A systematic search of three databases (PsycInfo, PubMed, and Web of Science) was conducted. To be eligible for inclusion, studies had to investigate the challenges, lessons learnt, or factors operating as barriers and/or facilitators to the implementation of online video therapy in veteran health care systems. RESULTS The initial search revealed a total of 202 articles. This was reduced to 133 when duplicates were removed. After screening the titles and abstracts a further 70 articles were excluded leaving 63 to be retrieved for full review. A total of 10 studies were included in this review. The most commonly reported barriers were related to clinician concerns, logistical problems, and technology. Other barriers included access to resources as well as challenges posed by collaborations, policy and recruitment. Facilitators included experience using the modality and having dedicated staff responsible for promoting and managing the new service (e.g., on-site champions and telehealth technicians). CONCLUSIONS This review suggests that numerous barriers must be identified and addressed before attempting to implement an online video therapy service in veteran organisations. Further research is needed to establish best practice for implementation, particularly across geographically dispersed sites. It is hoped that the findings of this review will be used to help inform future implementation efforts and research initiatives in this space.
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Affiliation(s)
- Samuel D Muir
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia.
| | - Kathleen de Boer
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Maja Nedeljkovic
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Denny Meyer
- School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
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Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: a Case Study and Lessons Learned. J Gen Intern Med 2020; 35:2675-2679. [PMID: 32642929 PMCID: PMC7343380 DOI: 10.1007/s11606-020-05979-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 06/11/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care. AIM This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents. SETTING Primary Care Internal Medicine residents at a large urban academic hospital. PROGRAM DESCRIPTION In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter. PROGRAM EVALUATION Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development. DISCUSSION Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.
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Myers US, Birks A, Grubaugh AL, Axon RN. Flattening the Curve by Getting Ahead of It: How the VA Healthcare System Is Leveraging Telehealth to Provide Continued Access to Care for Rural Veterans. J Rural Health 2020; 37:194-196. [PMID: 32282955 PMCID: PMC7262401 DOI: 10.1111/jrh.12449] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ursula S Myers
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Mental Health Service Line, Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
| | - Anna Birks
- Mental Health Service Line, Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
| | - Anouk L Grubaugh
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
| | - R Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina.,Department of Medicine, Division of General Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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Shura RD, Brearly TW, Tupler LA. Telehealth in Response to the COVID-19 Pandemic in Rural Veteran and Military Beneficiaries. J Rural Health 2020; 37:200-204. [PMID: 32402128 PMCID: PMC7273091 DOI: 10.1111/jrh.12454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Robert D Shura
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, North Carolina.,Salisbury VA Medical Center, Salisbury, North Carolina.,Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Larry A Tupler
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, North Carolina.,Durham VA Medical Center, Durham, North Carolina.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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King K, Ford D, Haschker M, Harvey J, Kruis R, McElligott J. Clinical and Technical Considerations of an Open Access Telehealth Network in South Carolina: Definition and Deployment. J Med Internet Res 2020; 22:e17348. [PMID: 32441657 PMCID: PMC7275254 DOI: 10.2196/17348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 11/13/2022] Open
Abstract
Background Today, telehealth is experiencing exponential growth in utilization. Paralleling this trend is the growth in the telehealth industry, with sharp increases in the number of platforms, functionalities, and levels of integrations within both the electronic health record and other technical systems supporting health care. When a telehealth network is intended to be used across independent health care systems, an additional layer of complexity emerges. In the context of regionalized telehealth networks that are not within the same health care system, not only are technical interoperability challenges a practical barrier, but administrative, clinical, and competitive elements also quickly emerge, resulting in fragmented, siloed technologies. Objective The study aimed to describe a statewide approach to deploying an interoperable open access telehealth network across multiple health systems. Methods One promising solution to the abovementioned concerns is an open access telehealth network. In the field of telehealth, an open access network (OAN) can be defined as a network infrastructure that can be used by health care providers without