Each week the monthly spotlight features a topic-related HSR&D study.
Spotlight on Telehealth Research
Telehealth is a way to provide healthcare via phone or computer; however, telehealth is more than just a substitute for a patient’s visit to a clinic—providers can also use telehealth technologies to work together to improve treatment and diagnosis. Within VA, there are several telehealth modalities in use, including:
- Clinical Video Telehealth—using real-time interactive video conferencing to assess, treat, and provide care to patients remotely.
- Home Telehealth—applying care and case management principles to coordinate care using health informatics, disease management, and technologies such as in-home and mobile-monitoring messaging and/or video technologies.
- Store and Forward Telehealth—using technologies to acquire and store clinical information (i.e., data, image, sound, and video) that is then forwarded to or retrieved by a provider at another location for clinical evaluation.
In 2016, VA provided care to more than 700,000 Veterans via these three telehealth services, with 45% of those Veterans living in rural areas. 
HSR&D conducts a variety of studies on telehealth, including: assessing how best to reach Veterans living in rural settings; demonstrating the impact of VA connected-care technologies on outcomes such as Veterans’ perceptions of access and experience of care; and developing and pilot-testing materials and procedures that facilitate medication assisted treatment delivery via telemedicine to Veterans at community-based outpatient clinics across the VA New England Healthcare System. The following are just a few of those completed and ongoing studies.
(Photo © iStock/agrobacter)
Impact: VA is a leader in telemedicine, however there are ways those capabilities can be better used to improve care for Veterans with poorly-controlled diabetes mellitus (PPDM). This study proposes an intervention that can be delivered using VA’s existing home-telehealth services and that may represent an effective, practical approach to reducing poor diabetes control and improving the health of Veterans with PPDM.
Overview. Despite receiving clinic-based care, approximately 12% of Veterans with type 2 diabetes have PPDM, which can put them at increased risk for health complications. (PPDM is defined as maintenance of a hemoglobin A1c [HbA1c] >8.5% for >1 year, despite receiving clinic-based diabetes care during that period.) Telemedicine-based management that addresses factors underlying PPDM could improve outcomes for these high-risk Veterans.
In this ongoing study, investigators are evaluating Practical Telemedicine to Improve Control and Engagement for Veterans with Clinic-Refractory Diabetes Mellitus (PRACTICE-DM)—a novel, comprehensive telemedicine intervention for PPDM that’s been designed for practical, feasible delivery within VA’s existing telemedicine infrastructure.
Investigators are recruiting 200 Veterans with PPDM from two sites (Durham, NC and Richmond, VA), who will be randomized to one of two home-telehealth interventions:
- PRACTICE-DM that combines telemonitoring, self-management support, diet/activity support, medication management, and depression support; or
- Standard home-telehealth care coordination and telemonitoring (active control).
Both interventions will be delivered over a 12-month period, and all participating Veterans will continue to receive usual VA care. Interviews will be conducted with 20 intervention-group Veterans, the home-telehealth nurses delivering the intervention, as well as administrators at each site. In addition, intervention costs will be assessed and compared to standard home-telehealth care coordination and telemonitoring. Primary outcome measures will be changes in HbA1c from study baseline to 12 months. The secondary measures will include diabetes self-care, diabetes burden, self-efficacy, and depressive symptoms.
Principal Investigator: Matthew Crowley, MD, is an investigator with HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation in Durham, NC.
(Photo © iStock/AndreyPopov)
Impact. VA's Office of Mental Health and Suicide Prevention (OMHSP) is strongly committed to ensuring that Veterans who obtain inpatient detoxification services receive substance use disorder (SUD) treatment post-discharge. Results from this study support that goal by leveraging telehealth interventions to increase Veterans' access to, engagement in, and benefit from SUD treatment services—particularly for Veterans using VA care who need SUD services but are not receiving them.
Overview. Every year, approximately 30,000 Veterans receive inpatient detoxification for substance use disorder. Detoxification is not SUD treatment—it is the medical management of withdrawal to prevent complications, which, in some cases, may be fatal. Detoxification inpatients who enter SUD treatment and peer-based mutual-help groups have been shown to have better outcomes—including less substance use, HIV/HCV risk behaviors, homelessness, rehospitalizations, and emergency Department visits—than those who do not. However, because of their unique characteristics (i.e., severe and chronic addictions, comorbidities, and lack of resources) most Veterans discharged from inpatient detoxification do not enter SUD treatment. For many Veterans, a pattern of repeated inpatient detoxification occurs, with each episode incurring higher risk of overdose.
