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  • Significant Increase in Tel ehealth for Primary Care among Homeless Veterans Following the Pandemic
    This study sought to examine the extent to which homeless-experienced Veterans used tel ehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic tel ehealth use, Veterans experiencing homelessness sustained a high use of tel ehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High tel ehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, tel ehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that tel ehealth may address access disparities among these homeless-experienced patient groups.
    Date: January 22, 2024
  • Black Veterans with Chronic Pain Express Dissatisfaction with VA Tel ehealth Options during Pandemic
    This study sought to understand how Black Veterans with chronic pain experienced pandemic-related changes in VA healthcare delivery. Investigators conducted qualitative interviews with Black Veterans who had completed a randomized controlled trial of an intervention focused on communication and patient activation for Black patients with chronic pain. Findings showed that Veterans described mostly negative effects from the shift to telecare after the pandemic’s onset including: decreased ability to self-manage their chronic pain; difficulty obtaining non-pharmacological services such as physical therapy; difficulty seeing their primary care providers; and trouble scheduling surgery. Many Veterans said phone and video visits were inadequate to handle complaints related to their pain. Some Veterans were willing to accept the tradeoff of tel ehealth to avoid possible exposure to COVID-19, while others saw positive aspects to a virtual format.
    Date: November 14, 2022
  • VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Tel ehealth
    At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to tel ehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to tel ehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of tel ehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to tel ehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for tel ehealth prescribing of buprenorphine) could have major implications for patient care.
    Date: July 28, 2022
  • Characteristics of the Rise in Tel ehealth During COVID Pandemic
    This study sought to examine patient, provider, and site-level characteristics of any virtual and video-based care in primary care (PC). Findings showed that before the onset of COVID-19, only 14% of PC patients used any tel ehealth services, and only 0.3% used video-based care. However, during the first 12 months of COVID-19, 63% of patients used tel ehealth services, and 11% used video-based care. Veterans at community-based clinics had a higher percentage of any tel ehealth use (38%) compared to Veterans receiving primary care at the main medical facility (30%). Conversely, video use was lower among community-based PC patients (10%) compared to PC patients at the medical facility (13%). Social workers, nutritionists, and pharmacists had the highest percentage of tel ehealth use (54%, mostly telephone) compared to primary care providers (34%), whereas mental healthcare providers were more likely to provide video-based care (43%) compared to PC clinicians (15%). Among all age groups except the oldest (75+), women were more likely to use tel ehealth or video. Additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) vs video-based care (e.g., integrated mental health visits).
    Date: June 18, 2022
  • Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options
    This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-tel ehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized tel ehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-tel ehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-tel ehealth). The centralized VA-tel ehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-tel ehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-tel ehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-tel ehealth model than the VA traditional model. VA should assess structural barriers to using centralized tel ehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access.
    Date: April 11, 2022
  • Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior
    This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a suicide-related ED visit, and a 22% reduction in the likelihood of suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via tel ehealth and for preventing suicides among rural residents.
    Date: April 6, 2022
  • 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

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