a closed or proprietary platform, specific obligatory network, or service-specific telehealth technologies. This framework for the development of an OAN is grounded in practical examples of clinical programs that function in each stage of network maturity based on the experience of the South Carolina Telehealth Alliance (SCTA). The SCTA’s experience details successes and challenges in an ongoing effort to achieve an OAN. The model describes an OAN in stages of collaborative maturity and provides insights into the technological, clinical, and administrative implications of making the collaboration possible. Results The four stages of an OAN are defined according to operational maturity, ranging from feasibility to demonstration of implementation. Each stage is associated with infrastructure and resource requirements and technical and clinical activities. In stage 1, technical standards are agreed upon, and the clinical programs are designed to utilize compliant technologies. In stage 2, collaboration is demonstrated through technical teams working together to address barriers, whereas clinical and administrative teams share best practices. In stage 3, a functional interoperable network is demonstrated with different institutions providing service through common telehealth end points at different patient care sites. In stage 4, clinical workflows are streamlined and standardized across institutions, and economies of scale are achieved through technical and administrative innovations. Conclusions The approach to OAN development described provides a roadmap for achieving a functional telehealth network across independent health systems. The South Carolina experience reveals both successes and challenges in achieving this goal. The next steps toward the development of OANs include advocacy and ongoing engagement with the developers of telehealth technologies regarding their commitment to interoperability.
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Affiliation(s)
- Kathryn King
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Dee Ford
- Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Michael Haschker
- Center for Telehealth, Medical University of South Carolina, Charleston, SC, United States
| | - Jillian Harvey
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC, United States
| | - Ryan Kruis
- Center for Telehealth, Medical University of South Carolina, Charleston, SC, United States
| | - James McElligott
- Center for Telehealth, Medical University of South Carolina, Charleston, SC, United States
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Gibson-Gill CM, Williams J, Fyffe D. Triangle of Healthy Caregiving for Veterans With Spinal Cord Injury: Proposal for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e14051. [PMID: 32396130 PMCID: PMC7251480 DOI: 10.2196/14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/30/2019] [Accepted: 07/07/2019] [Indexed: 12/01/2022] Open
Abstract
Background Spinal cord injury (SCI) is a debilitating injury that results in chronic paralysis, impaired functioning, and drastically altered quality of life (QOL). The Department of Veterans Affairs (VA) estimates that approximately 450 newly injured veterans and active-duty members receive rehabilitation at VA’s Spinal Cord Injury/Disorders Centers annually. VA virtual health services use technology and health informatics to provide veterans with better access and more effective care management. The “Triangle of Healthy Caregiving for SCI Veterans” is a patient-centered intervention that incorporates SCI veterans’ caregivers into the VA SCI health care team and extends into the homes of veterans with SCI by using real-time clinical video teleconferencing (CVT). CVT facilitates video-clinic visits, which can include different types of clinical evaluations, therapy (physical/occupational), or psychosocial services. The “Triangle of Healthy Caregiving for SCI Veterans” builds on interactive, interdisciplinary health care relationships that exist between the veterans with SCI, their caregivers, and the VA SCI health care team. SCI veterans’ propensity to multiple secondary complications makes a healthy partnership crucial for the success of keeping better health and functional outcomes as well as quality of life while living in their homes. Objective The goal of the proposed mixed methods project will assess SCI veterans’, their caregivers’, and the VA health care team’s perspectives and experiences in the “Triangle of Healthy Caregiving for SCI Veterans” to determine the benefits, challenges, and outcomes for everyone involved in the intervention. Methods Data collection methods will be implemented over three sequential phases. First, in-depth interviews will be conducted with the telehealth coordinators to systematically document the administrative procedures involved in enrollment of veterans with SCI into the CVT system. Next, structured observation of the CVT enrollment process and logistics of home installation of the CVT system will be conducted to validate the content of the in-depth interviews and highlight any discrepancies observed. Semistructured interviews will be conducted to assess specific elements of the “Triangle of Healthy Caregiving for SCI Veterans” program, their perceived utility, and effectiveness of the CVT system as well as the general impressions of the impact of the intervention on the SCI veterans’ health and function outcomes, caregiver burden, and daily caregiver burden. Finally, the research team will conduct a focus group to evaluate the ways in which the “Triangle of Healthy Caregiving for SCI Veterans” is useful for health care delivery to veterans with SCI and support services to SCI caregivers. Results This proposal was funded in July 2017. It was reviewed and received institutional review board approval in March 2018, and the project was started immediately after, in the same month. As of September 2019, we have completed Phases I and III and have recruited 52 subjects for Phase II. We are beginning the data analysis. The study is projected to be completed in late summer of 2020, and the expected results are to be published in the fall of 2020. Conclusions The findings from this study will highlight the ways in which virtual health care technologies can be used to improve access to SCI specialized care for veterans and provide an estimation of the potential impact on clinical outcomes for veterans with SCI and their caregivers. International Registered Report Identifier (IRRID) DERR1-10.2196/14051
