Spotlight: Telehealth Improves Access to Care for Veterans with Hepatitis C or HIV Infection
The VA healthcare system maintains an extensive network of infectious disease and hepatology specialty clinics that deliver state-of-the-art care for Veterans with HIV or hepatitis C infection, but rural-dwelling Veterans often have inadequate access to these specialty clinics. To address this gap in access, VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (HH-QUERI) investigators have recently developed and evaluated care delivery models that employ clinical video telehealth (CVT) to improve access to specialty care for rural Veterans with HIV or hepatitis C.
In this QUERI study, Dr. Benjamin Sun and colleagues at the VA Greater Los Angeles Healthcare System evaluated the use of CVT to deliver HIV or hepatitis C specialty care for 43 Veterans in the Santa Maria and Bakersfield clinics, which serve rural areas and are more than a 100 mile drive from the nearest VA specialty clinic.1 Study findings show that CVT improved access to specialty care, as reflected by an increase in visit completion rates for scheduled specialty clinic encounters â€“ from 61% for in-person visits in specialty clinics prior to the telehealth program to 76% for CVT visits. After adjusting for patient characteristics, study results showed that care by CVT was strongly associated with visit completion. More than 95% of Veterans rated CVT visits at the highest level of satisfaction and preferred CVT over in-person visits. Due largely to less travel time, Veterans reported a substantial decrease in time devoted to clinic visits with CVT compared to in-person visits in specialty clinics, with a median decrease of 340 minutes.
In a separate study supported by the VA Office of Rural Health, Dr. Michael Ohl, a member of HH-QUERI's Executive Committee and an expert indelivering HIV care in rural settings, along with colleagues at the Iowa City VA Health Care System evaluated an innovative care delivery model for rural Veterans with HIV.2 This model integrated HIV specialty care delivered by CVT with onsite primary care delivered by PACTs in eight VA outpatient clinics serving rural areas. As rural Veterans with HIV grow older and accumulate multiple interacting chronic conditions, it will be necessary not only to improve access to HIV specialty care, but also to ensure that they receive comprehensive and coordinated primary care closer to their homes. Key principles guiding development of the "Telehealth Collaborative Care" program were:
- Clear delineation of specialty care and primary care-PACT roles in co-managed care;
- Creation of defined processes to coordinate specialty care delivered by CVT with primary care by PACTs (e.g., "telehealth care coordination huddles" during CVT visits that involved the Veteran, PACT nurse care manager, and HIV clinic nurse care manager and assigned care tasks for follow up), and
- Use of a patient registry for population management across sites.
Results of this study showed that 30 of 32 Veterans who lived closer to a CBOC than the HIV specialty clinic chose CVT and collaborative care over traveling to the specialty clinic, and 88% reported that they were very or completely satisfied with care. An analysis of interviews with Veterans also identified several factors that enabled their participation in telehealth collaborative care, and that will influence wider implementation of this model. Interview themes included the need for attention to Veterans' concerns about privacy and HIV stigma in rural care sites when designing the telehealth collaborative care program, and Veterans' preferences for involvement of the HIV specialty care team and PACT in specific care tasks.
Together, these projects demonstrate that CVT improves access to specialty care, and that Veterans are highly satisfied with care via telehealth. Importantly, these studies also developed practices for implementing CVT that used existing resources only, which are widely available in VA. Moreover,investigators developed approaches for integrating specialty care delivered by CVT with primary care delivered by local Patient Aligned Care Teams (PACTs) in rural VA clinics.
HH-QUERI is committed to promoting the spread of these models to improve access to specialty care for rural Veterans with HIV or hepatitis C, without compromising the high quality of specialty care that currently exists in VA.
- Saifu H, Asch S, Goetz M, et al. Evaluation of human immunodeficiency virus and hepatitis C telemedicine clinics. American Journal of Managed Care 2012;18(4):207-12.
- Ohl M, Moeckli J, Ono S., et al. Mixed methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Journal of General Internal Medicine March 9, 2013; Epub ahead of print.