Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes

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Abstract

Veterans residing in Veterans Health Administration (VA) contracted Community Nursing Homes (CNHs) receive primary care from the CNH they reside in, but often travel to Veterans Affairs Medical Centers (VAMCs) for specialty care services. The Vet Connect project is a quality improvement project aiming to implement video technology to support access to specialty care. Methods: Eight Denver VAMC specialty care providers and three project nurses underwent telehealth training and obtained appropriate equipment. To identify in-person visits eligible for substitution of video visits, project nurses review charts of CNH Veterans, consult directly with Veterans, and obtain recommendations from staff. Project nurses serve as tele-presenters within the CNHs, while VA specialists provide care from the VAMC. After each visit, team nurses coordinate care with and deliver specialty care recommendations to CNH staff. Results: We assessed clinical, business, and technical domains of the Vet Connect project, and utilized process mapping to identify barriers and facilitators to implementation. Clinically, starting on 26 June 2017 through 1 June 2018, N = 203 video visits have been conducted with 11 different CNHs in three subspecialties: geriatrics, palliative care, and mental health. These visits generated 49 referrals for 37 Veterans. Fiscally, cost analyses indicate that per visit, the health care system saves an estimated $310. Technologically, the success rate was 83%. Process mapping helped identify facilitators and barriers to implementation of the telehealth program, including cultivating buy-in from key stakeholders (i.e., medical and mental health providers, telehealth staff, and CNH staff), communication allowing for ongoing program adaptation, and building relationships. Conclusion: Subspecialty care delivery to nursing homes using video visit technology in the Vet Connect program is feasible using centralized organization to coordinate complex clinical, business and technical processes. Vet Connect has proved sustainable and has potential to expand within and outside of the VA.

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The application of systems thinking in health: why use systems thinking?

David H. Peters (2014)

This paper explores the question of what systems thinking adds to the field of global health. Observing that elements of systems thinking are already common in public health research, the article discusses which of the large body of theories, methods, and tools associated with systems thinking are more useful. The paper reviews the origins of systems thinking, describing a range of the theories, methods, and tools. A common thread is the idea that the behavior of systems is governed by common principles that can be discovered and expressed. They each address problems of complexity, which is a frequent challenge in global health. The different methods and tools are suited to different types of inquiry and involve both qualitative and quantitative techniques. The paper concludes by emphasizing that explicit models used in systems thinking provide new opportunities to understand and continuously test and revise our understanding of the nature of things, including how to intervene to improve people’s health.

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Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Trisha Greenhalgh, Sara Shaw, Joseph Wherton … (2018)

Background There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. Objective The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. Methods A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). Results When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

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Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

John L Foster, Adam Darkins, Rita Kobb … (2008)

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

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Author and article information

Journal

Journal ID (nlm-ta): Geriatrics (Basel)

Journal ID (iso-abbrev): Geriatrics (Basel)

Journal ID (publisher-id): geriatrics

Title: Geriatrics

Publisher: MDPI

ISSN (Electronic): 2308-3417

Publication date (Electronic): 05 September 2018

Publication date Collection: September 2018

Volume: 3

Issue: 3

Electronic Location Identifier: 57

Affiliations

[1 ]VA Eastern Colorado Healthcare System Center of Innovation for Veteran-Centric and Value-Driven Care, 13611 East Colfax Ave., Aurora, CO 80045, USA; leah.haverhals@ 123456va.gov (L.M.H.); chelsea.manheim@ 123456va.gov (C.M.); cari.levy@ 123456va.gov (C.L.)

[2 ]School of Medicine, The University of Colorado Denver, Aurora, CO 80045, USA

Author notes

[* ]Correspondence: anne.hale@ 123456va.gov ; Tel.: +1-720-857-5136

Author information

Anne Hale https://orcid.org/0000-0003-4750-7506

Article

Publisher ID: geriatrics-03-00057

DOI: 10.3390/geriatrics3030057

PMC ID: 6319220

PubMed ID: 31011051

SO-VID: f37d9210-28b0-4d42-a43e-aaa239ad305f

License:

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

History

Date received : 29 June 2018

Date accepted : 31 August 2018

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Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes

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Telehealth & Medicine Today

Most cited references 15

The application of systems thinking in health: why use systems thinking?

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

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