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Affiliation(s)
- Carol McMara Gibson-Gill
- Veterans Administration, New Jersey Health Care System, East Orange, NJ, United States.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Joyce Williams
- Veterans Administration, New Jersey Health Care System, East Orange, NJ, United States
| | - Denise Fyffe
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States.,Kessler Foundation, West Orange, NJ, United States
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Peracca SB, Jackson GL, Lamkin RP, Mohr DC, Zhao M, Lachica O, Prentice JC, Grenga AM, Gifford A, Chapman JG, Weinstock MA, Oh DH. Implementing Teledermatology for Rural Veterans: An Evaluation Using the RE-AIM Framework. Telemed J E Health 2020; 27:218-226. [PMID: 32343924 DOI: 10.1089/tmj.2020.0013] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction: Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA) initiative to expand asynchronous consultative teledermatology services for rural veterans. Methods: The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding. Results: Sixteen hub facilities expanded teledermatology's reach over the 2-year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding. Discussion: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention. Conclusions: A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.
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Affiliation(s)
- Sara B Peracca
- Dermatology Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Population Health Sciences and Division of General Internal Medicine, Department of Medicine, Duke University, North Carolina, USA
| | - Rebecca P Lamkin
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Molly Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - Olevie Lachica
- Dermatology Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA.,Department of Psychiatry, School of Medicine, Boston University, Massachusetts, USA
| | | | - Allen Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
| | - Jennifer G Chapman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Martin A Weinstock
- Providence VA Medical Center, Providence, Rhode Island.,Office of Connected Care, Veterans Health Administration, Washington, District of Columbia, USA.,Dermatoepidemiology Unit, Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Dennis H Oh
- Dermatology Service, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA.,Office of Connected Care, Veterans Health Administration, Washington, District of Columbia, USA.,Department of Dermatology, University of California at San Francisco, San Francisco, California, USA
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Muir SD, de Boer K, Thomas N, Seabrook E, Nedeljkovic M, Meyer D. Videoconferencing Psychotherapy in the Public Sector: Synthesis and Model for Implementation. JMIR Ment Health 2020; 7:e14996. [PMID: 31961334 PMCID: PMC7001045 DOI: 10.2196/14996] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Videoconferencing psychotherapy (VCP) is a growing practice among mental health professionals. Early adopters have predominantly been in private practice settings, and more recent adoption has occurred in larger organizations, such as the military. The implementation of VCP into larger health service providers in the public sector is an important step in reaching and helping vulnerable and at-risk individuals; however, several additional implementation challenges exist for public sector organizations. OBJECTIVE The aim of this study was to offer an implementation model for effectively introducing VCP into public sector organizations. This model will also provide practical guidelines for planning and executing an embedded service trial to assess the effectiveness of the VCP modality once implemented. METHODS An iterative search strategy was employed, drawing on multiple fields of research across mental health, information technology, and organizational psychology. Previous VCP implementation papers were considered in detail to provide a synthesis of the barriers, facilitators, and lessons learned from the implementation attempts in the military and other public sector settings. RESULTS A model was formulated, which draws on change management for technology integration and considers the specific needs for VCP integration in larger organizations. A total of 6 phases were formulated and were further broken down into practical and measurable steps. The model explicitly considers the barriers often encountered in large organizational settings and suggests steps to increase facilitating factors. CONCLUSIONS Although the model proposed is time and resource intensive, it draws on a comprehensive understanding of larger organizational needs and the unique challenge that the introduction of VCP presents to such organizations.
