- Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs
This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Findings showed that offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, tel
ehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account. There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired. Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services.
Date: June 18, 2021
- VA/HSR&D Research on Complementary and Integrative Health Therapies within VA
Funded by HSR&D, this special issue of Medical Care highlights how research on complementary and integrative health (CIH) therapies in the VA healthcare system has progressed along the QUERI (Quality Enhancement Research Initiative) Implementation Roadmap – from pre-implementation to implementation to sustainment. CIH approaches are becoming more available throughout VA, due to: 1) increased implementation of the Whole Health System of Care, which integrates allopathic and CIH care; and 2) development of the infrastructure for CIH implementation, which includes new standards for hiring CIH providers, the involvement of volunteers who teach CIH, and development of policy and guidance for providing CIH at VAMCs, via tel
ehealth, and/or in the community. Conducting pre-implementation, implementation, and sustainment phases of research on CIH approaches in VA is yet another way to boost the scale-up and spread of these therapies to reach as many Veterans as possible.
Date: September 1, 2020
- Veterans Participating in a VA National Tel
ehealth Tablet Initiative Save Both Time and Money
In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, and/or social access barriers to in-person care so that they could receive services in their homes or other convenient locations. As part of a national evaluation of this initiative, a patient experience survey was conducted with a subset of tablet recipients. Investigators in this study sought to determine patient-reported monetary and time savings, as well as characteristics associated with those savings. Findings showed that 92% of respondents reported that the tablets saved them money or time; 89% reported saving money, and 71% reported saving time. Among those who reported monetary savings, 41% reported saving $25-50 and 31% reported saving >$50 per appointment. Monetary savings were most pronounced among Veterans living a greater distance from VA or experiencing travel barriers and those without mental health conditions.
Date: December 26, 2019
- Video Tel
ehealth Tablet Initiative Improves Access to and Continuity of Mental Healthcare for Veterans
In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national dissemination of tablets. Findings showed that distributing the tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to the control group, tablet recipients experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months post-tablet receipt.
Date: August 5, 2019
- Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers
This study examined the potential impacts of reforms to improve access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop tel
ehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers.
Date: May 29, 2018
- Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes
Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Tel
ehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Tel
ehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA.
Date: November 5, 2015
- Changes in VA Care since PACT Implementation
This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using tel
ehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11.
Date: July 10, 2013
- Prediction Model Using VA Data May Help Identify Primary Care Patients at Increased Risk for Hospitalization or Death
In an attempt to identify high-risk patients, investigators in this study developed statistical models using health information from VA’s clinical and administrative databases to predict the risk of hospitalization or death among all Veterans who were assigned to a primary care provider as of 10/1/10. Findings showed that prediction models using electronic clinical data accurately identified Veterans receiving VA primary care who were at increased risk of hospitalization or death. Of the top 5% of Veterans in terms of predicted risk, 51% were hospitalized or died within the following year. Predictors of death were quite different from predictors of hospitalization. In general, clinical and demographic characteristics (i.e., increasing age, metastatic cancer) were most predictive of death, while recent use of health services was most predictive of hospitalization. The authors suggest that in clinical settings, these values can be used to identify high-risk patients who might benefit from care coordination and special management programs, such as intensive case management, tel
ehealth, home care, specialized clinics, and palliative care.
Date: April 1, 2013
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including:
eHealth technologies (e.g., Care Coordination Home Tel
ehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Long-Term Impact of Home Tel
ehealth on Preventable Hospitalizations for Veterans with Diabetes
This study assessed the longitudinal effect of a VA Care Coordination Home Tel
ehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
Date: October 1, 2009