2023 HSR&D/QUERI National Conference

1022 — The VA national teleneurology program (NTNP): Implementing telehealth care to improve access to outpatient neurologists

Lead/Presenter: Linda Williams,  COIN - Indianapolis
All Authors: Williams LS (EXTEND QUERI, Indianapolis COIN), Damush, TD (EXTEND QUERI, Indianapolis COIN) Miech, E (EXTEND QUERI, Indianapolis COIN) Martin H (EXTEND QUERI, Regenstrief Institute) Bastin G (EXTEND QUERI) Yang, Z (Indiana University School of Medicine, Dept of Biostatistics) Daggy J (Indiana University School of Medicine, Dept of Biostatistics) Narechcania A (NTNP, Jesse Brown VAMC) Wilkinson J (NTNP, Corporal Michael J. Crescenz VAMC)

VHA has focused on increasing the use of telehealth to improve access to specialty care, especially for rurally-residing Veterans. The National Teleneurology Program (NTNP) was developed as the first national outpatient Teleneurology program to address these critical gaps; we sought to conduct a robust evaluation of the impact of implementing the NTNP.

The NTNP was designed as a virtual cohort of general neurology providers who leverage existing VHA telehealth modalities (in-home and in-clinic) and shared electronic health records to provide outpatient consultative and follow-up services. Partnerships with VHA facilities and their associated community-based outpatient clinics were established with a focus on sites with low neurology access and high rurality. Implementation strategies used included a pre-implementation checklist, kickoff calls with facility teams, and weekly check-in meetings pre-implementation. Post-implementation, monthly check-ins with data feedback and scheduling assistance was provided. Evaluation of the NTNP implementation used the RE-AIM framework and included: 1) comparison of consult scheduling and completion times between NTNP and community care neurology using a Wilcoxon-Mann-Whitney test, 2) assessment of Veteran and referring provider satisfaction, 3) three-month post-implementation interviews with participating facility practice managers, telehealth clinic leadership, schedulers, and referring providers, and 4) a generalized linear mixed model of the change in monthly community care neurology (CCN) consultation rates from pre- to post-implementation in NTNP sites (12) compared to similar non-NTNP VA sites (7).

In FY21, the program began with 7 neurologists providing 3.75 FTEE at 12 VAMCs. Of 1481 new patient consults placed, 1128 (76.2%) were completed in FY21 or scheduled for completion in early FY22; 55.2% of these were for Veterans classified as rurally residing. The most common provisional diagnosis categories were headache (24% of consults) movement disorders (15%), and neurologic symptoms (15%). NTNP was significantly faster than CCN to schedule (mean 9.7 vs. 27.4 days, p < 0.001) and complete consults (mean 45.0 vs. 97.2 days, p < 0.001). Veterans (N = 259) were highly satisfied (7-point scale) with mean (SD) overall satisfaction score 6.3 (1.2) and likelihood of recommending NTNP score of 6.3 (1.3). Referring providers (N = 130) were also highly satisfied (10-point scale), with mean (SD) overall satisfaction 9.0 (1.6). Site staff reported that NTNP coordination of start-up activities were facilitators to implementation; a common barrier was difficulty with use of the telehealth scheduling system; this was addressed with an adaptation of adding an NTNP staff member to assist sites. The mean number of CCN consults per month decreased more in NTNP than control sites: 31.6% from pre- to post-implementation in NTNP sites (39.6 to 27.1 per month) and 21.4% in control sites (52.0 to 40.9 per month); modeling this change is ongoing.

National implementation of Teleneurology is feasible and improves timeliness of outpatient neurology care while maintaining high Veteran and provider satisfaction. Strategies focusing on pre-implementation coordination and assistance with scheduling were key to successful implementation. Ongoing modeling will provide information about the overall impact of NTNP implementation on monthly CCN consultation rates.

Implementation of the NTNP improved neurology access and may reduce rates of CCN consultation.