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Affiliation(s)
- Samuel David Muir
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
| | - Kathleen de Boer
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
| | - Neil Thomas
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
| | - Elizabeth Seabrook
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
| | - Maja Nedeljkovic
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
| | - Denny Meyer
- Centre for Mental Health, Swinburne University of Technology, Hawthorn, Australia
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Kirkland EB, DuBose-Morris R, Duckett A. Telehealth for the internal medicine resident: A 3-year longitudinal curriculum. J Telemed Telecare 2019; 27:599-605. [PMID: 31888396 DOI: 10.1177/1357633x19896683] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Across the United States of America, patients are increasingly receiving healthcare using innovative telehealth technologies. As healthcare continues to shift away from traditional office-based visits, providers face new challenges. Telehealth champions are needed to adapt technologies to meet the needs of patients, providers and communities, especially within the realm of primary care specialties. Given these challenges, this intervention aimed to incorporate telemedicine into internal medicine resident training across multiple training years to prepare them for practice in the current and changing healthcare system. METHODS Education and telehealth leaders at the Medical University of South Carolina identified key topics relevant to telehealth and the provision of general internal medicine services. With this as a framework, we developed a 3-year longitudinal telehealth curriculum for internal medicine resident physicians, consisting of an introduction to telemedicine equipment in the first year, didactic learning through in-person education and online modules in the second year and experiential learning through remote monitoring of chronic disease in the third year. Participants included approximately 100 internal medicine residents per year (2016-2019). Self-perceived knowledge, comfort and ability to provide telehealth services was assessed via a survey completed before and after participation in the curriculum. RESULTS Resident physicians' self-reported knowledge of telehealth history, access to care, contributions of telehealth applications and quality of care and communication each improved after completion of the online curriculum. There were also significant improvements in resident comfort and perceived ability to provide telehealth services after participation in the curriculum, as assessed via a survey. Overall, 41% of residents felt their ability to utilize telehealth as part of their current or future practice was greater than average after completion of the online modules compared to only 2% at baseline (p<0.01). Results also show residents accurately identify barriers to telehealth adoption at the healthcare system level, including the lack of clinical time to implement services (67% post- vs 47% pre-curriculum, p = 0.02), unfamiliarity with concepts (65% post- vs 21% pre-curriculum, p<-0.01) and concerns about consistent provider reimbursement (74% post- vs 39% pre-curriculum, p < 0.01). CONCLUSION Telemedicine and remote patient monitoring are an increasingly prevalent form of healthcare delivery. Internal medicine residents must be adept in caring for patients utilizing this technology. This curriculum was effective in improving resident comfort and self-efficacy in providing care through telehealth and provided residents with hands-on opportunities through supervised inclusion in remote patient-monitoring services. This curriculum model could be employed and evaluated within other internal medicine residency programmes to determine the feasibility at institutions with and without advanced telehealth centres.
