Improving Access to Care through Telehealth
Telehealth uses electronic communications to exchange medical information from one site to another. Some of the services that can be provided via telehealth can include the use of live interactive video or the store-and-forward transmission of diagnostic images, vital signs, and/or other patient data important for diagnosis and treatment. Telehealth can also apply to remote patient monitoring that utilizes devices that remotely collect and send data to a home health agency or a remote diagnostic testing facility for interpretation.
VA Telehealth Services uses health informatics, disease management and telehealth technologies to target care and improve access to care for all Veterans. VA telehealth helps to ensure that Veterans get the right care in the right place at the right time - and aims to make the home the preferred place of care, whenever possible. Some examples of VA telehealth include:
- TeleMental Health is the delivery of services using virtual linkages between VA patients and mental healthcare providers separated by distance or time.
- TeleRehabilitation includes services such as using video teleconferencing to link a speech pathologist located at an urban VAMC with a post-stroke Veteran located at a local VA community-based outpatient clinic.
- TeleSurgery can aid in the diagnosis of surgical conditions, as well as the coordination of care and triage of surgical patients that can be enhanced by telesurgical consultation. TeleSurgery also can provide intra-operative consultation, patient and staff education, in in addition to pre-and post-operative assessment.
VA continues to add new telehealth specialties, including TeleCardiology, TeleGenomics, and TeleNeurology, to name a few.
HSR&D Research on Telehealth
Following are just some of the research studies HSR&D funds to help improve telehealth services for Veterans.
Psychotherapy for Depression in Older Veterans via Telemedicine: A Randomized Trial
Depression is especially problematic for Veterans, with substantial depressive symptoms 2 to 5 times more likely than in their civilian counterparts. Cognitive behavioral therapies are the most recommended forms of psychotherapy for depression, but older Veterans can experience barriers to receiving care, such as mobility issues and living in rural areas. Telemedicine could increase access to evidence-based care for older Veterans; thus, this randomized study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Between April 2007 and July 2011, Veterans (n=241) aged >58 were recruited from the VA medical center and four associated community-based outpatient centers in Charleston, SC, and then were randomly assigned to either telemedicine or same-room psychotherapy. The primary outcome was treatment response: 50% reduction in symptoms from baseline to 12 months and no longer being diagnosed with major depressive disorder at 12 months, depending on the instrument used. Findings show:
- Telemedicine-delivered psychotherapy for older Veterans with major depression produced outcomes that were no worse than in-person treatment delivery.
- Treatment response did not differ significantly between the telemedicine and same-room therapy groups on any of the instruments used (i.e., Geriatric Depression Scale, Beck Depression Scale, or Structured Clinical Interviews for DSM-IV).
Implications: This study represents a timely and significant addition to the field, as it provides novel results to inform implementation of evidence-based mental health treatment (Hoge & Rye, 2015). Findings suggest that home-based telemedicine can be used to overcome barriers to care associated with distance from - and difficulty with attendance at in-person sessions. Investigators suggest that resources be devoted to offering services directly into patients' homes via telemedicine methods.
Principal Investigator: Leonard Egede, MD, MS, is Director of HSR&D's Charleston Health Equity and Rural Outcomes Innovation Center (HEROIC) in Charleston, SC.
Egede L, Acierno R, Knapp R, et al. Psychotherapy for depression in older Veterans via telemedicine: A randomized, open-Label, non-inferiority trial. Lancet Psychiatry.August 2015;2(8):693-701.
Tele-Support for Women's Healthcare in VA Community-Based Outpatient Clinics
Women Veterans are a rapidly growing proportion of VA patients. To address some of their unique healthcare issues, VA is implementing two innovations:
- Gynecology serial patient-based education and virtual consultation (GYN SCAN-ECHO), and
- Medical record-based interactive communication between Designated Women's Health Providers (DWHPs) and gynecologists (gynecology electronic consultations [e-consults]).
Combined, this women's health educational and virtual consultation program is referred to as "DWHP Support."
This ongoing HSR&D funded study is assessing the effect of DWHP Support on the quality and efficiency of women's healthcare by exploring its impact in changing DWHP clinical practices and self-rated women's health knowledge, skills, and self-efficacy. Investigators also are examining attitudes about DWHP support, its implementation, and other features that could influence effectiveness, sustainability and spread. Thus far, findings show:
- Among 32 DWHPs surveyed, all reported having an overall positive experience with e-consults, and identified benefits in patient care, including improved clinical efficiency and enhanced knowledge and quality of care.
