A Primary Care Telehealth Pilot Program to Improve Access: Associations with Patients' Health Care Utilization and Costs

Exploring Contactless Vital Signs Collection in Video Telehealth Visits Among Veterans Affairs Providers and Patients: Pilot Usability Study

BACKGROUND

To expand veterans' access to health care, the Veterans Affairs (VA) Office of Connected Care explored a novel software feature called "Vitals" on its VA Video Connect telehealth platform. Vitals uses contactless, video-based, remote photoplethysmography (rPPG) through the infrared camera on veterans' smartphones (and other devices) to automatically scan their faces to provide real-time vital statistics on screen to both the provider and patient.

OBJECTIVE

This study aimed to assess VA clinical provider and veteran patient attitudes regarding the usability of Vitals.

METHODS

We conducted a mixed methods evaluation of Vitals among VA providers and patients, collecting data in July and August 2023 at the VA Boston Healthcare System and VA San Diego Healthcare System. We conducted analyses in October 2023. In-person usability testing sessions consisted of a think-aloud procedure while using the software, a semistructured interview, and a 26-item web-based survey.

RESULTS

Usability test sessions with 20 VA providers and 13 patients demonstrated that both groups found Vitals "useful" and "easy to use," and they rated its usability highly (86 and 82 points, respectively, on a 100-point scale). Regarding acceptability or willingness/intent to use, providers and patients generally expressed confidence and trust in Vitals readings, with high ratings of 90 and 85 points, respectively. Providers and patients rated Vitals highly for its feasibility and appropriateness for context (90 and 90 points, respectively). Finally, providers noted that Vitals' flexibility makes it appropriate and advantageous for implementation in a wide range of clinical contexts, particularly in specialty care. Providers believed that most clinical teams would readily integrate Vitals into their routine workflow because it saves time; delivers accurate, consistently collected vitals; and may reduce reporting errors. Providers and veterans suggested training and support materials that could improve Vitals adoption and implementation.

CONCLUSIONS

While remote collection of vital readings has been described in the literature, this is one of the first accounts of testing a contactless vital signs measurement tool among providers and patients. If ongoing initiatives demonstrate accuracy in its readings, Vitals could enhance telemedicine by providing accurate and automatic reporting and recording of vitals; sending patients' vital readings (pending provider approval) directly to their electronic medical record; saving provider and patient time; and potentially reducing necessity of some home-based biometric devices. Understanding usability issues before US Food and Drug Administration approval of Vitals and its implementation could contribute to a seamless introduction of Vitals to VA providers and patients.

Health care utilization in Alaska Native people receiving chronic disease specialty care by videoconsultation compared to propensity-matched controls

INTRODUCTION

Previous studies have had mixed findings about the effects of telemedicine on health care utilization. We designed this study to assess differences in health care utilization between ever users of telemedicine for chronic disease specialty care compared to propensity-matched controls.

METHODS

This observational study of usual care in the Alaska Tribal Health System evaluated telemedicine use (videoconsultation) and healthcare utilization using data from the electronic medical record between 1 January 2015 and 30 June 2019. Eligibility criteria included: age 18 and older, chronic condition diagnosis, and residing in one of four study regions. Cases had ever used telemedicine while controls had not. We used propensity score matching to achieve covariate balance between cases and controls, and then estimated the effect of telemedicine on outcomes using multivariable models. Outcomes included rates of hospitalizations, outpatient visits, and emergency department visits.

RESULTS

Cases (ever users of telemedicine) had higher hospitalization rates (rate ratio 1.31, p < 0.01) and higher outpatient visit rates (rate ratio 1.23, p < 0.01). Cases had lower rates of emergency department visits, though non-statistically significant (rate ratio 0.87, p = 0.07). Cases were more likely than controls to have no emergency department visits per follow-up time (49% vs 36%, p < 0.01).

DISCUSSION

We found higher rates of inpatient and outpatient health care utilization in people who had ever used telemedicine compared to propensity-matched controls, with potentially lower rates of emergency department visits. These findings contribute to the literature on telemedicine and should be considered in the context of other factors influencing telemedicine use and outcomes.

The Clinical Resource Hub Telehealth Program and Use of Primary Care, Emergency, and Inpatient Care During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic disrupted delivery of health care services worldwide. We examined the impact of the pandemic on clinics participating in the Veterans Affairs (VA) Clinical Resource Hub (CRH) program, rolled out nationally in October 2019, to improve access to care at under-resourced VA clinics or "spoke" sites through telehealth services delivered by regional "hub" sites.

OBJECTIVE

To assess whether the CRH program was associated with increased access to primary care, we compared use of primary, emergency, and inpatient care at sites that adopted CRH for primary care (CRH-PC) with sites that did not adopt CRH-PC, pre-post pandemic onset.

DESIGN

Difference-in-difference and event study analyses, adjusting for site characteristics.

STUDY COHORT

A total of 1050 sites (254 CRH-PC sites; 796 comparison sites), fiscal years (FY) 2019-2021.

INTERVENTION

CRH Program for Primary Care.

MAIN MEASURES

Quarterly number of VA visits per site for primary care (across all and by modality, in-person, video, and phone), emergency care, and inpatient care.