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Affiliation(s)
| | | | - Ashley Duckett
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, USA
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Altalib HH, Galluzzo D, Argraves S, Goulet J, Bornovski Y, Cheung KH, Jackson-Shaheed E, Tolchin B, Fenton BT, Pugh MJ. Managing Functional Neurological Disorders: Protocol of a Cohort Study on Psychogenic Non-Epileptic Seizures Study. Neuropsychiatr Dis Treat 2019; 15:3557-3568. [PMID: 31920316 PMCID: PMC6939176 DOI: 10.2147/ndt.s234852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/20/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Functional neurological disorders (FNDs) are neurological symptoms that cannot be explained by an underlying neurological lesion or other medical illness and that do not have clear neuropathological correlates. Psychogenic non-epileptic seizures (PNES) are a common and highly disabling form of FND, characterized by paroxysmal episodes of involuntary movements and altered consciousness that can appear clinically similar to epileptic seizures. PNES are unique among FNDs in that they are diagnosed by video electroencephalographic (VEEG), a well-established biomarker for the disorder. The course of illness and response to treatment of PNES remain controversial. This study aims to describe the epidemiology of PNES in the Department of Veterans Affairs Healthcare System (VA), evaluate outcomes of veterans offered different treatments, and compare models of care for PNES. METHODS This electronic health record (EHR) cohort study utilizes an informatics search tool and a natural language processing algorithm to identify cases of PNES nationally. We will use VA inpatient, outpatient, pharmacy, and chart abstraction data across all 170 medical centers to identify cases in fiscal years 2002-2018. Outcome measurements such as seizure frequency, emergency room visits, hospital admissions, suicide-related behavior, and the utilization of psychotherapy prior to and after PNES diagnosis will be used to assess the effectiveness of models of care. DISCUSSION This study will describe the risk factors and course of treatment of a large cohort of people with PNES. Since PNES are cared for by a variety of different modalities, treatment orientations, and models of care, effectiveness outcomes such as seizure outcomes and utilization of emergency visits for seizures will be assessed. Outcome measurements such as seizure frequency, emergency room visits, hospital admissions, suicide-related behavior, and psychotherapy prior to and after PNES diagnosis will be used to assess the effectiveness of models of care.
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Affiliation(s)
- Hamada Hamid Altalib
- VA Connecticut Healthcare System, West Haven, CT, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Stephanie Argraves
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Yarden Bornovski
- VA Connecticut Healthcare System, West Haven, CT, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kei-Hoi Cheung
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ebony Jackson-Shaheed
- VA Connecticut Healthcare System, West Haven, CT, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin Tolchin
- VA Connecticut Healthcare System, West Haven, CT, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Mary Jo Pugh
- University of Utah, Salt Lake City, UT, USA
- Salt Lake City Veterans Healthcare System, Salt Lake City, UT, USA
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Wootton R, Bonnardot L. Experience of Supporting Telemedicine Networks With the Collegium System: First 6 Years. Front Public Health 2019; 7:226. [PMID: 31497587 PMCID: PMC6712066 DOI: 10.3389/fpubh.2019.00226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
The Collegium system was first made available in 2012 to support organizations conducting humanitarian or non-commercial telemedicine work in low resource settings. It provides the technical infrastructure necessary to establish a store-and-forward telemedicine service. During the subsequent 6 years a total of 46 networks were established, based on the Collegium infrastructure. The majority of the networks were set up to provide a clinical service (33), with six designed for education and training, and the remainder for test or administrative purposes. Of the potentially operational networks which were set up (i.e., those established for clinical or educational purposes), 15 networks (38%) were stillborn and did not handle a single case after being established. In contrast, the two most active networks had handled almost 12,000 cases. The average case rate of the five most active clinical networks operating in low-resource settings (i.e., the total number of cases divided by the length of time for which the network had been established) ranged from 0.5 to 29.4 cases/week. Across the networks there was little evidence of sigmoidal growth in activity, which is consistent with reports of other telemedicine activity in North America. A brief survey was sent to 49 network coordinators, from 31 networks. Responses were received from 9 coordinators (18% of those invited to participate). The median satisfaction with the system was 8 (on a scale from 1 = not at all satisfied to 10 = very satisfied). The free text comments were mainly technical suggestions regarding image transfer, the mobile application, or other modes of communication. The results of operating the Collegium system demonstrate that supporting telemedicine work in low resource settings can be successful, since the networks handled a very wide range of clinical cases, and at activity levels up to several cases per day. However, approximately one-third of the networks that were established did not handle a single clinical case. Nonetheless, this might represent a form of success in the sense that it prevented the waste of resource involved in an organization purchasing a telemedicine infrastructure only to find that it was not used.