- Nine of 32 DWHPs identified potential barriers or limitations to e-consults, including increased workload to implement recommendations from specialists.
- Among eighteen DWHPs who participated in baseline interviews, all reported finding the women's health SCAN-ECHO program to be useful for building and maintaining women's health knowledge.
- DWHPs expressed relatively greater interest in learning about topics related to conditions they more frequently encountered in their clinics, or that they anticipated seeing more frequently in the future. They were relatively less interested in learning about topics for conditions that they perceived as being less appropriate for patients in primary care.
Implications: Findings from this study have already impacted clinical operations by leading to its focus on GYN SCAN-ECHO - and by securing protected time for participating DWHPs. Investigators also anticipate that this study will inform the ongoing development of DWHP Support and other VA WH educational/clinical innovations. Moreover, findings on DWHP Support's effectiveness and implementation will influence VA's approach and use of technology-supported interventions for other clinical conditions and special populations.
Principal Investigator: Donna L. Washington, MD, MPH, and Co-principal investigator, Kristina M. Cordasco, MD, MPH, MSHS, HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA.
Cordasco K, Zuchowski J, Hamilton A, et al. Early lessons learned in implementing a women's health educational and virtual consultation program in VA. Medical Care. April 1, 2015;53(4 Suppl 1):S88-92.
TeleMonitoring to Improve Substance Use Disorder Treatment after Detoxification
Annually, about 30,000 Veterans receive inpatient detoxification (detox) for substance use disorders (SUDs). Detox inpatients who enter SUD treatment and peer-based mutual-help groups (e.g., Alcoholics Anonymous) have much better outcomes than those who do not, including less substance use, re-hospitalizations, and emergency department visits. However, because of their unique characteristics (severe and chronic addictions, comorbidities, lack of resources, self- and provider-perceptions as unsuitable for treatment), most Veterans discharged from inpatient detox do not enter SUD treatment. Therefore, the primary objective of this HSR&D ongoing study is to implement and evaluate Enhanced Telephone Monitoring (ETM) as a new and innovative telehealth intervention to facilitate the transition from inpatient detox to SUD specialty treatment (residential, outpatient, pharmacotherapy), thereby improving Veterans' outcomes and decreasing VA healthcare costs.
In a randomized trial at two sites (VA Palo Alto and VA Boston), Veterans with substance use disorder receiving ETM will be compared to Veterans with SUD in usual care. Patients in the ETM condition are receiving an in-person session while in detox, followed by coaching over the telephone for three months after discharge. The intervention incorporates motivational interviewing as well as reinforcement to provide support for Veterans while they wait for treatment. The intervention also facilitates entry into treatment and mutual-help, and improves responses to crises. Veterans are assessed at baseline, and three and six months post-discharge for outcomes.
Implications: Telehealth interventions have not yet been used to help inpatients going through detoxification. Therefore, this project will help increase Veterans' access to, engagement in, and benefit from SUD treatment services, particularly among Veterans who need SUD services but are not receiving them.
Principal Investigator: Christine Timko, PhD, HSR&D's Center for Innovation to Implementation (Ci2i): Fostering High-Value Care, Palo Alto, CA.
Telemedicine Management of PTSD and Chronic Insomnia for Veterans with PTSD
Most Veterans with post-traumatic stress disorder (PTSD) experience chronic insomnia that has independent, negative effects on quality of life and may exacerbate other symptoms of PTSD. Cognitive behavioral therapy for insomnia (CBT-I) is highly effective in patients with primary insomnia, but the lack of clinicians trained in CBT-I limits Veterans' access to this treatment. Video teleconferencing holds the promise of increasing access to care for Veterans living in rural and remote areas. This ongoing HSR&D study is evaluating the delivery of CBT-I to groups of Veterans with PTSD and chronic insomnia via video teleconferencing. Specifically, investigators will:
- Determine if CBT-I administered by video teleconferencing is not clinically inferior to in-person treatment in terms of improving insomnia symptoms;
- Compare the differences in cost and quality-adjusted life years between the treatment delivery approaches;
- Determine the effectiveness of CBT-I on functional outcomes, sleep quality, and non-sleep-related PTSD symptoms; and
- Conduct a patient- and provider-focused formative evaluation of CBT-I delivery by video teleconferencing to assess potential barriers to its widespread implementation.
