Original Research

The Veterans Health Administration (VA) has increasingly partnered with non-VA hospitals to improve access to care.^1,2 However, veterans who receive healthcare services at both VA and non-VA hospitals are more likely to have adverse health outcomes, including increased hospitalization, 30-day readmissions, fragmented care resulting in duplication of tests and treatments, and difficulties with medication management.^3-10 Postdischarge care is particularly a high-risk time for these patients. Currently, the VA experiences challenges in coordinating care for patients who are dual users.¹¹

As the VA moves toward increased utilization of non-VA care, it is crucial to understand and address the challenges of transitional care faced by dual-use veterans to provide high-quality care that improves healthcare outcomes.^7,11,12 The VA implemented a shift in policy from the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146; “Choice Act”) to the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act beginning June 6, 2019.^13,14 Under the MISSION Act, veterans have more ways to access healthcare within the VA’s network and through approved non-VA medical providers in the community known as “community care providers.”¹⁵ This shift expanded the existing VA Choice Act of 2014, where the program allowed those veterans who are unable to schedule an appointment within 30 days of their preferred date or the clinically appropriate date, or on the basis of their place of residence, to elect to receive care from eligible non-VA healthcare entities or providers.^14,15 These efforts to better serve veterans by increasing non-VA care might present added care coordination challenges for patients and their providers when they seek care in the VA.

High-quality transitional care prevents poor outcomes such as hospital readmissions.^16-18 When communication and coordination across healthcare delivery systems are lacking, patients and their families often find themselves at risk for adverse events.^19,20 Past research shows that patients have fewer adverse events when they receive comprehensive postdischarge care, including instructions on medications and self-care, symptom recognition and management, and reminders to attend follow-up appointments.^17,21,22 Although researchers have identified the components of effective transitional care,²³ barriers persist. The communication and collaboration needed to provide coordinated care across healthcare delivery systems are difficult due to the lack of standardized approaches between systems.²⁴ Consequently, follow-up care may be delayed or missed altogether. To our knowledge, there is no published research identifying transitional care challenges for clinicians, staff, and veterans in transitioning from non-VA hospitals to a VA primary care setting.

The objective of this quality assessment was to understand VA and non-VA hospital clinicians’ and staff as well as veterans’ perspectives of the barriers and facilitators to providing high-quality transitional care.

METHODS

Study Design

We conducted a qualitative assessment within the VA Eastern Colorado Health Care System, an urban tertiary medical center, as well as urban and rural non-VA hospitals used by veterans. Semi-structured interview guides informed by the practical robust implementation and sustainability (PRISM) model, the Lean approach, and the Ideal Transitions of Care Bridge were used.^25-27 We explored the PRISM domains such as recipient’s characteristics, the interaction with the external environment, and the implementation and sustainability infrastructure to inform the design and implementation of the intervention.²⁵ The Lean approach included methods to optimize processes by maximizing efficiency and minimizing waste.²⁶ The Ideal Transitions of Care Bridge was used to identify the domains in transitions of care such as discharge planning, communication of information, and care coordination.²⁷

Setting and Participants

We identified the top 10 non-VA hospitals serving the most urban and rural veterans in 2015 using VA administrative data. Purposive sampling was used to ensure that urban and rural non-VA hospitals and different roles within these hospitals were represented. VA clinicians and staff were selected from the Denver VA Medical Center, a tertiary hospital within the Eastern Colorado Health Care System and one VA Community-Based Outpatient Clinic (CBOC) that primarily serves rural veterans. The Denver VA Medical Center has three clinics staffed by Patient Aligned Care Teams (PACTs), a model built on the concept of Patient-Centered Medical Home.²⁸ Hospital leadership were initially approached for permission to recruit their staff and to be involved as key informants, and all agreed. To ensure representativeness, diversity of roles was recruited, including PACT primary care physicians, nurses, and other staff members such as medical assistants and administrators. Veterans were approached for sampling if they were discharged from a non-VA hospital during June–September 2015 and used the VA for primary care. This was to ensure that they remembered the process they went through postdischarge at the time of the interview.

Data Collection and Analysis

The evaluation team members (RA, EL, and MM) conducted the interviews from November 2015 to July 2016. Clinicians, staff, and veterans were asked semi-structured questions about their experiences and their role in transitioning VA patients across systems (see Appendix for interview guides). Veterans were asked to describe their experience and satisfaction with the current postdischarge transition process. We stopped the interviews when we reached data saturation.²⁹

Interviews were audio-recorded, transcribed verbatim, and validated (transcribed interviews were double-checked against recording) to ensure data quality and accuracy. Coding was guided by a conventional content analysis technique^{30, 31} using a deductive and inductive coding approach.³¹ The deductive coding approach was drawn from the Ideal Transitions of Care Bridge and PRISM domains. ^32,33 Two evaluation team members (RA and EL) defined the initial code book by independently coding the first three interviews, worked to clarify the meanings of emergent codes, and came to a consensus when disagreements occurred. Next, a priori codes were added by team members to include the PRISM domains. These PRISM domains included the implementation and sustainability infrastructure, the external environment, the characteristics of intervention recipients, and the organizational and patient perspectives of an intervention.

