QUERI – Quality Enhancement Research Initiative

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Virtual Specialty Care QUERI Program: Implementing and Evaluating Technology Facilitated Clinical Interventions to Improve Access to High Quality Specialty Care for Rural Veterans

Puget Sound, WA

Principal Investigator: John Fortney, PhD (VA Puget Sound), Co-Is: Michael Ohl, MD (VA Iowa City), Greg Reger, PhD (VA Puget Sound), Carolyn Turvey, PhD (VA Iowa City), Bonnie Wakefield, PhD (VA Iowa City)

Principal Operational Partners: Rural Health (ORH), VA Telehealth Services, Connected Health (Virtual Care)

Executive Summary:

The VA healthcare system provides care to 3.3 million Veterans living in rural areas, comprising 36% of all VA enrollees. In 1995, VA began expanding its system of community-based outpatient clinics (CBOCs) in order to improve access for the geographically dispersed Veteran population. There are now approximately 900 CBOCs delivering a range of services to about 64% of VA enrollees. While these CBOCs have dramatically improved access to first-class primary care services, it has been more challenging to deliver specialty care to rural Veterans. Evidence-based specialty care practices developed for large VA medical centers are often not feasible to deploy in small CBOCs, and thus not accessible to rural Veterans. This QUERI Program will work to implement and evaluate technology-facilitated clinical interventions designed to improve outcomes for rural Veterans.

Program MyVA and Choice Act Goals: Improve healthcare access for Veterans living in rural settings, and enhance strategic partnerships through engagement with the U.S. Postal Service (Project 2). The MyVA initiative will reorient VA around Veterans' needs and empower employees to assist them in delivering excellent customer service to improve their experience with VA healthcare.

Program Objectives:

Implement and evaluate promising clinical practices incorporating virtual care technologies in order to improve access to high-quality care for Veterans residing in rural settings. To achieve this goal, the Virtual Specialty Care QUERI has three specific aims:

  • Develop, evaluate, and refine implementation strategies to roll out promising clinical practices that incorporate various virtual care technologies, e.g., teleheath, ehealth, and mhealth (mobile health);
  • Evaluate and refine promising clinical practices that incorporate virtual care technologies - developed at VA Rural Resource Centers and elsewhere - that are designed to improve access to high-quality care for rural Veterans; and
  • Measure implementation costs and assess the budget impact for operational partners.

Program Methods:

Proposed projects will compare enhanced implementation strategies to standard implementation strategies. Enhanced implementation will include a variety of strategies including ethnographic methods to assess the existing clinical workflow at implementation sites, and modification of both the existing clinical workflow and the new clinical intervention to maximize fit. Evaluation of the implementation strategies will be assessed to measure provider adoption and sustainability. Population-level effectiveness of the clinic intervention will be examined to measure reach and outcomes. Given the dynamic nature of technology and the high degree of variability in context across clinics, investigators will employ methods that enable the new clinical intervention to be adapted from setting to setting, and to be refined over time rather than focusing on fidelity to a manualized protocol.

Project Summaries:

Project 1:Compare standard to enhanced VA implementation strategy through Telemedicine Outreach for PTSD to increase Veterans' access to PTSD services, especially in rural areas, and to determine cost effectiveness.

Project 2:Use the electronic exchange of health communication to increase the communication between VA, community care, and Veterans' informal care provider networks providers through another comparison of standard and enhanced implementation strategies, in collaboration with the US Postal Service.
Project 3 (Quality Improvement):Evaluate the use of clinical video-telehealth to home incorporated with Home-Based cardiac rehabilitation (CR) for Veterans who live far away from CR services.

Project 4 (Quality Improvement):Analyze how effectively and frequently the prolonged exposure mobile app 'PE Coach' is being used by therapists and patients, and evaluate the success of implementation strategies in the VA Puget Sound Healthcare System.