RESULTS

In adjusted analyses, CRH-PC sites, compared with non-CRH-PC sites, had on average 221 additional primary care visits (a volume increase of 3.4% compared to pre-pandemic). By modality, CRH-PC sites had 643 fewer in-person visits post-pandemic (- 14.4%) but 723 and 128 more phone and video visits (+ 39.9% and + 159.5%), respectively. CRH-PC sites, compared with non-CRH-PC sites, had fewer VA ED visits (- 4.2%) and hospital stays (- 5.1%) in VA medical centers. Examining visits per patient, we found that CRH-PC sites had 48 additional telephone primary care visits per 1000 primary care patients (an increase of 9.8%), compared to non-program sites.

CONCLUSIONS

VA's pre-pandemic rollout of a new primary care telehealth program intended to improve access facilitated primary care visits during the pandemic, a period fraught with care disruptions, and limited in-person health care delivery, indicating the potential for the program to offer health system resilience.

A National Perspective of Telemedicine Use and Direct Medical Costs: Who Uses It and How Much It Costs

BACKGROUND

Telemedicine has the potential to reduce medical costs among health systems. However, there is a limited understanding of the use of telemedicine and its association with direct medical costs.

OBJECTIVES

Using nationally representative data, we investigated telemedicine use and the associated direct medical costs among respondents overall and stratified by medical provider type and patient insurance status.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

We used the 2020 Medical Expenditure Panel Survey full-year consolidated file, and outpatient department (OP) and office-based (OB) medical provider event files. Outcomes included total and out-of-pocket costs per visit for OP and OB. The primary independent variable was a binary variable indicating visits made through any telemedicine modality. We used multivariable generalized linear models and 2-part models, adjusting for types of providers and care, patient characteristics, and survey design.

RESULTS

Among total OP (n = 2938) and OB (n = 20,204) visits, 47.6% and 24.7% of visits, respectively were made through telemedicine. For OP, telemedicine visits were associated with lower total costs (average marginal effect: -$228; 95% confidence interval -$362, -$95) and out-of-pocket costs for all visits and for visits to specialists and to nurse practitioners or physicians assistants. For OB, telemedicine visits were associated with lower total costs, but not with lower out-of-pocket costs, for visits to primary care physicians or nurse practitioners or physician assistants, and for visits by Medicare patients.

CONCLUSION

Telemedicine was associated with lower direct medical costs. Its potential for cost curbing should be proactively identified and integrated into clinical practice and health policy design.

Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation

BACKGROUND

The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams.

METHODS

The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners.

DISCUSSION

Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Offsite primary care providers using telehealth to support a sustainable workforce in rural and remote general practice: A rapid review of the literature

INTRODUCTION

Rural and remote general practices face increasing demands for care without the workforce required to meet patient needs. The coronavirus pandemic has created an opportunity to explore sustainable, telehealth-driven solutions to this chronic and complex problem.

OBJECTIVE

This review examined interventions using offsite primary care providers to deliver ongoing patient care via telehealth to support rural and remote general practices. We aimed to understand the impact of such interventions on the Quadruple Aim (patient experience, provider experience, health care costs, and health outcomes).

DESIGN

A rapid review of studies published from 2011 and grey literature published from 2016.

FINDINGS

Six studies met the eligibility criteria. No eligible Australian studies were identified. Most studies investigated ongoing primary care services provided via telehealth by offsite pharmacists. Patients and rural primary care staff reported positive experiences with the interventions. One study demonstrated potential return on investment for rural practices. While one study reported clinically and statistically significant improvements in health outcomes over time, two studies did not observe statistically significant differences in health outcomes between intervention and control cohorts.

DISCUSSION

The Quadruple Aim should be carefully considered when designing, implementing, and evaluating interventions that involve offsite primary care providers using telehealth to support a sustainable workforce in rural and remote general practice.

CONCLUSION

Sustainable solutions to workforce shortages in rural and remote general practice are needed urgently. Using offsite primary care providers to deliver telehealth and support practices in these regions is one possible solution that warrants further investigation, particularly in Australia.

Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians

Social support is bidirectionally linked to symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that family involvement in veterans' mental health treatment is desired by both veterans and family members, and that such involvement has the potential to improve treatment outcomes. However, rates of family involvement are low in the Veterans Health Administration (VHA). We sought to understand VHA clinicians' perspectives on family involvement in PTSD treatment by conducting qualitative interviews with 31 providers at 10 VHA facilities across the U.S. The i-PARIHS framework was used to guide the interviews and analysis, and several major themes were identified. All clinicians reported that they at least occasionally offered family-inclusive sessions, and they frequently referenced both the influence of family behaviors or attitudes on veterans' functioning, and also how veterans' symptoms could cause tremendous disruption in the family. Clinicians' past experience with supervised family- or couple-based work strongly influenced their current comfort with family-inclusive sessions. Multiple potential avenues exist to support increased family involvement in PTSD treatment in VHA.

Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial

BACKGROUND

The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI).

METHOD/DESIGN

The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation.

DISCUSSION

This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap."

TRIAL REGISTRATION

ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.