Additional emergent codes were added to the code book and agreed upon by team members (RA, EL, and MM). Consistent with previously used methods, consensus building was achieved by identifying and resolving differences by discussing with team members (RA, EL, MM, CB, and RB).²⁹ Codes were examined and organized into themes by team members.^29,34-36 This process was continued until no new themes were identified. Results were reviewed by all evaluation team members to assess thoroughness and comprehensiveness.^34,35 In addition, team members triangulated the findings with VA and non-VA participants to ensure validity and reduce researcher bias.^29,37

RESULTS

We conducted a total of 70 interviews with 23 VA and 29 non-VA hospital clinicians and staff and 18 veterans (Table 1). Overall, we found that there was no standardized process for transitioning veterans across healthcare delivery systems. Participants reported that transitions were often inefficient when non-VA hospitals could not (1) identify patients as veterans and notify VA primary care of discharge; (2) transfer non-VA hospital medical records to VA primary care; (3) obtain follow-up care appointments with VA primary care; and (4) write VA formulary medications for veterans to fill at VA pharmacies. In addition, participants discussed about facilitators and suggestions to overcome these inefficiencies and improve transitional care (Table2). We mapped the identified barriers as well as the suggestions for improvement to the PRISM and the Ideal Transitions of Care Bridge domains (Table 3).

Unable to Identify Patients as Veterans and Notify VA Primary Care of Discharge

VA and non-VA participants reported difficulty in communicating about veterans’ hospitalizations and discharge follow-up needs across systems. Non-VA clinicians referenced difficulty in identifying patients as veterans to communicate with VA, except in instances where the VA is a payor, while VA providers described feeling largely uninformed of the veterans non-VA hospitalization. For non-VA clinicians, the lack of a systematic method for veteran identification often left them to inadvertently identify veteran status by asking about their primary care clinicians and insurance and even through an offhanded comment made by the veteran. If a veteran was identified, non-VA clinicians described being uncertain about the best way to notify VA primary care of the patient’s impending discharge. Veterans described instances of the non-VA hospital knowing their veteran status upon admission, but accounts varied on whether the non-VA hospital notified the VA primary care of their hospitalization (Table 2, Theme 1).

Unable to Transfer Non-VA Hospital Medical Records to VA Primary Care

VA clinicians discussed about the challenges associated with obtaining the veteran’s medical record from the non-VA hospitals, and when it was received, it was often incomplete information and significantly delayed. They described relying on the veteran’s description of the care received, which was not complete or accurate information needed to make clinical judgment or coordinate follow-up care. Non-VA clinicians mentioned about trying several methods for transferring the medical record to VA primary care, including discharge summary via electronic system and sometimes solely relying on patients to deliver discharge paperwork to their primary care clinicians. In instances where non-VA hospitals sent discharge paperwork to VA, there was no way for non-VA hospitals to verify whether the faxed electronic medical record was received by the VA hospital. Most of the veterans discussed receiving written postdischarge instructions to take to their VA primary care clinicians; however, they were unsure whether the VA primary care received their medical record or any other information from the non-VA hospital (Table 2, Theme 2).

Unable to Obtain Follow-Up Care Appointments with VA Primary Care

All participants described how difficult it was to obtain a follow-up appointment for veterans with VA primary care. This often resulted in delayed follow-up care. VA clinicians also shared that a non-VA hospitalization can be the impetus for a veteran to seek care at the VA for the very first time. Once eligibility is determined, the veteran is assigned a VA primary care clinician. This process may take up to six weeks, and in the meantime, the veteran is scheduled in VA urgent care for immediate postdischarge care. This lag in primary care assignment creates delayed and fragmented care (Table 2, Theme 3).

Non-VA clinicians, administrators, and staff also discussed the difficulties in scheduling follow-up care with VA primary care. Although discharge paperwork instructed patients to see their VA clinicians, there was no process in place for non-VA clinicians to confirm whether the follow-up care was received due to lack of bilateral communication. In addition, veterans discussed the inefficiencies in scheduling follow-up appointments with VA clinicians where attempts to follow-up with primary care clinicians took eight weeks or more. Several veterans described walking into the clinic without an appointment asking to be seen postdischarge or utilizing the VA emergency department for follow-up care after discharge from a non-VA hospital. Veterans admitted utilizing the VA emergency department for nonemergent reasons such as filling their prescriptions because they are unable to see a VA PCP in a timely manner (Table 2, Theme 3).

Unable to Write VA Formulary Medications for Veterans to Fill at VA Pharmacies

All participants described the difficulties in obtaining medications at VA pharmacies when prescribed by the non-VA hospital clinicians. VA clinicians often had to reassess, and rewrite prescriptions written by clinicians, causing delays. Moreover, rural VA clinicians described lack of VA pharmacies in their locations, where veterans had to mail order medications, causing further delays in needed medications. Non-VA clinicians echoed these frustrations. They noted that veterans were confused about their VA pharmacy benefits as well as the need for the non-VA clinicians to follow VA formulary guidelines. Veterans expressed that it was especially challenging to physically go to the VA pharmacy to pick up medications after discharge due to lack of transportation, limited VA pharmacy hours, and long wait times. Several veterans discussed paying for their prescriptions out of pocket even though they had VA pharmacy benefits because it was more convenient to use the non-VA pharmacy. In other instances, veterans discussed going to a VA emergency department and waiting for hours to have their non-VA clinician prescription rewritten by a VA clinician (Table 2, Theme 4).

Facilitators of the Current Transition Process

Several participants provided examples of when transitional care communication between systems occurred seamlessly. VA staff and veterans noted that the VA increased the availability of urgent care appointments, which allowed for timelier postacute care follow-up appointments. Non-VA hospital clinicians also noted the availability of additional appointment slots but stated that they did not learn about these additional appointments directly from the VA. Instead, they learned of these through medical residents caring for patients at both VA and non-VA hospitals. One VA CBOC designated two nurses to care for walk-in veterans for their postdischarge follow-up needs. Some VA participants also noted that the VA Call Center Nurses occasionally called veterans upon discharge to schedule a follow-up appointment and facilitated timely care.

Participants from a VA CBOC discussed being part of a Community Transitions Consortium aimed at identifying high-utilizing patients (veteran and nonveteran) and improving communication across systems. The consortium members discussed each facility’s transition-of-care process, described having access to local non-VA hospital medical records and a backline phone number at the non-VA hospitals to coordinate transitional care. This allowed the VA clinicians to learn about non-VA hospital processes and veteran needs.

