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QUERI Helps Ensure Veterans Receive High-Quality Care: Anytime, Anywhere

Between January 2020 and 2021, the number of VA telehealth appointments increased by 1,831%. In January 2020 alone, VA facilitated about 41,000 telehealth appointments. By April – one month into the COVID-19 pandemic – Veterans had used VA telehealth services for more than 393,000 appointments.¹ Even before the pandemic, Veterans’ use of telehealth was surging. In 2019, more than 900,000 Veterans used VA virtual care, with the use of VA’s Video Connect app up by 235%.²

Through expanding telehealth during the COVID pandemic, VA has made substantial gains in improving access to timely healthcare services among Veterans via the following telehealth modalities:

• Clinical Video Telehealth is the use of real-time interactive video conferencing to assess, treat, and provide care to a patient remotely.
• Home Telehealth is a program into which Veterans are enrolled that applies care and case management principles to coordinate care using health informatics, disease management, and technologies, such as in-home and mobile monitoring, messaging, and/or video technologies.
• Store-and-Forward Telehealth is the use of technologies to acquire and store clinical information (i.e., data, image, video) that is forwarded to or retrieved by a provider at another location for clinical evaluation.

QUERI is supporting sites and frontline providers in delivering care to Veterans using virtual care technologies. The following are QUERI-funded initiatives that are implementing and evaluating evidence-based practices to ensure that Veterans receive high-quality care anytime, anywhere.

Dynamic Diffusion Network (DDN) QUERI Program: DDN QUERI works to expand evidence-based practices in diabetes and moral injury care. As part of these efforts, QUERI investigators are working with the VHA Innovation Ecosystem to evaluate strategies for the implementation of Advanced Comprehensive Diabetes Care (ACDC) across 10 additional VA facilities. Already in place in 13 sites, ACDC is a nurse-administered telehealth program for Veterans with persistently poor diabetes control despite use of existing VA services. The program uses existing VHA telehealth staffing and equipment to deliver diabetes self-management support and clinician-guided medication management. ACDC began as a QUERI sponsored rapid response project in 2014. The VHA Office of Rural Health (ORH) began supporting ACDC in 2017 and designated ACDC a Rural Promising Practice in 2020. ACDC was also named a Diffusion of Excellence Promising Practice in 2018. 

By providing special support to Veterans whose diabetes remains poorly controlled despite receiving standard VA diabetes care, ACDC empowers Veterans to achieve improved control, better self-management, and a positive experience. The DDN QUERI Program will build on ACDC’s prior success and will expand our understanding of how to implement the intervention most effectively. —Mathew Crowley, MD, MHS, Multiple Principal Investigator, DDN QUERI

eHealth Partnered Evaluation: eHealth QUERI investigators are working on: the Veterans Engagement with Technology Collaborative (VET-C), which gathers data on demographics, technology use, health-related goals, and perceptions about communication and access from more than 2,700 Veterans across the U.S.; the COVID-19 New Users Rapid Evaluation collects data from VA clinical team members who use select connected care technologies and identifies challenges encountered among team members who started using these technologies during the outbreak; and the Rapid Evaluation of the VA Pain Coach Mobile App, which is suggesting positive impacts on pain self-efficacy and emphasized the importance of provider endorsement to app adoption.

Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): The goal of EMPOWER QUERI is to expand access to virtual, evidence-based, preventive and mental health services for women Veterans. As part of this objective, EMPOWER is implementing three evidence-based practices: 1) The Virtual Diabetes Prevention Program—a 12-month evidence-based lifestyle intervention, emphasizing moderate weight loss, diet, and physical activity, that has been shown to prevent and/or delay progression to type 2 diabetes. 2) The Telephone Lifestyle Coaching Program (TLC), developed by one of their partners (National Center for Health Promotion and Disease Prevention), provides evidence-based virtual (telephone-based), individual-level, personalized health coaching focused on wellness and cardiovascular disease prevention. 3) Reach Out, stay Strong, Essentials (ROSE) – an evidence-based intervention for prevention or perinatal depression that can be delivered via telehealth.

Expanding Expertise through E-Health Network Development (EXTEND) QUERI: EXTEND works to expand Veterans access to evidence-based care via telehealth services and helps optimize shared care between telehealth, specialty, and primary care services. Working with national and regional partners, QUERI investigators will work to achieve VA’s goal of “Anywhere to Anywhere” telehealth that crosses traditional organizational and geographic boundaries.

