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O'Shea AMJ, Haraldsson B, Augustine MR, Shahnazi A, Mulligan K, Kaboli PJ. Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration. J Gen Intern Med 2024:10.1007/s11606-024-08835-2. [PMID: 38867100 DOI: 10.1007/s11606-024-08835-2] [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] [Received: 12/18/2023] [Accepted: 05/21/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access. OBJECTIVE To evaluate PC wait times before and after CRH implementation. DESIGN Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods. PARTICIPANTS Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics. MAIN MEASURES Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations. KEY RESULTS PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time. CONCLUSIONS In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.
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Affiliation(s)
- Amy M J O'Shea
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bjarni Haraldsson
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, 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
| | - Ariana Shahnazi
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA.
| | - Kailey Mulligan
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, IA, USA
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Jaske E, Wheat CL, Rubenstein LV, Leung L, Curtis I, Wahlberg L, Felker B. Understanding How Contingency Staffing Programs Can Support Mental Health Services in the Veterans Health Administration. Telemed J E Health 2024; 30:1857-1865. [PMID: 38563753 DOI: 10.1089/tmj.2023.0573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Introduction: Beginning in 2019, the Department of Veterans Affairs (VA) prioritized improving access to care nationally to deliver virtual care and implemented 18 regionally based Clinical Resource Hubs (CRHs) to meet this priority. This observational study describes the quantity and types of care delivered by CRH Mental Health teams, and the professions of those hired to deliver it. Methods: A retrospective cohort study, based on national VA CRH mental health care utilization data and CRH staffing data for CRH's first 3 years, was conducted. Results: CRH Mental Health teams primarily used Telemental Health (TMH) to provide care (98.1% of all CRH MH encounters). The most common disorders treated included depression, post-traumatic stress disorder, and anxiety disorders. The amount of care delivered overtime steadily increased as did the racial and ethnic diversity of Veterans served. Psychologists accounted for the largest share of CRH staffing, followed by psychiatrists. Conclusions: CRH TMH delivered from a regional hub appears to be a feasible and acceptable visit modality, based on the continuously increasing CRH TMH visit rates. Our results showed that CRH TMH was predominantly used to address common mental health diagnoses, rather than serious mental illnesses. Traditionally marginalized patient populations increased over the 3-year window, suggesting that CRH TMH resources were accessible to many of these patients. Future research should assess barriers and facilitators for accessing CRH TMH, especially for difficult-to-service patient populations, and should consider whether similar results to ours occur when regional TMH is delivered to non-VA patient populations.
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Affiliation(s)
- Erin Jaske
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Chelle L Wheat
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Lisa V Rubenstein
- Center for the Study of Health care Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Department of Veterans Affairs, Los Angeles, California, USA
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Evidence-Based Practice Center, RAND Corporation, Santa Monica, CA, USA
| | - Lucinda Leung
- Center for the Study of Health care Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Department of Veterans Affairs, Los Angeles, California, USA
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Idamay Curtis
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, Washington, USA
| | - Lawrence Wahlberg
- Department of Veterans Affairs, National Clinical Resource Hub, VA Central Office, Washington, District of Columbia, USA
- Department of Psychiatry, School of Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Bradford Felker
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Seattle, Washington, USA
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Parikh DA, Rodgers TD, Passero VA, Chang JC, Tisdale R, Kelley MJ, Das M. Teleoncology in the Veterans Health Administration: Models of Care and the Veteran Experience. Am Soc Clin Oncol Educ Book 2024; 44:e100042. [PMID: 38870449 DOI: 10.1200/edbk_100042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The Veterans Health Administration (VHA) has pioneered teleoncology to address access challenges faced by Veterans requiring cancer care. This ASCO Educational Book highlights the development of teleoncology programs within the VHA: the local VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Center, the National TeleOncology Program (NTO), and the regional Clinical Resource Hub (CRH) Oncology Program. These initiatives provide oncology care using a hub-and-spoke model, which centralizes expertise at hub sites and reaches Veterans at distant spoke sites through synchronous and asynchronous care. The deployment of these teleoncology programs has resulted in significant benefits, such as decreased travel for Veterans, high levels of patient satisfaction, and improved access to specialized treatments. Despite these advancements, disparities in teleoncology utilization and access to clinical trials persist. This educational manuscript highlights the successes and challenges of tele-oncology within the VHA, underscoring the critical role of telehealth in overcoming access barriers.
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Affiliation(s)
- Divya A Parikh
- Department of Medicine, Stanford University, Stanford, CA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Thomas D Rodgers
- VA National TeleOncology, Durham, NC
- Department of Medicine and Duke Cancer Institute, Duke University, Durham, NC
- Durham Veterans Affairs Health Care System, Durham, NC
| | - Vida A Passero
- VA National TeleOncology, Durham, NC
- University of Pittsburgh School of Medicine, Pittsburgh, PA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Jenni C Chang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Rebecca Tisdale
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Michael J Kelley
- VA National TeleOncology, Durham, NC
- Department of Medicine and Duke Cancer Institute, Duke University, Durham, NC
- Durham Veterans Affairs Health Care System, Durham, NC
- National Oncology Program, Department of Veterans Affairs, Washington, DC
| | - Millie Das
- Department of Medicine, Stanford University, Stanford, CA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Tisdale R, Der-Martirosian C, Yoo C, Chu K, Zulman D, Leung L. Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease. J Gen Intern Med 2024; 39:60-67. [PMID: 38252244 PMCID: PMC10937859 DOI: 10.1007/s11606-023-08475-y] [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: 04/20/2023] [Accepted: 10/11/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered. OBJECTIVE Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension. DESIGN Retrospective cohort study. PATIENTS Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years. MAIN MEASURES The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering. KEY RESULTS Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06). CONCLUSIONS Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.
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Affiliation(s)
- Rebecca Tisdale
- Veterans Affairs Palo Alto Healthcare System/Center for Innovation to Implementation (Ci2i), Palo Alto, CA, USA.
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - Claudia Der-Martirosian
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- 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), North Hills, CA, USA
| | - Donna Zulman
- Veterans Affairs Palo Alto Healthcare System/Center for Innovation to Implementation (Ci2i), Palo Alto, CA, USA
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Lucinda 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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