Suggestions for Improving the Transitional Care Process

VA and non-VA clinicians suggested hiring a VA liaison, preferably with a clinical background to facilitate care coordination across healthcare systems. They recommended that this person work closely with VA primary care, strengthen the relationship with non-VA hospitals, and help veterans learn more about the transition-of-care processes. Topics discussed for veteran education included how to (1) access their primary care team; (2) alert VA of non-VA hospitalization and the billing process; (3) recognize symptoms and manage care; and (4) obtain follow-up care appointments. Furthermore, they suggested that the liaison would help facilitate the transfer of medical records between VA and non-VA hospitals. Other suggestions included allowing veterans to fill prescriptions at non-VA pharmacies and dedicating a phone line for non-VA clinicians to speak to VA clinicians and staff.

Veterans agreed that improvements to the current process should include an efficient system for obtaining medications and the ability to schedule timely follow-up appointments. Furthermore, veterans wanted education about the VA transition-of-care process following a non-VA hospitalization, including payment and VA notification processes (Table 2, Theme 5).

DISCUSSION

Participants described the current transitional care process as inefficient with specific barriers that have negative consequences on patient care and clinician and staff work processes. They described difficulties in obtaining medications prescribed by non-VA clinicians from VA pharmacies, delays in follow-up appointments at the VA, and lack of bilateral communication between systems and medical record transfer. Participants also provided concrete suggestions to improving the current process, including a care coordinator with clinical background. These findings are important in the context of VA increasing veteran access to care in the community.

Despite an increasing emphasis on veteran access to non-VA care as a result of the VA strategic goals and several new programs,^7,12,13 there has not been a close examination of the current transition-of-care process from non-VA hospitals to VA primary care. Several studies have shown that the period following a hospitalization is especially vulnerable and associated with adverse events such as readmission, high cost, and death.^12,31,32 Our findings agree with previous research that identified medical record transfer across systems as one of the most challenging issues contributing to deficits in communication between care teams.³³ In addition, our study brought into focus the significant challenges faced by veterans in obtaining medications post non-VA hospital discharge. Addressing these key barriers in transitional care will improve the quality, safety, and value of healthcare in the current transition process.^38,39

Based on our findings, our participants’ concern in transitional care can be addressed in various ways. First, as veterans are increasingly receiving care in the community, identifying their veteran status early on in the non-VA hospital setting could help in improved, real time communication with the VA. This could be done by updating patient intake forms to ask patients whether they are veterans or not. Second, VA policy-level changes should work to provide veterans access to non-VA pharmacy benefits equivalent to the access patients are receiving for hospital, specialty, and outpatient care. Third, patient and provider satisfaction for dual-use veterans should be examined closely. Although participants expressed frustration with the overall transitions of care from non-VA hospitals to VA primary care setting, influence of this on the Quadruple Aim-improving patient outcomes, experience, and reducing clinician and staff burnout should be examined closely.⁴⁰ Fourth, evidence-based interventions such as nurse-led transitional care programs that have proven helpful in reducing adverse outcomes in both VA and non-VA settings will be useful to implement.^41-45 Such programs could be located in the VA, and a care coordinator role could help facilitate transitional care needs for veterans by working with multiple non-VA hospitals.

The limitations of this study are that the perspectives shared by these participants may not represent all VA and non-VA hospitals as well as veterans’ experiences with transition of care. In addition, the study was conducted in one state and the findings may not be applicable to other healthcare systems. However, our study highlighted the consistent challenges of receiving care across VA and other hospital systems. Two strengths of this study are that it was conducted by multidisciplinary research team members with expertise in qualitative research, clinical care, and implementation science and that we obtained convergent information from VA, non-VA, and veteran participants.

Our current transition-of-care process has several shortcomings. There was a clear agreement on barriers, facilitators, and suggestions for improving the current transitions-of-care process among VA and non-VA hospital participants, as well as from veterans who experienced transitions across different delivery systems. Transitioning veterans to VA primary care following a non-VA hospitalization is a crucial first step for improving care for veterans and reducing adverse outcomes such as avoidable hospital readmissions and death.

These results describe the inefficiencies experienced by patients, clinicians, and staff and their suggestions to alleviate these barriers for optimal continuum of care. To avoid frustration and inefficiencies, the increased emphasis of providing non-VA care for veterans should consider the challenges experienced in transitional care and the opportunities for increased coordination of care.