The VA National Teleneurology program completed 836 new patient consultations at 12 VAMCs in FY21, significantly improving Veteran access to and time to scheduling and completion for outpatient neurology care. Veterans and referring providers were highly satisfied with the Teleneurology care, noting ease of access and communication with the teleneurologists as a benefit of the system. —Linda Williams, MD, Multiple Principal Investigator, EXTEND QUERI

Measurement Science QUERI: Working with VA’s National Office of Cardiology, QUERI investigators are helping expand the remote monitoring of cardiac implantable electronic devices, such as pacemakers and implantable cardioverter-defibrillators. It is estimated that remote monitoring will mitigate harm from faulty devices and reduce cardiovascular mortality for more than 2,500 Veterans from 2020 to 2025.

In collaboration with the National Cardiovascular Device Surveillance Program, Measurement Science QUERI developed and implemented a national dashboard that providers now use to view remote transmissions from patients. —Mary Whooley, MD, Principal Investigator, Measurement Science QUERI

We have received a large amount of positive feedback on the Dashboard. The prominent display of their clinic’s adherence seems to bring the issue to their attention – and the ease of identifying patients who have not been adherent really enhances their ability to improve their clinic’s performance on this important metric. —Merritt Raitt, MD, Director, Arrhythmia Service, VA Portland Healthcare System

RIVET QUERI Program: High-RIsk VETerans (RIVET) QUERI is addressing barriers to medication adherence by supporting the uptake of phone-based health coaching to identify and address patient goals, preferences, and barriers around taking medications.

QUERI Evaluation of Video Telehealth Tablets: Working with VA’s Offices of Rural Health and Connected Care, QUERI investigators are evaluating the effectiveness of VA-issued tablets for high-risk Veterans. Over the first year of the COVID-19 pandemic, nearly 76,000 VA patients received tablets, with more than 70% having a mental health condition. Investigators are working to enhance the reach, adoption, and implementation of the tablet initiative.

TeleWound Practice Initiative: QUERI teams are evaluating the impact of the TeleWound Practice Program (TWP), a Diffusion of Excellence practice that provides wound care to Veterans using telehealth technologies. Evaluation of the TWP roll-out in VISN15 showed that of 161 Veterans who participated in the TWP, the vast majority were highly satisfied with their care (86%) – and it reduced their travel costs (81%). A majority of Veterans also were interested in continuing to receive TeleWound care (66%).

Virtual Care QUERI: This QUERI Program supports clinical operations partners in the roll-out of evidence-based practices that incorporate virtual care technologies to improve access for rural Veterans receiving care at home and in Community Based Outpatient Clinics (CBOCs). Operational partners include VA Offices of Rural Health (ORH), Connected Care (OCC), Mental Health and Suicide Prevention (OMHSP), and Electronic Health Record Modernization.

Advance Diversity in Implementation Leadership

QUERI’s Advancing Diversity in Implementation Leadership (ADIL) initiative aims to promote implementation, quality improvement (QI), and evaluation leadership opportunities that reflect the diversity of our Veterans. QUERI is supporting nine ADIL awardees who are addressing VA priorities, including improving the uptake of strategies to address health disparities and Veteran social determinants of health, assessing and improving quality and cost of community care, improving Veteran experience and quality of virtual care options, and promoting the uptake of strategies that improve VA women’s health services.

ADIL Awardees working to improve Veteran experience and quality of virtual care options in VA and community care include:

• Sarah Ferguson, PhD, under the mentorship of Donna Zulman, MD, is examining patient characteristics associated with the frequency and quantity of video-based telehealth and will evaluate whether VA’s Digital Divide consult is an effective implementation strategy for facilitating video-based care.
• Tanya Olmos-Ochoa, PhD, MPH, under the mentorship of Alison Hamilton, PhD, is working to promote equitable access to evidence-based virtual lifestyle interventions for women Veterans with diverse backgrounds and lived experiences.
• Kamal Henderson, MD, MSc, under the mentorship of Michael Ho, MD, and Karen Albright, PhD, is leading an evaluation of sub-specialty wait-times among priority Veteran populations.

References

1. Ogrysko N. VA’s meteoric telehealth expansion poses new questions for the future. Federal News Network. April 28, 2021.
2. Eddy N. VA sees a surge in Veterans’ use of telehealth services. Healthcare IT News. November 25, 2019.