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Research Highlight

Providing Care Closer to Home: The Role of Virtual Points of Access

Ensuring access to health care has been a VA focus and is highlighted in the work of HSR&D through its measurement and interventions to improve access. Fortney, et al. expanded upon the traditional definition of access to "represent the potential ease of having virtual or face-toface interactions with a broad array of health care providers including clinicians, caregivers, peers, and computer applications." ¹ This new definition further describes actual access (i.e., directly observable and objectively measurable dimensions) and perceived access (i.e., selfreported and subjective dimensions). Fortney et al. demonstrate that, in fact, geographic distance is just one of many barriers that prevent Veterans from getting the care they need. Though VA providers have a broad array of telehealth technologies at their fingertips, care for Veterans with complex chronic conditions requires innovative applications of these tools, for considerable barriers to care remain. The technology used—be it clinical video telehealth (CVT), home monitoring, or mobile devices—needs to match the clinical need. Whatever technology selected, the innovation must also address cultural, workflow, workload, and policy issues that affect access.

Three Telehealth Innovations

We will describe three examples of telehealth innovations that take a comprehensive approach to overcoming barriers to access, and where technology is just one component of the intervention. These projects, funded through collaborations between the VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, and the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, all address identified disparities in access to care for rural Veterans, but can be applied to other populations with access barriers.

The first example overcomes an often under-recognized form of access for rural Veterans: availability of multidisciplinary treatment team approaches to complex chronic illnesses. Ohl et al. have expanded upon standard single provider CVT use to create a Telehealth Collaborative Care (TCC) model that provides access to team-based consultation for rural Veterans with HIV. ² TCC integrates team-based HIV specialty care delivered in Community Based Outpatient Clinics (CBOCs) using CVT with primary care delivered by local Patient Aligned Care Teams (PACTs). Preliminary studies at the Iowa City VA indicate that TCC is well-accepted by Veterans and PACTs and it maintains previously-existing high quality HIV care. Planned studies will evaluate factors influencing spread of TCC serving rural Veterans with HIV.

The second example addresses improving access for rural Veterans through greater VA collaboration with local non-VA health systems. A team headed by Carolyn Turvey established a campus-based tele-mental health clinic at Western Illinois University (WIU) in Macomb, IL through extensive negotiation between the Iowa City VA Mental Health Service Line and Student Health Services at WIU. Now, Veterans making use of their military benefit to pursue a college degree can receive expert care for service-related mental health issues directly from VA providers using CVT.

Finally, a novel home-based cardiac rehabilitation program developed by Bonnie Wakefield provides Phase 2 cardiac rehabilitation in the home of eligible Veterans.³ Only 25 percent of VA hospitals provide cardiac rehabilitation onsite. Thus, most Veterans who receive cardiac rehabilitation are enrolled in community-based programs through non-VA care. To provide an alternative, the team developed a home program that uses two forms of telehealth. The first uses the most basic modality, the telephone, to engage patients in weekly sessions covering important topics such as activity, diet, and stress management. The second utilizes CVT to enroll patients from CBOCs. In this program, Veterans are offered the option of a home-based or center-based program. Not only does the majority choose the home program, but completion rates are higher. This intervention goes beyond standard homebased symptom monitoring and actually conducts a much needed clinical service right in the Veteran's home.

Lessons Learned

The unifying principle of all these programs is the desire to bring a broad range of health care services closer to Veterans' homes, improving the convenience of these services and thus, improving compliance. Although all three examples were ultimately successful, each was accompanied by significant implementation barriers that are common across VA: workflow barriers to multidisciplinary care, administrative barriers to closer collaboration with non-VA providers, health information technology issues, hiring of personnel, and under-recognition of the value of actual care delivery closer to home.

Though the ever-expanding availability of sophisticated communication technologies is dazzling, implementing the technology was the easiest aspect of the three interventions described. Rethinking clinical roles, optimal site of care, and the role of VA within the larger health care system was far more challenging.

References

1. Fortney, J. et al. "A Re-conceptualization of Access for 21st Century Healthcare," Journal of General Internal Medicine 2011; 26(Suppl 2):639-47.
2. Ohl, M. 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 2013; 28(9):1165-73.
3. Wakefield, B. et al. "Feasibility and Effectiveness of Remote, Telephone-based Delivery of Cardiac Rehabilitation," Telemedicine Journal and e-health: The Official Journal of the American Telemedicine Association 2014; 20(1):32-8.