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Affiliation(s)
- Richard Wootton
- Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway
| | - Laurent Bonnardot
- Fondation Médecins Sans Frontières, Paris, France.,Department of Medical Ethics and Legal Medicine, Paris Descartes University, Paris, France
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Caver KA, Shearer EM, Burks DJ, Perry K, De Paul NF, McGinn MM, Felker BL. Telemental health training in the Veterans Administration Puget Sound Health Care System. J Clin Psychol 2019; 76:1108-1124. [PMID: 31115049 DOI: 10.1002/jclp.22797] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 01/13/2018] [Accepted: 02/15/2019] [Indexed: 12/14/2022]
Abstract
As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.
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Affiliation(s)
- Kelly A Caver
- VA Puget Sound Health Care System, Seattle, Washington
| | | | - Derek J Burks
- VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Kristen Perry
- VA Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | | | - Meghan M McGinn
- VA Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Bradford L Felker
- VA Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
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Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. J Gen Intern Med 2019; 34:11-17. [PMID: 31098966 PMCID: PMC6542870 DOI: 10.1007/s11606-019-04970-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.
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Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Devan Kansagara
- VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Donna M Zulman
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Steven M Asch
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephan D Fihn
- VA Office of Clinical System Development and Evaluation, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services and Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Laurence J Meyer
- VA Office of Specialty Care Services, Washington, DC, USA.,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan R Kirsh
- Office of Veterans Access to Care, Washington, DC, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David Atkins
- VA Office of Research and Development, Health Services Research and Development, Washington, DC, USA
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Adams SV, Mader MJ, Bollinger MJ, Wong ES, Hudson TJ, Littman AJ. Utilization of Interactive Clinical Video Telemedicine by Rural and Urban Veterans in the Veterans Health Administration Health Care System. J Rural Health 2019; 35:308-318. [PMID: 30600557 DOI: 10.1111/jrh.12343] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE Interactive clinical video telemedicine (CVT) has the potential to benefit health care systems and patients by improving access, lowering costs, and more efficiently distributing providers. However, there is a gap in current knowledge around the demand for and potential uses of CVT in large integrated health care systems. METHODS We conducted an observational study using Veterans Health Administration (VHA) administrative databases to analyze trends in CVT utilization, and types of care received, among 7.65 million veterans during fiscal years (FY) 2009-2015 (October 1, 2008-September 30, 2015). Trends were stratified by veteran rurality and analyzed using linear regression. Among 4.95 million veterans in FY2015, we used logistic regression to identify characteristics associated with CVT utilization for any care, mental health care, and major specialties. FINDINGS Over 6 years, the annual CVT utilization grew from 30 to 124 encounters per 1,000 veterans (>300% increase), with faster growth among rural veterans than urban veterans. Over the study period, ≥50% of all CVT-delivered care was mental health care. In FY2015, 3.2% of urban and 7.2% of rural veterans utilized CVT for nearly 725,000 clinical encounters. Rural residence, younger age, longer driving distance to VHA facilities, one or more comorbidities, and higher rates of traditional, non-video utilization were independently associated with higher odds of CVT use. CONCLUSIONS CVT utilization in VHA has increased quickly and exceeds published rates in the private health care market. The availability of CVT has likely increased access to VHA care for rural veterans, especially for mental health care.