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References

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26. Schweikhart SA, Dembe AE. The applicability of lean and six sigma techniques to clinical and translational research. J Investig Med. 2009;57(7):748-755. https://doi.org/10.2310/JIM.0b013e3181b91b3a.
27. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102-109. https://doi.org/10.1002/jhm.1990.
28. Patient Aligned Care Team (PACT)-Patient Care. Services. https://www.patientcare.va.gov/primarycare/PACT.asp. Accessed November 20, 2017.
29. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212-1222. https://doi.org/10.1177/1049732315588501.
30. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288. https://doi.org/10.1177/1049732305276687.
31. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80-92. https://doi.org/10.1177/160940690600500107.
32. Ayele RA, Lawrence E, McCreight M, et al. Study protocol: improving the transition of care from a non-network hospital back to the patient’s medical home. BMC Health Serv Res. 2017;17(1):123. https://doi.org/10.1186/s12913-017-2048-z.
33. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102-109. https://doi.org/10.1002/jhm.1990.
34. Qualitative research & evaluation methods. https://us.sagepub.com/en-us/nam/qualitative-research-evaluation-methods/book232962. Accessed April 16, 2017. SAGE Publications Inc.
35. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119(10):1442-1452. https://doi.org/10.1161/CIRCULATIONAHA.107.742775.
36. Creswell JW, Hanson WE, Clark Plano VL, Morales A. Qualitative research designs: selection and implementation. Couns Psychol. 2007;35(2):236-264. https://doi.org/10.1177/0011000006287390.
37. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545-547. https://doi.org/10.1188/14.ONF.545-547.
38. Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. https://doi.org/10.1056/NEJMp1212324.
39. Improving Care Transitions. Health affairs-health policy briefs. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76. Accessed August 13, 2016.
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41. Burke RE, Kelley L, Gunzburger E, et al. Improving transitions of care for veterans transferred to tertiary VA medical centers. Am J Med Qual. 2018;33(2):147-153. https://doi.org/10.1177/1062860617715508.
42. Capp R, Misky GJ, Lindrooth RC, et al. Coordination program reduced acute care use and increased primary care visits among frequent emergency care users. Health Aff (Millwood). 2017;36(10):1705-1711. https://doi.org/10.1377/hlthaff.2017.0612.
43. Kind AJH, Brenny-Fitzpatrick M, Leahy-Gross K, et al. Harnessing protocolized adaptation in dissemination: successful implementation and sustainment of the veterans affairs coordinated-transitional care program in a non-veterans affairs hospital. J Am Geriatr Soc. 2016;64(2):409-416. https://doi.org/10.1111/jgs.13935.
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45. Reese RL, Clement SA, Syeda S, et al. Coordinated-transitional care for veterans with heart failure and chronic lung disease. J Am Geriatr Soc. 2019;67(7):1502-1507. https://doi.org/10.1111/jgs.15978.

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Author and Disclosure Information

¹Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado; ²University of Colorado, Anschutz Medical Campus, Aurora, Colorado; ³University of California San Diego, San Diego, California; ⁴VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania.

Disclosures

Ms. Fehling reports grants from Department of Veterans Affairs, during the conduct of the study. All other authors have nothing to disclose.

Funding

This project was funded by Veterans Affairs Health Services Research and Development grant (QUE 15-268). The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Journal of Hospital Medicine 15(3)

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Hospital Medicine

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133-139. Published Online First October 23, 2019

Read more about Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System

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Original Research

Author(s)

Roman A Ayele, PhD, MPH

Emily Lawrence, MPH

Marina McCreight, MPH

Kelty Fehling, MPH

Russell E Glasgow, PhD

Borsika A Rabin, MPH, PhD, PharmD

Robert E Burke, MD, MS

Catherine Battaglia, PhD, RN

Author(s)

Roman A Ayele, PhD, MPH

Emily Lawrence, MPH

Marina McCreight, MPH

Kelty Fehling, MPH

Russell E Glasgow, PhD

Borsika A Rabin, MPH, PhD, PharmD

Robert E Burke, MD, MS

Catherine Battaglia, PhD, RN

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Disclosures

Ms. Fehling reports grants from Department of Veterans Affairs, during the conduct of the study. All other authors have nothing to disclose.

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Author and Disclosure Information

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Ms. Fehling reports grants from Department of Veterans Affairs, during the conduct of the study. All other authors have nothing to disclose.

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METHODS

Study Design

Setting and Participants

Data Collection and Analysis

RESULTS

Unable to Identify Patients as Veterans and Notify VA Primary Care of Discharge

Unable to Transfer Non-VA Hospital Medical Records to VA Primary Care

Unable to Obtain Follow-Up Care Appointments with VA Primary Care

Unable to Write VA Formulary Medications for Veterans to Fill at VA Pharmacies

Facilitators of the Current Transition Process

Suggestions for Improving the Transitional Care Process

DISCUSSION

METHODS

Study Design

Setting and Participants

Data Collection and Analysis

RESULTS

Unable to Identify Patients as Veterans and Notify VA Primary Care of Discharge

Unable to Transfer Non-VA Hospital Medical Records to VA Primary Care

Unable to Obtain Follow-Up Care Appointments with VA Primary Care

Unable to Write VA Formulary Medications for Veterans to Fill at VA Pharmacies

Facilitators of the Current Transition Process

Suggestions for Improving the Transitional Care Process

DISCUSSION

References

Issue

Journal of Hospital Medicine 15(3)

Issue

Journal of Hospital Medicine 15(3)

Page Number

133-139. Published Online First October 23, 2019

Page Number

133-139. Published Online First October 23, 2019

Topics

Hospital Medicine

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Article

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Roman A Ayele, PhD, MPH

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Roman A. Ayele; E-mail: [email protected]; Telephone: (720) 857-5907

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GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities

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Article

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Mon, 11/04/2019 - 16:14

A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care.

Author(s)

Camilla B. Pimentel, PhD, MPH

Megan Gately, OTD, OTR/L

Steven R. Barczi, MD

Kenneth S. Boockvar, MD

Ella H. Bowman, MD, PhD

Thomas V. Caprio, MD, MPH, MS

Cathleen S. Colón-Emeric, MD

Stuti Dang, MD, MPH

Sara E. Espinoza, MD, MSc

Kimberly K. Garner, MD

Patricia C. Griffiths, PhD

Judith L. Howe, PhD

Hillary D. Lum, MD

Alayne D. Markland, DO, MSc

Michelle I. Rossi, MD, MPH

Stephen M. Thielke, MD, MSPH, MA

Willy M. Valencia-Rodrigo, MD, MSc

Lauren R. Moo, MD*

William W. Hung, MD, MPH*

Nearly 2.7 million veterans who rely on the Veterans Health Administration (VHA) for their health care live in rural communities.¹ Of these, more than half are aged ≥ 65 years. Rural veterans have greater rates of service-related disability and chronic medical conditions than do their urban counterparts.^1,2 Yet because of their rural location, they face unique challenges, including long travel times and distances to health care services, lack of public transportation options, and limited availability of specialized medical and social support services.