In this study, investigators sought to implement and evaluate Enhanced Telephone Monitoring (ETM) to facilitate the transition from inpatient detoxification to SUD specialty treatment (residential, outpatient, and monitored pharmacotherapy) with the goal of improving Veterans’ health outcomes. Investigators conducted a randomized trial at VA Palo Alto and VA Boston, with 148 Veterans assigned to the intervention (ETM with an in-person session while in the detoxification program, followed by coaching over the telephone for three months after discharge) and 150 Veterans receiving usual care (UC). Usual care consisted of medically supervised withdrawal and a referral to or an appointment with addiction treatment services, if the patient chose to consider seeking treatment.
The ETM intervention incorporated two proven strategies: Motivational Interviewing, and Contracting, Prompting, and Reinforcing, (developed by Dr. Steven Lash in a series of HSR&D-funded studies.) ETM provided support while waiting for treatment, facilitated entry into treatment and mutual-help, and improved responses to crises. Patients were assessed at baseline and at 3- and 6-months post-discharge for outcomes, and to learn whether they had received non-VA healthcare.
Findings. Results showed that at the 3-month follow-up, ETM patients were significantly less likely to have received additional inpatient detoxification, but no more likely to have participated in 12-step groups or received outpatient addiction treatment than those in UC. However, ETM patients had better alcohol, drug, and mental health outcomes. At the 6-month follow-up, patients in ETM and UC generally did not differ on primary or secondary outcomes. Baseline demographic and clinical characteristics did not differ between Veterans assigned to either group.
These data suggest that ETM deters additional detoxification episodes while the intervention is ongoing, but not after the intervention ends. Because telephone monitoring is low-intensity and low-cost, its extension over time may help reduce repeated inpatient detoxification treatment.
Principal Investigator. Christine Timko, PhD, is an HSR&D Senior Research Career Scientist awardee with the HRS&D Center for Innovation to Implementation at the VA Palo Alto Healthcare System.
Publications. This study has resulted in the following publication:
Timko C, Below M, Vittorio L, et al. Randomized controlled trial of enhanced telephone monitoring with detoxification patients: Outcomes at 3- and 6-month follow-ups. Journal of Substance Abuse Treatment.
Cordasco KM, Zuchowski J, Hamilton AB, Kirsh S, Veet L, Saavedra JO, Knapp H, Washington DL. Early Lessons Learned in Implementing a Women's Health Educational and Virtual Consultation Program in VA. Med Care. 2015;53(4 Suppl 1):S88-92
(Photo ©iStock/AJ Wattamaniuk)
Impact. Results from this study have been used to guide the educational programming for gynecology patient-based education and virtual consultation, and have been presented to VA Women's Health Services to guide other designated women’s health provider (DWHP) educational initiatives. In addition, the quality measures developed have advanced the science of women Veterans’ healthcare by addressing complex aspects of care management.
Overview. Women Veterans are a rapidly growing proportion of VA patients. To address some of their unique healthcare issues, VA has implemented two women's health educational and virtual consultation programs, which comprise the DWHP Support initiative:
- Patient-based gynecology education and virtual consultation (GYN SCAN-ECHO); and
- Medical record-based interactive communication between DWHPs and gynecologists (gynecology electronic consultations, or e-consults).
Investigators assessed the effect of DWHP Support on the quality and efficiency of women's healthcare, and explored its impact in changing DWHP clinical practices and self-rated women's health knowledge, skills, and self-efficacy. Investigators also examined attitudes about DWHP support, its implementation, and other features that could influence effectiveness, sustainability and spread.
Findings. Designated Women's Health (WH) Providers’ attitudes about DWHP Support were positive. With respect to e-consults, all 32 e-consult interviewees reported having an overall positive experience with e-consults and identified benefits in patient care, including improving clinical efficiency and enhancing DWHPs' knowledge and care quality. Additional findings include:
- SCAN-ECHO participants found it useful for building and maintaining their women’s health knowledge. In post-session surveys, 90% of respondents indicated that the information provided would influence their patient care. However, interviews and study logs revealed that when sessions were conducted during lunch hour, it was a limiting factor for consistent participation. Interviews and key stakeholder discussions also revealed that the rotating specialists and topics across the breadth of women’s health limited submission of cases.