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Affiliation(s)
- Scott V Adams
- Center of Innovation for Veteran-Centered and Value-Driven Care,, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington
| | - Michael J Mader
- South Texas Veterans Health Care System, US Department of Veterans Affairs, San Antonio, Texas
| | - Mary J Bollinger
- Central Arkansas Veterans Healthcare System, US Department of Veterans Affairs, Little Rock, Arkansas
| | - Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care,, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington
| | - Teresa J Hudson
- Central Arkansas Veterans Healthcare System, US Department of Veterans Affairs, Little Rock, Arkansas
| | - Alyson J Littman
- Center of Innovation for Veteran-Centered and Value-Driven Care,, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, Washington.,Seattle Epidemiologic Research Information Center, VA Puget Sound Health Care System, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington
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Goodrich DE, Lowery JC, Burns JA, Richardson CR. The Phased Implementation of a National Telehealth Weight Management Program for Veterans: Mixed-Methods Program Evaluation. JMIR Diabetes 2018; 3:e14. [PMID: 30305265 PMCID: PMC6307696 DOI: 10.2196/diabetes.9867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/16/2018] [Accepted: 07/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background The burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services. Objective The primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program’s clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination. Methods We employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews. Results Although stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at −5.2 lb (SD 14.4) and −5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders. Conclusions This implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.
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Affiliation(s)
- David E Goodrich
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Julie C Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jennifer A Burns
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Caroline R Richardson
- Department of Family Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, United States
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Abstract
Background Veterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine’s effectiveness in delivering endocrinology care from Atlanta-based endocrinologists. Methods We conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth. Results Thirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans. Conclusions Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.
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Affiliation(s)
- Timothy Xu
- Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN 55905. .,Emory University, Atlanta, Georgia
| | | | - Sarah Sutton
- Central Alabama Veterans Health Care System, Montgomery, Alabama
| | - Mary Rhee
- Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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Abstract
BACKGROUND The recent growth in telehealth has been facilitated by the need to deliver healthcare to patients living in remote or rural areas. In contrast, the role of telehealth in more urban settings is less clear. A teleneurology program was established in 2011 at the Tibor Rubin VA Medical Center (TRVAMC) in Long Beach, California. A review of teleneurology encounters was conducted to assess the feasibility of applying this telehealth modality to patients with chronic neurological disorders living in an urban setting. METHODS Teleneurology encounters were conducted by clinical video telehealth (CVT) between a provider at the TRVAMC and patients at local community-based outpatient clinics from November 2011 to December 2014. In a random sampling of veterans, they were asked to complete a patient satisfaction survey. RESULTS A total of 745 teleneurology encounters were performed including 570 unique patients. Veterans with a broad range of neurological disorders were seen, including Parkinson's disease, headaches, epilepsy, dementia, cerebrovascular disease, peripheral nervous system disorders, multiple sclerosis, and other problems such as dizziness and paresthesia. Compared with patients in face-to-face clinics, patients in teleneurology clinics consistently kept their appointments. Technical problems were rare and easily resolved. The majority of patients were satisfied with the care they received through teleneurology, and preferred CVT rather than a face-to-face encounter. CONCLUSIONS This report demonstrates the successful application of telehealth to evaluate and manage a diverse group of neurological disorders in an urban setting. Despite the relatively short distances involved, the majority of patients preferred telehealth over face-to-face encounters.