Compounding these geographic barriers is a more general lack of workforce infrastructure and a dearth of clinical health care providers (HCPs) skilled in geriatric medicine. The demand for geriatricians is projected to outpace supply and result in a national shortage of nearly 27 000 geriatricians by 2025.³ Moreover, the overwhelming majority (90%) of HCPs identifying as geriatric specialists reside in urban areas.⁴ This creates tremendous pressure on the health care system to provide remote care for older veterans contending with complex conditions, and ultimately these veterans may not receive the specialized care they need.

Telehealth modalities bridge these gaps by bringing health care to veterans in rural communities. They may also hold promise for strengthening community care in rural areas through workforce development and dissemination of educational resources. The VHA has been recognized as a leader in the field of telehealth since it began offering telehealth services to veterans in 1977^5-8 and served more than 677 000 Veterans via telehealth in fiscal year (FY) 2015.⁹ The VHA currently employs multiple modes of telehealth to increase veterans’ access to health care, including: (1) synchronous technology like clinical video telehealth (CVT), which provides live encounters between HCPs and patients using videoconferencing software; and (2) asynchronous technology, such as store-and-forward communication that offers remote transmission and clinical interpretation of veteran health data. The VHA has also strengthened its broad telehealth infrastructure by staffing VHA clinical sites with telehealth clinical technicians and providing telehealth hardware throughout.

The Department of Veterans Affairs (VA) Office of Geriatrics and Extended Care (GEC) and Office of Rural Health (ORH) established the Geriatric Research Education and Clinical Centers (GRECC) Connect project in 2014 to leverage the existing telehealth technologies at the VA to meet the health care needs of older veterans. GRECC Connect builds on the VHA network of geriatrics expertise in GRECCs by providing telehealth-based consultative support for rural primary care provider (PCP) teams, older veterans, and their families. This program profile describes this project’s mission, structure, and activities.

Program Overview

GRECC Connect leverages the clinical expertise and administrative infrastructure of participating GRECCs in order to reach clinicians and veterans in primarily rural communities.¹⁰ GRECCs are VA centers of excellence focused on aging and comprise a large network of interdisciplinary geriatrics expertise. All GRECCs have strong affiliations with local universities and are located in urban VA medical centers (VAMCs). GRECC Connect is based on a hub-and-spoke model in which urban GRECC hub sites are connected to community-based outpatient clinic (CBOC) and VAMC spokes that primarily serve veterans in other communities. CBOCs are stand-alone clinics that are geographically separate from a related VA medical center and provide outpatient primary care, mental health care services, and some specialty care services such as cardiology or neurology. They range in size from small, mainly telehealth clinics with 1 technician to large clinics with several specialty providers. Each GRECC hub site partners with an average of 6 CBOCs (range 3-16), each of which is an average distance of 92.8 miles from the related VA medical center (range 20-406 miles).

GRECC Connect was established under the umbrella of the VA Geriatric Scholars Program, which since 2008 integrates geriatrics into rural primary care practices through tailored education for continuing professional development.¹¹ Through intensive courses in geriatrics and quality improvement methods and through participation in local quality improvement projects benefiting older veterans, the Geriatric Scholars Program trains rural PCPs so that they can more effectively and independently diagnose and manage common geriatric syndromes.¹² The network of clinician scholars developed by the Geriatric Scholars Program, all rural frontline clinicians at VA clinics, has given the GRECC Connect project a well-prepared, geriatrics-trained workforce to act as project champions at rural CBOCs and VAMCs. The GRECC Connect project’s goals are to enhance access to geriatric specialty care among older veterans with complex medical problems, geriatric syndromes, and increased risk for institutionalization, and to provide geriatrics-focused educational support to rural HCP teams.

Geriatric Provider Consultations

The first overarching goal of the GRECC Connect project is to improve access to geriatrics specialty care by facilitating linkages between GRECC hub sites and the CBOCs and VAMCs that primarily serve veterans in rural communities. GRECC hub sites offer consultative support from geriatrics specialty team members (eg, geriatricians, nurse practitioners, pharmacists, gero- or neuropsychologists, registered nurses [RNs], and social workers) to rural PCP in their catchment area. This support is offered through a variety of telehealth modalities readily available in the VA (Table 1). These include CVT, in which a veteran located at a rural CBOC is seen using videoconferencing software by a geriatrics specialty provider who is located at a GRECC hub site. At some GRECC hub sites, CVT has also been used to conduct group visits between a GRECC provider at the hub site and several veterans who participate from a rural CBOC. Electronic consultations, or e-consults, involve a rural provider entering a clinical question in the VA Computerized Patient Record System. The question is then triaged, and a geriatrics provider at a GRECC responds, based on review of that veteran’s chart. At some GRECC hub sites, the e-consults are more extensive and may include telephone contact with the veteran or their caregiver.

Consultations between GRECC-based teams and rural PCPs may cover any aspect of geriatrics care, ranging from broad concerns to subspecialty areas of geriatric medicine. For instance, general geriatrics consultation may address polypharmacy, during either care transitions or ongoing care. Consultation may also reflect the specific focus area of a particular GRECC, such as cognitive assessment (eg, Pittsburgh GRECC), management of osteoporosis to address falls (eg, Durham GRECC, Miami GRECC), and continence care (eg, Birmingham/Atlanta GRECC).¹³ Most consultations are initiated by a remote HCP who is seeking geriatrics expertise from the GRECC team.