Veterans with PTSD and chronic insomnia who receive their primary care at community-based outpatient clinics (CBOC) affiliated with the Philadelphia VAMC are being randomized to receive one of the following interventions in a group setting at their CBOC: 1) manual-based CBT-I program delivered via video teleconferencing; 2) CBT-I program delivered in-person; and 3) in-person delivery of sleep hygiene education, a known active control intervention. Study participants are being assessed at baseline, and two weeks and every three months following the intervention. Thus far, investigators have completed participant enrollment, and data collection is expected to be completed by October 31, 2016.
Implications: Study findings are expected to provide the evidence needed to justify clinical implementation of this telemedicine model for CBT-I delivery to Veterans with PTSD. This will significantly increase access to treatment, particularly for Veterans residing in remote and rural settings, and also will decrease treatment-related costs.
Principal Investigator: Sam Kuna, MD, HSR&D's Center for Health Equity Research & Promotion (CHERP), Philadelphia, PA.
Telemedicine Intervention to Improve Functioning for Veterans with Parkinson's Disease
Parkinson's disease (PD) is the second most common neurodegenerative disease, affecting more than one million Americans. The principal clinical manifestations of PD are motoric, which limits functional mobility leading to difficulty working, caring for family members, or managing a household - and to overall decreased independence and quality of life. Increasing data indicate tremendous benefits of exercise for patients with PD. Not only have exercise programs been shown to improve motor function and reduce the risk of falls, but they also improve overall quality of life and possibly the course of disease pathology. However, programs that involve supervision in the home of people with PD are expensive to roll out widely, and programs that involve people with PD traveling to a central site not only result in non-compliance over time because of difficulty getting to the site, but also rule out the involvement of a large number of people with PD who simply live too far from larger centers where such programs are typically established.
The goal of this ongoing HSR&D study is to evaluate the effectiveness of a home-based approach to providing the known benefits of a safe exercise program for Veterans with PD. This randomized controlled trial of a structured exercise program will examine the effects on fall rates, physical functioning, and quality of life. Community-dwelling Veterans with PD will be randomized either to a group who receives structured and remote exercise instruction and supervision in real-time, or a group who receives an educational healthy lifestyle program. The interventions will last one year.
Implications: Study findings will help make effective exercise programs available to the many Veterans with Parkinson's disease who are currently unable to participate in such programs due to distance from a facility providing such a program, or limited functional mobility making travel to a facility-based program difficult.
Principal Investigator: Daniel Sparrow, DSc, is part of the VA Boston Healthcare System.
Mood Management and Telephone-Based Smoking Cessation in Primary Care
Many patients with chronic medical illnesses continue to smoke, and there is a strong interrelationship between depression and chronic medical illness. Depression can derail sustained smoking cessation and may be an important barrier to smoking cessation for Veterans with chronic medical illness; thus, depressed smokers are more likely to quit when behavioral mood-management is added to traditional cessation approaches. Telephone counseling can deliver intensive and effective treatment to people who smoke, yet its implementation has been limited among smokers with depression. The aims of this ongoing HSR&D study are to:
- Evaluate the impact of a telephone-delivered smoking cessation intervention augmented with behavioral mood management on rates of smoking abstinence among Veterans with chronic medical illnesses and depression;
- Monitor the impact of a behavioral mood management intervention on depressive symptoms;
- Assess whether change in self-efficacy, positive and negative affect, and motivation to quit mediate the impact of the mood-enhanced intervention on smoking cessation; and
- Examine the cost-effectiveness of the mood-enhanced intervention.
Using VA data, investigators will identify Veterans with chronic disease who receive treatment at the Durham VA Medical Center, and who were screened for tobacco use and depressive symptoms. The main outcome they will examine is prolonged smoking abstinence at 6-month and 12-month follow-up. If there is a significant intervention effect on smoking cessation, further analysis will be conducted to assess whether changes in self-efficacy, affect, and motivation to quit mediate the impact of the mood management intervention.
Implications: By studying the impact of mood enhancement on Veterans who smoke and have depression, along with chronic disease, VA may better understand how to sustain abstinence from smoking among patients in this group.
Principal Investigator: Jennifer Gierisch, PhD, is part of HSR&D's Center for Health Services Research in Primary Care in Durham, NC.