There are over 250,000 individuals with spinal cord injuries and disorders (SCI/D) in the United States. There are approximately 42,000 Veterans with SCI/D, and at least half of those Veterans have utilized VA health care in recent years. The SCI/D system of care provides comprehensive, life-long services to Veterans with SCI/D through a "hub and spokes" system of care that includes 24 SCI Centers (hubs) and approximately 134 facilities (spokes) that have SCI primary care teams. Veterans with SCI/D frequently use health care to prevent and treat complications from their SCI/D, and for prevention and management of chronic diseases such as diabetes. Across VA, telehealth programs have been implemented to allow Veterans to access services in their home and at clinics or facilities that are closer to home than the nearest regional SCI Center. Clinical video telehealth (CVT) programs allow patients to communicate with providers in their home or between different healthcare facilities. Understanding the issues associated with implementing CVT in the spoke sites will provide the basis for future work to improve access to care for Veterans with SCI/D by enhancing implementation of CVT in the VA SCI/D system of care.
Our specific aims were to: (1) Characterize approaches to CVT use for providing services to Veterans with SCI/D at spoke sites; (2) Describe the best practices and challenges associated with implementing different models of CVT for Veterans with SCI/D; and (3) Identify potential strategies that could be used to enhance implementation.
In aims 1 and 2, we examined the range of factors that relate to the implementation of CVT to enhance care for Veterans with SCI/D. Semi-structured interviews were conducted with 40 VA SCI/D providers from VHA spoke sites (n=38) and Community Based Outpatient Clinics (CBOCs) (n=2). Interviews focused on barriers to implementing CVT for SCI/D management and strategies for enhancing its implementation. Interviews lasted approximately 60 minutes, were audio-recorded, and transcribed verbatim. Transcripts were coded using qualitative content analysis procedures.
Forty providers-including social workers (45%), nurses (28%), physicians (15%), advanced practice nurses (10%), and other (2%)-agreed to take part in the study. Based on the semi-structured interviews with providers, the top reported barriers to implementing CVT for Veterans with SCI/D included challenges with scheduling (n=17, 42.5%; e.g., coordinating CVT appointment time for multiple providers), equipment-related problems (n=16, 40%; e.g., equipment malfunctions, limited bandwidth), administrative aspects (n=13, 32.5%; e.g., difficulties in establishing telehealth service agreements), and patient preference (n=13, 32.5%; i.e., some patients prefer face-to-face appointments). Providers also discussed strategies to enhance implementation of CVT which included increasing capacity to respond to technical problems (n=16, 40%; e.g., having resources/channels to contact relevant staff in the event of equipment issues), improving coordination and completion of logistical details (n=13, 32.5%; i.e., planning ahead to ensure providers are available, camera is ready, etc.), and increasing involvement of patients in CVT process (n=10, 25%; e.g., educating patients to participate in care, reviewing goals of appointment, etc.). Moreover, providers indicated that there are advantages to utilizing CVT, including increased patient satisfaction. Providers reported that patients express a great deal of satisfaction with receiving care through CVT in part because of travel convenience (n=28, 70%) and better care coordination and access (n=23, 57.5%). Many providers also reported that the use of CVT promotes efficiency in coordinating care (n=16, 40%) such that CVT facilitates communication between providers and patients allowing for patient information to be shared and discussed in a timely manner. The physical limitations of CVT appointments (n=16, 40%) were one main disadvantage to using CVT reported by providers. Providers also commented that it is difficult to assess the condition of the patient using CVT, without the hands-on portion of the evaluation. Despite the challenges to using CVT, our analysis demonstrates that providers consider CVT an effective technology to increase access and to efficiently coordinate care for patients with SCI/D.
There is extensive evidence that supports the use of telehealth in VA to improve access to care and outcomes for Veterans. While there is not extensive literature examining outcomes of telehealth in the SCI/D population, there are clearly benefits, and VA has already devoted substantial resources to developing telehealth programs and emphasizing virtual care in SCI/D. The knowledge we gained from this project about the successes and challenges that spoke sites and CBOCs are experiencing while implementing CVT, and the strategies that providers are using to overcome these challenges, will be critical for developing and testing implementation strategies to increase use of CVT. To determine the practices that are most effective for increasing and enhancing telehealth use (aim 3), we will continue to work with our operational partners to develop and test strategies to enhance implementation of CVT.
- Stroupe KT, Martinez R, Hogan TP, Evans CT, Scholten J, Bidelspach D, Osteen C, Taylor BC, Smith BM. Health Care Utilization and Costs of Veterans Evaluated for Traumatic Brain Injury Through Telehealth. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2019 Dec 1; 25(12):1144-1153.
- Martinez RN, Hogan TP, Balbale S, Lones K, Goldstein B, Woo C, Smith BM. Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2017 Jul 1; 23(7):567-576.
- Martinez RM, Hogan TP, Lones K, Balbale SN, Goldstein B, Woo C, Smith BM. Enhancing Implementation of Telehealth for Veterans with Spinal Cord Injury and Disorders. Poster session presented at: Paralyzed Veterans of America Summit; 2016 Aug 30; Orlando, FL.
- Martinez RM, Smith BM, Hogan TP, Lones K, Balbale SN, Goldstein B, Woo C. Enhancing Implementation of Telehealth for Veterans with SCI/D. Presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD.
Treatment - Observational