Some GRECC hub sites, however, employ case finding strategies, or detailed chart reviews, in order to identify older veterans who may benefit from geriatrics consultation. For veterans identified through those mechanisms, the GRECC clinicians suggest that the rural HCP either request or allow an e-consult or evaluation via CVT for those veterans. The geriatric consultations may help identify additional care needs for older veterans and lead to recommendations, orders, or remote provision of a variety of other actions, including VA or non-VA services (eg, home-based primary care, home nursing service, respite service, social support services such as Meals on Wheels); neuropsychological testing; physical or occupational therapy; audiology or optometry referral; falls and fracture risk assessment and interventions to reduce falls (eg, home safety evaluation, physical therapy); osteoporosis risk assessments (eg, densitometry, recommendations for pharmacologic therapy) to reduce the risk of injury or nontraumatic fractures from falls; palliative care for incontinence and hospice; and counseling on geriatric issues such as dementia caregiving, advanced directives, and driving cessation.

More recently, the Miami GRECC has begun evaluating rural veterans at risk for hypoglycemia, providing patient education and counseling about hypoglycemia, and making recommendations to the veterans’ primary care teams.¹⁴ Consultations may also lead to the appropriate use or discontinuation of medications, related to polypharmacy. GRECC-based teams, for example, have helped rural HCPs modify medication doses, start appropriate medications for dementia and depression, and identify and stop potentially inappropriate medications (eg, those that increase fall risk or that have significant anticholinergic properties).¹⁵

GRECC Connect Geriatric Case Conference Series

The second overarching goal of the GRECC Connect project is to provide geriatrics-focused educational support to equip PCPs to better serve their aging veteran patients. This is achieved through twice-monthly, case-based conferences supported by the VA Employee Education System (EES) and delivered through a webinar interface. Case conferences are targeted to members of the health care team who may provide care for rural older adults, including physicians, nurse practitioners, physician assistants, RNs, psychologists, social workers, physical and occupational therapists, and pharmacists. The format of these sessions includes a clinical case presentation, a didactic portion to enhance knowledge of participants, and an open question/answer period. The conferences focus on discussions of challenging clinical cases, addressing common problems (eg, driving concerns), and the assessment/management of geriatric syndromes (eg, cognitive decline, falls, polypharmacy). These conferences aim to improve the knowledge and skills of rural clinical teams in taking care of older veterans and to disseminate best practices in geriatric medicine, using case discussions to highlight practical applications of practices to clinical care. Recent GRECC Connect geriatric case conferences are listed in Table 2 and are recorded and archived to ensure that busy clinicians may access these trainings at the time of their choosing. These materials are catalogued and archived on the EES server.

Early Experience

GRECC Connect tracks on an annual basis the number of unique veterans served, number of participating GRECC hub sites and CBOCs, mileage from veteran homes to teleconsultation sites, and number of clinicians and staff engaged in GRECC Connect education programs.¹⁶ Since its inception in 2014, the GRECC Connect project has provided direct clinical support to more than 4000 unique veterans (eFigure), of whom half were seen for a cognition-related issue. Consultations were made on behalf of 1,622 veterans in FY 2018, of whom 60% were from rural or highly rural communities and 56.8% were served by CVT visits. The number of GRECC hub sites has increased from 4 in FY 2014 to 12 (of 20 total GRECCs) in FY 2018. The locations of current GRECC hub sites can be found on the Geriatric Scholars website: www.gerischolars.org. Through this expansion, GRECC Connect provides geriatric consultative and educational support to > 70 rural VA clinics in 10 of the 18 Veterans Integrated Service Networks (VISNs).

To assess the reduction in commute times from teleconsultation, we calculated the difference between the mileage from veteran homes to teleconsultation sites (ie, rural clinics) and the mileage from veteran homes to VAMCs where geriatric teams are located. We estimate that the 1622 veterans served in FY 2018 saved a total of 179 121 miles in travel through GRECC Connect. Veterans traveled 106 fewer miles and on average saved $58 in out-of-pocket savings (based on US General Services Administration 2018 standard mileage reimbursement rate of $0.545 per mile). However, many of the veterans have reported anecdotally that the reduction in mileage traveled was less important than the elimination of stress involved in urban navigating, driving, and parking.

More difficult to measure, GRECC Connect seeks to enhance veteran safety by reducing driving distances for older veterans whose driving abilities may be influenced by many age-related health conditions (eg, visual changes, cognitive impairment). For these and other reasons, surveyed veterans overwhelmingly reported that they would be likely to recommend teleconsultation services to other veterans, and that they preferred telemedicine consultation over traveling long distances for in-person clinical consultations.¹⁶

Since its inception in 2014, GRECC Connect has provided case-based education to a total of 2335 unique clinicians and staff. Participants have included physicians, nurse practitioners, RNs, social workers, and pharmacists. This distribution reflects the interdisciplinary nature of geriatric care. A plurality of participants (39%) were RNs. Surveyed participants in the GRECC Connect geriatrics case conference series report high overall satisfaction with the learning activity, acquisition of new knowledge and skills, and intention to apply new knowledge and skills to improve job performance.¹⁰ In addition, participants agreed that the online training platform was effective for learning and that they would recommend the education series to other HCPs.^10,16

Discussion

During its rapid 4-year scale up, GRECC Connect has established a national network and enhanced relationships between GRECC-based clinical teams and rural provider teams. In doing so, the program has begun to improve rural veterans’ access to geriatric specialty care. By providing continuing education to members of the interprofessional health care team, GRECC Connect develops rural providers’ clinical competency and promotes geriatrics skills and expertise. These activities are synergistic: Clinical support enables rural HCPs to become better at managing their own patients, while formal educational activities highlight the availability of specialized consultation available through GRECC Connect. Through ongoing creation of handbooks, workflows, and data analytic strategies, GRECC Connect aims to disseminate this model to additional GRECCs as well as other GEC programs to promote “anywhere to anywhere” VA health care.¹⁷

Barriers and Facilitators

GRECC Connect has had notable implementation challenges while new consultation relationships have been forged in order to provide geriatric expertise to rural areas where it is not otherwise available. Many GRECCs had already established connections with rural CBOCs. Among GRECCs that had previously established consultative relationships with rural clinics, the use of telehealth modalities to provide geriatric clinical resources has been a natural extension of these partnerships. GRECCs that lacked these connections, however, often had to obtain buy-in from multiple stakeholders, including rural HCPs and teams, administrative leads, and local telehealth coordinators, and they required VISN- and facility-level leadership to encourage and sustain rural team participation.