- Nine of 32 DWHP e-consult interviewees identified potential barriers or limitations to e-consults, including increased workload to implement recommendations from specialists.
- 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.
Investigators also measured the quality of care provided by DWHPs across four VA healthcare systems for primary care for abnormal uterine bleeding (AUB), menopause symptoms, contraception management, and urinary incontinence. Across conditions, quality was found to vary widely. VA primary care physicians (PCPs) have high guideline-adherence caring for post-menopausal women with AUB. Documentation of guideline adherence in care is lower for: pre-menopausal women with AUB, prescribing systemic hormone therapy for menopause symptom management, prescribing contraception in women with selected high-risk medical conditions, and managing urinary incontinence. For urinary incontinence care, community comparisons were available, and revealed that VA PCPs' adherence to published urinary incontinence care quality indicators was similar to the variation in urinary incontinence care quality seen in the community.
Principal Investigators. Donna L. Washington, MD, MPH, and Kristina M. Cordasco, MD, MPH, MSHS, are Core Investigators with the HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, in Los Angeles, CA.
Publications. This study has resulted in numerous publications and media, some of which include:
Zuchowski JL, Hamilton AB, Washington DL, Gomez AG, Veet L, Cordasco KM. Drivers of Continuing Education Learning Preferences for Veterans Affairs Women's Health Primary Care Providers. The Journal of Continuing Education in The Health Professions. 2017 Jan 1; 37(3):168-172.
HSR&D Podcast Series. Live from the Meeting. Measuring Quality of Care for Women Veterans.
Federal Briefing. VA's Research Efforts on Women Veterans. Panelist Briefing Response to "Women Veterans: The Journey Ahead," a Report from Disabled American Veterans (DAV). Briefing before the members and staffers of the US Congress; 2018 Sep 12.
Federal Briefing. Advances in Women Veterans Research. Briefing before the National Association of State Women Veteran Coordinators; 2018 Jun 25; Alexandria, VA.
(Photo © iStock/sturti)
Implications: This study addresses the need for culturally appropriate health information for an under-studied population—Spanish-speaking Hispanic caregivers—by providing education and support. The key long-term goal is to partner with leaders to implement a culturally relevant, accessible, and cost-effective intervention throughout VA for caregivers of Veterans post-stroke
Overview: Stroke is a major cause of disability and a leading cause of outpatient medical utilization within the VA healthcare system. Non-paid caregivers, particularly family members, are the major sources of support for stroke survivors. Previous research has found that family members, particularly Hispanics, have high rates of depression and burden when their stroke survivors return home. Providing caregivers with culturally-appropriate information, support, and skills has the potential to reduce negative caregiver outcomes and increase the likelihood that stroke survivors remain in the community. Unfortunately, no studies have focused on support interventions specifically for Hispanic caregivers. In this ongoing (2017–2021) study, investigators are testing the efficacy of a brief telephone and online problem-solving intervention using the Spanish version of the VA RESCUE (Resources & Education for Stroke Caregivers’ Understanding and Empowerment) website (RESCUE En Espanol) The objectives are to:
- Reduce caregiver burden and depression;
- Improve caregivers' problem-solving abilities, self-efficacy, and quality of life;
- Improve Veterans' functional abilities and determine the intervention's impact on Veterans' healthcare utilization;
- Determine budgetary impact; and
- Determine caregivers' perceptions of the intervention.
Study investigators will conduct a two-arm, randomized controlled clinical trial with 290 Hispanic stroke caregivers who will be randomly assigned to either an intervention or a standard care group. The intervention consists of a problem-solving intervention and information/tools on the previously developed, evidence-based Spanish version of the RESCUE stroke caregiver website to improve stroke caregiver outcomes. The intervention will be conducted via telephone by a trained healthcare professional. Baseline measurements will be conducted with the caregivers prior to the intervention. Post-test assessments will be collected at 1 and 12 weeks post-intervention. In addition, investigators will examine pre- and post-test measures of Veteran-related variables via electronic health records, and interviews will be conducted to assess caregivers' perceptions of the intervention. In addition, investigators will measure the budgetary impact of providing the RESCUE intervention by comparing the costs of the intervention group to the costs of the control group.
Principal Investigator: Ivette Magaly (Maggie) Freytes, PhD, MEd, is part of the North Florida/South Georgia Veterans Health System in Gainesville, FL.