1022 — The VA national teleneurology program (NTNP): Implementing telehealth care to improve access to outpatient neurologists

Lead/Presenter: Linda Williams,  COIN - Indianapolis
All Authors: Williams LS (EXTEND QUERI, Indianapolis COIN), Damush, TD (EXTEND QUERI, Indianapolis COIN) Miech, E (EXTEND QUERI, Indianapolis COIN) Martin H (EXTEND QUERI, Regenstrief Institute) Bastin G (EXTEND QUERI) Yang, Z (Indiana University School of Medicine, Dept of Biostatistics) Daggy J (Indiana University School of Medicine, Dept of Biostatistics) Narechcania A (NTNP, Jesse Brown VAMC) Wilkinson J (NTNP, Corporal Michael J. Crescenz VAMC)

Objectives:
VHA has focused on increasing the use of telehealth to improve access to specialty care, especially for rurally-residing Veterans. The National Teleneurology Program (NTNP) was developed as the first national outpatient Teleneurology program to address these critical gaps; we sought to conduct a robust evaluation of the impact of implementing the NTNP.

Methods:
The NTNP was designed as a virtual cohort of general neurology providers who leverage existing VHA telehealth modalities (in-home and in-clinic) and shared electronic health records to provide outpatient consultative and follow-up services. Partnerships with VHA facilities and their associated community-based outpatient clinics were established with a focus on sites with low neurology access and high rurality. Implementation strategies used included a pre-implementation checklist, kickoff calls with facility teams, and weekly check-in meetings pre-implementation. Post-implementation, monthly check-ins with data feedback and scheduling assistance was provided. Evaluation of the NTNP implementation used the RE-AIM framework and included: 1) comparison of consult scheduling and completion times between NTNP and community care neurology using a Wilcoxon-Mann-Whitney test, 2) assessment of Veteran and referring provider satisfaction, 3) three-month post-implementation interviews with participating facility practice managers, telehealth clinic leadership, schedulers, and referring providers, and 4) a generalized linear mixed model of the change in monthly community care neurology (CCN) consultation rates from pre- to post-implementation in NTNP sites (12) compared to similar non-NTNP VA sites (7).

Results:
In FY21, the program began with 7 neurologists providing 3.75 FTEE at 12 VAMCs. Of 1481 new patient consults placed, 1128 (76.2%) were completed in FY21 or scheduled for completion in early FY22; 55.2% of these were for Veterans classified as rurally residing. The most common provisional diagnosis categories were headache (24% of consults) movement disorders (15%), and neurologic symptoms (15%). NTNP was significantly faster than CCN to schedule (mean 9.7 vs. 27.4 days, p < 0.001) and complete consults (mean 45.0 vs. 97.2 days, p < 0.001). Veterans (N = 259) were highly satisfied (7-point scale) with mean (SD) overall satisfaction score 6.3 (1.2) and likelihood of recommending NTNP score of 6.3 (1.3). Referring providers (N = 130) were also highly satisfied (10-point scale), with mean (SD) overall satisfaction 9.0 (1.6). Site staff reported that NTNP coordination of start-up activities were facilitators to implementation; a common barrier was difficulty with use of the telehealth scheduling system; this was addressed with an adaptation of adding an NTNP staff member to assist sites. The mean number of CCN consults per month decreased more in NTNP than control sites: 31.6% from pre- to post-implementation in NTNP sites (39.6 to 27.1 per month) and 21.4% in control sites (52.0 to 40.9 per month); modeling this change is ongoing.

Implications:
National implementation of Teleneurology is feasible and improves timeliness of outpatient neurology care while maintaining high Veteran and provider satisfaction. Strategies focusing on pre-implementation coordination and assistance with scheduling were key to successful implementation. Ongoing modeling will provide information about the overall impact of NTNP implementation on monthly CCN consultation rates.

Impacts:
Implementation of the NTNP improved neurology access and may reduce rates of CCN consultation.