Depending on the distance of the GRECC hub-site to the CBOC, efforts to establish and sustain partnerships may require multiple contacts over time (eg, via face-to-face meetings, one-on-one outreach) and large-scale advertising of consultative services. Continuous engagement with CBOC-based teams also involves development of case finding strategies (eg, hospital discharge information, diagnoses, clinical criteria) to better identify veterans who may benefit from GRECC Connect consultation. Owing to the heterogeneity of technological resources, space, scheduling capacity, and staffing at CBOCs, GRECC sites continue to have variable engagement with their CBOC partners.

The inclusion of GRECC Connect within the Geriatric Scholars Program helps ensure that clinician scholars can serve as project champions at their respective rural sites. Rural HCPs with full-time clinical duties initially had difficulty carving out time to participate in GRECC Connect’s case-based conferences. However, the webinar platform has improved and sustained provider participation, and enduring recordings of the presentations allow clinicians to participate in the conferences at their convenience. Finally, the project experienced delays in taking certain administrative steps and hiring staff needed to support the establishment of telehealth modalities—even within a single health care system like the VA, each medical center and regional system has unique policies that complicate how telehealth modalities can be set up.

Conclusion and Future Directions

The GRECC Connect project aims to establish and support meaningful partnerships between urban geriatric specialists and rural HCPs to facilitate veterans’ increased access to geriatric specialty care. VA ORH has recognized it as a Rural Promising Practice, and GRECC Connect is currently being disseminated through an enterprise-wide initiative. Early evidence demonstrates that over 4 years, the expansion of GRECC Connect has helped meet critical aims of improving provider confidence and skills in geriatric management, and of increasing direct service provision. We have also used nationwide education platforms (eg, VA EES) to deliver geriatrics-focused education to health care teams.

Older rural veterans and their caregivers may benefit from this program through decreased travel-associated burden and report high satisfaction with these programs. Through a recently established collaboration with the GEC Data Analysis Center, we will use national data to refine our ability to identify at-risk, older rural veterans and to better evaluate their service needs and the GRECC Connect clinical impact. Because the VA is rapidly expanding use of telehealth and other virtual and digital methods to increase access to care, continued investments in telehealth are central to the VA 5-year strategic plan.¹⁸ In this spirit, GRECC Connect will continue to expand its program offerings and to leverage telehealth technologies to meet the needs of older veterans.

Acknowledgments

The authors wish to acknowledge Lisa Tenover, MD, PhD, (Palo Alto GRECC) for her contributions to this manuscript; the VA Rural Health Resource Center–Western Region; and GRECC Connect team members for their tireless work to ensure this project’s success. The GRECC Teams include Atlanta/Birmingham (Julia [Annette] Tedford, RN; Marquitta Cox, LMSW; Lisa Welch, LMSW; Mark Phillips; Lanie Walters, PharmD; Kroshona Tabb, PhD; Robert Langford, and Jason [Thomas] Sanders, HT, TCT); Bronx/NY Harbor (Ab Brody, RN; PhD, GNP-BC; Nick Koufacos, LMSW; and Shatice Jones); Canandaigua (Gary Kochersberger, MD; Suzanne Gillespie, MD; Gary Warner, PhD; Christie Hylwa, RPh CCP; Sharon Fell, LMSW; and Dorian Savino, MPA); Durham (Mamata Yanamadala, MBBS; Christy Knight, LCSW, MSW; and Julie Vognsen); Eastern Colorado (Larry Bourg, MD; Skotti Church, MD; Morgan Elmore, DO; Stephanie Hartz, LCSW; Carolyn Horney, MD; Steven Huart, AuD; Kathryn Nearing, PhD; Elizabeth O’Brien, PharmD; Laurence Robbins, MD; Robert Schwartz, MD; Karen Shea, MD; and Joleen Sussman, PhD); Little Rock (Prasad Padala, MD; and Tanya Taylor, RN); Madison (Ryan Bartkus, MD; Timothy Howell, MD; Lindsay Clark, PhD; Lauren Welch, PharmD, BCGP; Ellen Wanninger, MSW, CAPSW; Stacie Monson, RN, BSN; and Teresa Swader, MSW, LCSW); Miami (Carlos Gomez Orozo); New England (Malissa Kraft, PsyD); Palo Alto (Terri Huh, PhD, ABPP; Philip Choe, DO; Dawna Dougherty, LCSW; Ashley Scales, MPH); Pittsburgh (Stacey Shaffer, MD; Carol Dolbee, CRNP; Nancy Kovell, LCSW; Paul Bulgarelli, DO; Lauren Jost, PsyD; and Marcia Homer, RN-BC); and San Antonio (Becky Powers, MD; Che Kelly, RN, BSN; Cynthia Stewart, LCSW; Rebecca Rottman-Sagebiel, PharmD, BCPS, CGP; Melody Moris; Daniel MacCarthy; and Chen-pin Wang, PhD).

References

1. US Department of Veterans Affairs. Office of Rural Health Annual report: Thrive 2016. https://www.ruralhealth.va.gov/docs/ORH2016Thrive508_FINAL.pdf. Accessed September 10, 2019.

2. Holder KA. Veterans in Rural America: 2011–2015. US Census Bureau: Washington, DC; 2016. American Community Survey Reports, ACS-36.

3. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis.2017. National and regional projections of supply and demand for geriatricians: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/GeriatricsReport51817.pdf. Published April 2017. Accessed September 10, 2019.

4. Peterson L, Bazemore A, Bragg E, Xierali I, Warshaw GA. Rural–urban distribution of the U.S. geriatrics physician workforce. J Am Geriatr Soc. 2011;59(4):699-703.

5. Lindeman D. Interview: lessons from a leader in telehealth diffusion: a conversation with Adam Darkins of the Veterans Health Administration. Ageing Int. 2010;36(1):146-154.

6. Darkins A, Foster L, Anderson C, Goldschmidt L, Selvin G. The design, implementation, and operational management of a comprehensive quality management program to support national telehealth networks. Telemed J E Health. 2013;19(7):557-564.

7. US Department of Veterans Affairs. Clinical video telehealth into the home (CVTHM)toolkit for providers. https://www.mirecc.va.gov/visn16//docs/CVTHM_Toolkit.pdf. Accessed September 10, 2019.

8. Darkins A. Telehealth services in the United States Department of Veterans Affairs (VA). https://myvitalz.com/wp-content/uploads/2016/07/Telehealth-Services-in-the-United-States.pdf. Published July 2016. Accessed September 10, 2019.

9. US Department of Veterans Affairs. VA announces telemental health clinical resource centers during telemedicine association gathering [press release]. https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Published May 16, 2016. Accessed September 10, 2019.

10. Hung WW, Rossi M, Thielke S, et al. A multisite geriatric education program for rural providers in the Veteran Health Care System (GRECC Connect). Gerontol Geriatr Educ. 2014;35(1):23-40.

11. Kramer BJ. The VA geriatric scholars program. Fed Pract. 2015;32(5):46-48.

12. Kramer BJ, Creekmur B, Howe JL, et al. Veterans Affairs Geriatric Scholars Program: enhancing existing primary care clinician skills in caring for older veterans. J Am Geriatr Soc. 2016;64(11):2343-2348.

13. Powers BB, Homer MC, Morone N, Edmonds N, Rossi MI. Creation of an interprofessional teledementia clinic for rural veterans: preliminary data. J Am Geriatr Soc. 2017;65(5):1092-1099.

14. Wright SM, Hedin SC, McConnell M, et al. Using shared decision-making to address possible overtreatment in patients at high risk for hypoglycemia: the Veterans Health Administration’s Choosing Wisely Hypoglycemia Safety Initiative. Clin Diabetes. 2018;36(2):120-127.

15. Chang W, Homer M, Rossi MI. Use of clinical video telehealth as a tool for optimizing medications for rural older veterans with dementia. Geriatrics (Basel). 2018;3(3):pii E44.

16. US Department of Veterans Affairs, Office of Rural Health. Rural promising practice issue brief: GRECC Connect Project: connecting rural providers with geriatric specialists through telemedicine. https://www.ruralhealth.va.gov/docs/promise/2017_02_01_Promising%20Practice_GRECC_Issue%20Brief.pdf. Published February 2017. Accessed September 10, 2019.

17. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA expands telehealth by allowing health care providers to treat patients across state lines [press release]. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4054. Published May 11, 2018. Accessed September 10, 2019.

18. US Department of Veterans Affairs. Department of Veterans Affairs FY 2018 – 2024 strategic plan. https://www.va.gov/oei/docs/VA2018-2024strategicPlan.pdf. Updated May 31, 2019. Accessed September 10, 2019.

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Author and Disclosure Information

Camilla Pimentel is a Research Health Scientist at the Center for Healthcare Organization and Implementation Research and the New England Geriatric Research Education and Clinical Center (GRECC), and Megan Gately is a Program Manager and Lauren Moo is Site Director at the New England GRECC, Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts. Steven Barczi is a Physician at Madison GRECC, William S. Middleton Memorial Veterans Hospital in Wisconsin. Kenneth Boockvar is Associate Director (research), Judith Howe is Deputy Director, and William Hung is Associate Director (clinical) at Bronx/NY Harbor GRECC, James J. Peters Veterans Affairs Medical Center in New York. Ella Bowman is a Geriatrician and Alayne Markland is Associate Director (clinical) at the Birmingham/Atlanta GRECC in Alabama. Thomas Caprio is a Geriatrician at the Canandaigua VA Medical Center in New York. Cathleen Colón-Emeric is Associate Director (clinical) at the Durham GRECC, Durham VA Medical Center in North Carolina. Stuti Dang and Willy Valencia-Rodrigo are Geriatricians at the Miami GRECC, Miami VA Healthcare System in Florida. Sara Espinoza is Associate Director (clinical) at the San Antonio GRECC, Audie L. Murphy Memorial VA Hospital in Texas. Kimberly Garner is Associate Director (education & evaluation) at the Little Rock GRECC, Central Arkansas Veterans Healthcare System. Patricia Griffiths is a Research Health Scientist at the Birmingham/ Atlanta GRECC, Atlanta VA Medical Center in Decatur, Georgia. Hillary Lum is a Geriatrician at the Eastern Colorado GRECC, VA Eastern Colorado Health Care System in Denver. Michelle Rossi is Associate Director (clinical) at the Pittsburgh GRECC, VA Pittsburgh Healthcare System in Pennsylvania. Stephen Thielke is Associate Director (education & evaluation) at the Puget Sound GRECC, Puget Sound VA Medical Center in Seattle, Washington.

Author affiliations can be found at the end of the article. *Both authors contributed equally to this manuscript.
Correspondence: Camilla Pimentel ([email protected])

Author disclosures
The authors report no actual or potential conflicts of interest with regard to the article.

Issue

Federal Practitioner - 36(10)a

Publications

Federal Practitioner

Topics

Geriatrics

Page Number

464-470

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