This article was downloaded by: [University of North Texas] On: 11 November 2014, At: 16:07 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
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A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect) William W. Hung
a b
c
d
, Michelle Rossi , Stephen Thielke , Thomas
e
f
g
Caprio , Steven Barczi , B. Josea Kramer , Gary Kochersberger , Kenneth S. Boockvar
a b
, Abraham Brody
a b
& Judith L. Howe
e
a b
a
Department of Geriatrics and Palliative Medicine , Mount Sinai School of Medicine , New York , New York , USA b
Geriatrics Research, Education, and Clinical Center , James J. Peters Veterans Affairs Medical Center , Bronx , New York , USA c
Geriatrics Research, Education, and Clinical Center, Pittsburgh VA Medical Center , Pittsburgh , Pennsylvania , USA d
Geriatrics Research, Education, and Clinical Center, Puget Sound VA Medical Center , Seattle , Washington , USA e
Canandaigua/ Rochester VA Medical Center, University of Rochester , Rochester , New York , USA f
Geriatrics Research, Education, and Clinical Center, William Middleton VA Medical Center , Madison , Wisconsin , USA g
VA Greater Los Angeles Healthcare System Geriatric Research, Education, and Clinical Center , Los Angeles , California , USA Accepted author version posted online: 08 Jan 2014.Published online: 17 Jan 2014.
To cite this article: William W. Hung , Michelle Rossi , Stephen Thielke , Thomas Caprio , Steven Barczi , B. Josea Kramer , Gary Kochersberger , Kenneth S. Boockvar , Abraham Brody & Judith L. Howe (2014) A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect), Gerontology & Geriatrics Education, 35:1, 23-40, DOI: 10.1080/02701960.2013.870902 To link to this article: http://dx.doi.org/10.1080/02701960.2013.870902
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Gerontology & Geriatrics Education, 35:23–40, 2014 ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2013.870902
A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect)
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WILLIAM W. HUNG Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
MICHELLE ROSSI Geriatrics Research, Education, and Clinical Center, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA
STEPHEN THIELKE Geriatrics Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, Washington, USA
THOMAS CAPRIO Canandaigua/ Rochester VA Medical Center, University of Rochester, Rochester, New York, USA
STEVEN BARCZI Geriatrics Research, Education, and Clinical Center, William Middleton VA Medical Center, Madison, Wisconsin, USA
B. JOSEA KRAMER VA Greater Los Angeles Healthcare System Geriatric Research, Education, and Clinical Center, Los Angeles, California, USA
GARY KOCHERSBERGER Canandaigua/Rochester VA Medical Center, University of Rochester, Rochester, New York, USA
KENNETH S. BOOCKVAR, ABRAHAM BRODY, and JUDITH L. HOWE Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
This article not subject to U.S. copyright law. Address correspondence to William W. Hung, Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA. E-mail: [email protected]
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Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts. KEYWORDS geriatrics education, rural, telehealth intervention
INTRODUCTION The aging of the baby boomer cohort in the United States is expected to lead to an increasing proportion of older adults in the population in the near future—with an increasing proportion of adults age older than 65 from 13.7% currently to 21.9% in 2060, and for age 85 and over from 2% to more than 5% (U.S. Census, 2013). For rural areas, recent data from the American Community Survey found that the age 65 and over age group accounted for more than 15% of the nonmetropolitan population, compared with 12% of the metropolitan population (U.S. Census Bureau, 2009). Although it is challenging to predict shifts in elderly population in rural areas given multiple trends in migration and aging, it is expected that the older population will continue to be disproportionately higher in rural regions (Glasgow & Brown, 2012). Within the veteran health care system (VHA), Veterans living in rural areas are, on average, older than their urban counterparts. Almost one half of rural Veterans are between age 55 to 74 and another 26% are older than age 75 (National Center for Veteran Analysis and Statistics, 2012). Older adults living in rural areas often have more significant health care needs—with a higher proportion living in poverty, poorer health status, and higher burden of chronic diseases (Rosenthal & Fox, 2000; U.S. Department of Agriculture, 2013; Wen, Browning, & Cagney, 2003). These older Veterans living in rural areas often do not have access to specialized geriatric care, the availability of which is important to improve the quality of care for older adults living