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Affiliation(s)
- Steven S Schreiber
- 1 Neurology Section, Tibor Rubin VA Medical Center , Long Beach, California.,2 Departments of Neurology, Anatomy and Neurobiology, Psychiatry and Human Behavior, UC Irvine School of Medicine , Irvine, California
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Alami H, Gagnon MP, Wootton R, Fortin JP, Zanaboni P. Exploring factors associated with the uneven utilization of telemedicine in Norway: a mixed methods study. BMC Med Inform Decis Mak 2017; 17:180. [PMID: 29282048 PMCID: PMC5745591 DOI: 10.1186/s12911-017-0576-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Norway has a long history of using telemedicine, especially for geographical reasons. Despite the availability of promising telemedicine applications and the implementation of national initiatives and policies, the sustainability and scaling-up of telemedicine in the health system is still far from accomplished. The main objective of this study was to explore and identify the multi-level (micro, meso and macro) factors affecting telemedicine utilization in Norway. METHODS We used a mixed methods approach. Data from a national registry were collected to analyze the use of outpatient visits and telemedicine contacts in Norway from 2009 to 2015. Interviews with key stakeholders at national, regional and local level helped complete and contextualize the data analysis and explore the main issues affecting the use of telemedicine by health authorities and hospitals. Relevant national documents were also used to support, contradict, contextualize or clarify information and data. RESULTS Telemedicine use in Norway from 2009 to 2015 remained very low, not exceeding 0.5% of total outpatient activity at regional level and 0.1% at national level. All four regions used telemedicine. Of the 29 hospitals, 24 used it at least once over the 7-year period. Telemedicine was not used regularly everywhere, with some hospitals using it sporadically. Telemedicine was mostly used in selected specialties, including rehabilitation, neurosurgery, skin and venereal diseases. Three major themes affecting implementation and utilization of telemedicine in Norway emerged: (i) governance and strategy; (ii) organizational and professional dimensions; (iii) economic and financial dimensions. For each theme, a number of factors and challenges faced at different health care levels were identified. CONCLUSIONS This study allowed shedding light on multi-level and interdependent factors affecting utilization of telemedicine in Norway. The identification of the main implementation and utilization challenges might support decision makers and practitioners in the successful scaling-up of telemedicine. This work provides a knowledge base useful to other countries which intend to implement telemedicine or other digital health services into their healthcare systems.
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Affiliation(s)
- H. Alami
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care. Laval University (CERSSPL-UL). CIUSSS-CN, Pavillon Landry-Poulin, 2525, chemin de la canardiere, Quebec, QC G1J 0A4 Canada
- Research Centre of the CHU de Quebec-Universite Laval, Hopital St-François d’Assise, Edifice D, 45, rue Leclerc, Quebec, QC G1L 2G1 Canada
| | - M. P. Gagnon
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care. Laval University (CERSSPL-UL). CIUSSS-CN, Pavillon Landry-Poulin, 2525, chemin de la canardiere, Quebec, QC G1J 0A4 Canada
- Research Centre of the CHU de Quebec-Universite Laval, Hopital St-François d’Assise, Edifice D, 45, rue Leclerc, Quebec, QC G1L 2G1 Canada
- Faculty of Nursing Science, Laval University. Pavillon Ferdinand-Vandry, 1050, avenue de la Medecine, Quebec, QC G1V 0A6 Canada
| | - R. Wootton
- Norwegian Centre for E-health Research, University Hospital of North Norway, P.O. Box 35, 9038 Tromso, Norway
| | - J. P. Fortin
- Research Center on Healthcare and Services in Primary Care, Institute of Health and Social Services in Primary Care. Laval University (CERSSPL-UL). CIUSSS-CN, Pavillon Landry-Poulin, 2525, chemin de la canardiere, Quebec, QC G1J 0A4 Canada
- Faculty of Medicine, Laval University Pavillon Ferdinand-Vandry, 1050, avenue de la Medecine, Quebec, QC G1V 0A6 Canada
| | - P. Zanaboni
- Norwegian Centre for E-health Research, University Hospital of North Norway, P.O. Box 35, 9038 Tromso, Norway
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Affiliation(s)
- Mike Smith
- Royal Centre for Defence Medicine, Birmingham, UK
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50
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Schneider RB, Biglan KM. The promise of telemedicine for chronic neurological disorders: the example of Parkinson's disease. Lancet Neurol 2017; 16:541-551. [DOI: 10.1016/s1474-4422(17)30167-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 04/02/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
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