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VA’s Telehealth Program for Bipolar Disorders Is Associated with Improved Symptoms, Suicide Risk, Quality of Life, and Prescription Quality
This study examined VA clinical, administrative, and survey data to evaluate outcomes (including symptoms, mood episodes, positive suicide screens, and mental health-related quality of life) for Veterans who were referred to the Bipolar Disorders Telehealth (BDTH) program from 2011 to 2021. Findings showed that Veterans who completed the program reported reductions in manic and depressive symptoms, and a reduction in mood episodes between their initial assessment and one month after completing the program. Veterans demonstrated significant improvements in mental health-related quality of life as well as increased lithium and prazosin (for those with a PTSD diagnosis) prescriptions, along with a 54% reduction in positive suicide screens. There was also a significant decrease in mental health hospitalizations, although Veterans who were referred for BDTH services but did not complete a consult saw a similar drop in rates. Findings from this 10-year evaluation provide further support for the general effectiveness and safety of telemental health via videoconferencing.
Date: October 18, 2024
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Telehealth Mindfulness-Based Interventions Improve Pain-Related Function and Biopsychosocial Outcomes Among Veterans with Chronic Pain
This randomized clinical trial aimed to test the effectiveness of two scalable, 8-week telehealth mindfulness-based interventions (MBIs) – group and self-paced – compared to usual care. Findings showed that both the group and self-paced MBI significantly improved pain-related function and biopsychosocial outcomes compared to usual care. Group and self-paced MBIs performed similarly. Averaged across all 3 time points (10 weeks, 6 months, and 1 year), pain interference scores were significantly lower for both MBIs. Both MBIs had significantly better scores on the secondary outcomes of pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and PTSD. Compared to usual care, the probability of 30% improvement from baseline was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI at all 3 time points. Scalable, relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in VA healthcare and beyond.
Date: August 19, 2024
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Veterans with Diabetes Receiving Community Primary Care Had Worse Diabetes Care Quality and Higher Costs than Veterans Receiving VA Primary Care
This study compared the quality, costs, and outcomes of community- and VA-provided primary care for Veterans with diabetes over 12 months during FY 2021–2022. Findings showed that Veterans who received community primary care had worse diabetes care quality and higher mean total costs (driven by higher inpatient and prescription drug costs) than Veterans who received VA primary care. There was no difference in health outcomes. Veterans who received community care were significantly less likely to receive a hemoglobin A1C test, eye exam, microalbumin urine test, and flu shot compared to the VA group. Community care patients had lower emergency care costs than VA patients. Thus, care provided by an integrated delivery system such as VA might have quality and value advantages over community care, but there are tradeoffs such as access barriers. Fully staffing primary care clinics, maintaining facilities based on the patient population, and using innovative telehealth programs to improve access might be as critical to VA’s future as the community care program.
Date: August 5, 2024
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Veterans’ Perceptions of VA Healthcare by Race and Sex
Investigators in this qualitative study focused on examining how Veterans’ perceptions of VA healthcare may differ by race and sex. Findings showed that, overall, there were differences in the perceived quality of interactions within the VA healthcare system by race and sex, with more positive experiences more likely to be reported by Veterans of White race and male sex. Some positive responses were salient across race and sex, including “good medical care” and telehealth as a “comfortable/great option,” as were some negative items, including “long waits/delays in getting care” and “transportation/traffic challenges.” Associations of VA with anxiety, stress, and fear were salient for all groups. However, it is unclear whether these were responses to extraordinary circumstances during the pandemic or were more deeply rooted experiences with VA care. Courtesy and respect were salient for White but not Black Veterans – and men but not women. While telehealth was seen as a good option, the perception of technology problems differed by race (reported by Black Veterans) and sex (reported by men), suggesting a digital divide. Divergent experiences of interpersonal care by race and sex provide insights for improving equitable, patient-centered VA healthcare.
Date: February 19, 2024
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Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic
This study sought to examine the extent to which homeless-experienced Veterans used telehealth 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 telehealth use, Veterans experiencing homelessness sustained a high use of telehealth 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 telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth 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 telehealth may address access disparities among these homeless-experienced patient groups.
Date: January 22, 2024
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Black Veterans with Chronic Pain Express Dissatisfaction with VA Telehealth 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 telehealth to avoid possible exposure to COVID-19, while others saw positive aspects to a virtual format.
Date: November 14, 2022
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VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth
At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-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 telehealth, 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 telehealth 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 telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care.
Date: July 28, 2022
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Characteristics of the Rise in Telehealth 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 telehealth services, and only 0.3% used video-based care. However, during the first 12 months of COVID-19, 63% of patients used telehealth services, and 11% used video-based care. Veterans at community-based clinics had a higher percentage of any telehealth 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 telehealth 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 telehealth 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
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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-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – 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-telehealth 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-telehealth). The centralized VA-telehealth 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-telehealth 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-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth 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
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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 telehealth and for preventing suicides among rural residents.
Date: April 6, 2022
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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, telehealth) 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
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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 telehealth, 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
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Patient Satisfaction with VA Virtual Care Delivered by Video-Enabled Tablet
In 2016, VA’s Offices of Rural Health and Connected Care developed a pilot initiative to distribute video-enabled tablets to Veterans who did not have the necessary technology and who had a geographic, clinical, or social barrier to in-person healthcare. During this pilot, 5,000 tablets were distributed to 6,745 patients at 86 VA facilities, with approximately half of the tablet recipients living in rural areas. To help inform optimal tablet distribution and technical support, investigators evaluated patient experiences with tablets through baseline and follow-up surveys. Many recipients of VA-issued tablets reported that video care is equivalent to or preferred to in-person care. Among follow-up survey respondents, 32% of tablet recipients indicated that they would prefer to conduct their future VA appointments by video; 32% indicated they would prefer these visits in person; and 36% indicated their preference was “about the same.” The most common barriers to in person care were travel time (66%), travel cost (55%), health conditions (54%), bad weather (57%), and feeling uncomfortable or uneasy at VA (33%). Between baseline and follow-up surveys, there were statistically significant increases in patient satisfaction regarding overall VA care, as well as primary care and mental healthcare. Satisfaction regarding technology and technical assistance also was high: 86% agreed or strongly agreed with statements regarding the ease of using the equipment, receiving help needed to learn the technology (84%), and that it was easy to ask questions (88%) and understand instructions (87%). Strong satisfaction ratings for tablets and the fact that characteristics such as age, health literacy, and prior technology use were not significantly associated with tablet preference suggest that engagement in video-based care is possible for many types of patients, including those often considered part of the “digital divide.”
Date: April 15, 2020
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Veterans Participating in a VA National Telehealth 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
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Video Telehealth 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
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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 telehealth 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
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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 Telehealth 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 Telehealth 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
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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 telehealth 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
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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, telehealth, home care, specialized clinics, and palliative care.
Date: April 1, 2013
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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 Telehealth 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
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Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (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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