December 2018

In This Issue: Advances in Telehealth
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Telehealth Collaborative Care for Veterans with HIV Living in Rural Settings

Feature Article

VA is the largest provider of care for persons with HIV in the U.S., with more than 26,000 Veterans in care. Historically, VA care for Veterans with HIV takes place in infectious diseases specialty clinics. This specialty-centered model has provided high-quality HIV care, but does not provide accessible care for Veterans with HIV in rural and out-lying urban areas. The telehealth collaborative care (TCC) model seeks to improve access for these Veterans.

TCC is a shared-care model that integrates HIV specialty care delivered by clinical video telehealth with primary care by teams in VA clinics serving rural and outlying areas. In addition to using clinical video telehealth to deliver HIV specialty care, TCC includes processes to improve care coordination between specialty and primary care teams, as well as the use of a registry to promote population management across sites. As part of its Rural Promising Practices initiative, VA’s Office of Rural Health (ORH) is currently supporting expansion of the TCC model as a quality improvement initiative in four VA facilities. This provides an opportunity to evaluate the impact of TCC on clinical outcomes and healthcare utilization. 

This ongoing (2016–2019) HSR&D study is evaluating the TCC quality improvement initiatives to determine their effectiveness – and the influence of TCC on VA healthcare use. The evaluation includes 1,686 Veterans who are in care for HIV infection in the Dallas, Houston, San Antonio, and Atlanta VA medical centers, and who live nearer to one of 28 primary care clinics than to an HIV clinic. Due to limited capacity to establish TCC in all primary care clinics simultaneously through local quality improvement initiatives, clinics were randomly assigned to establish TCC during the first-year vs. second-year of the ORH initiative. Measures of clinical effectiveness and healthcare utilization are being compared between TCC and usual care during the first year using VA data that are routinely gathered during care.

Findings:

Preliminary findings suggest a relationship between geographic access to care (i.e., travel time to HIV specialty clinic) and retention in care (defined as at least two visits in one year, at least 60 days apart) in the year prior to telehealth implementation. Results show retention in care at:

• 86% among Veterans with less than a 1-hour drive to a clinic;
• 58% for Veterans with 1-2 hours of travel time to a clinic, and
• 54% for Veterans with more than 2 hours of travel time.

In the first year of the intervention, 120 of 925 (13%) Veterans living in the service area of a telehealth clinic had at least one telehealth visit. Telehealth use increased with increasing travel time saved: 8% among those saving less than 30 minutes of travel time vs. 26% among those saving more than 60 minutes of travel time.

Analyses are ongoing to determine the impact of TCC on retention in care and HIV viral suppression in a cluster-randomized program evaluation.

Impact:
Understanding the impact of telehealth collaborative care on clinical outcomes and healthcare utilization will inform future policies regarding broader implementation of the TCC model both within and outside VA. 

Principal Investigator: Michael Ohl, MD, MSPH, is an investigator with HSR&D’s Center for Access & Delivery Research and Evaluation in Iowa City, IA.

Publications: None at this time.

View project abstract.