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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.
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
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.
- Fortney, J. et al. "A Re-conceptualization of Access
for 21st Century Healthcare," Journal of General Internal
Medicine 2011; 26(Suppl 2):639-47.
- 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.
- 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.