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in rural areas (Gruen, Weeramanthri, Knight, & Bailie, 2004; Williams, 1995; Williams, Ricketts, & Thompson, 1995). Currently workforce in the United States and also in the VHA is not likely to be able to meet the needs of providing adequate care for this rapidly expanding segment of the population (Institute of Medicine, 2008). Currently, geriatric physician workforce is small, with approximately 7,412 physicians according to the most recent report in 2008, accounting for 1.07 geriatricians per 10,000 older adults; more than 90% practicing in urban areas (Peterson, Bazemore, Bragg, Xierali, & Warshaw, 2011). This disparity in rural and urban distributions of the geriatric health care workforce makes provision of adequate care for older adults in rural areas even more challenging (Lund, Charlton, Steinman, & Kaboli, 2013). Novel models of care are needed to best utilize the limited resources in geriatric medicine to provide care for older adults in rural areas (Edirippulige, Martin-Khan, Beattie, Smith, & Gray, 2013; Esterle & Mathieu-Fritz, 2013; Fisk, 1997; Juretic et al., 2010). Within the Veterans Administration (VA), prior and ongoing programs have targeted this disparity by developing the workforce and equipping rural primary care providers with skills in managing geriatric problems (Tumosa et al., 2011). The Geriatric Scholars Program allowed rural clinics to send primary care providers (PCPs) and staff to geriatric centers for a short, intensive geriatric training coupled with elements of ongoing quality improvement projects to educate rural PCPs on geriatric care (Tumosa et al., 2012). Although the VA Geriatric Scholars Program has provided condensed training in geriatrics to empower rural PCPs to diagnose and manage common geriatric syndromes, significant care gaps still exist as these providers still struggle to address more medically and psychosocially complex cases that are best managed with the real-time input of an interdisciplinary geriatric team. Telemedicine is an attractive modality to bring patient-centered care to Veterans particularly in rural areas where access to specialist care is limited by distance and travel (Shah, McDermott, Gillespie, Philbrick, & Nelson, 2013) Because telemedicine does not require providers to be on-site at rural areas, geriatric providers located in urban health care centers can be accessed for management of patients located in rural areas (Rubegni et al., 2011; Scalvini & Zanelli, 2002; Solomon et al., 1996). Despite limited reports on the application of telemedicine in geriatric medicine, the majority have suggested that telemedicine can be applied safely (Brignell, Wootton, & Gray, 2007). Several small projects have demonstrated that care relevant to older adults can be delivered using telemedicine modalities, such as dementia assessment and wound care, and has the potential to improve access and patient satisfaction (Bratton & Short, 2001; Brignell et al., 2007; Cravens et al., 2005; Luptak et al., 2010). Telemedicine modalities may include direct patient consultation, teleconferencing for provider-to-provider discussions or consultation via electronic means such as chart-based electronic consultation, a model that has been increasingly utilized in the VA. Another model that has been
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tested and found effective is the extension for community healthcare outcomes (ECHO) model (Arora, Thornton, Jenkusky, Parish, & Scaletti, 2007) that was developed in New Mexico, primarily as an educational model to discuss cases brought by PCPs at rural sites, to a consultation specialist located at the urban center (Arora et al., 2011). The goal of the ECHO model was to educate rural providers in the care of future patients with similar conditions. This model was first applied to the treatment of patients with hepatitis C infection and achieved similar disease control as a specialist-based clinic for hepatitis C (Arora et al., 2010; Arora, Thornton, et al., 2011). VHA has adapted the ECHO approach, called SCAN-ECHO (Specialty Care Access NetworkECHO), to serve Veterans in rural areas in a pilot effort in several specialties, such as hepatitis and pain management (U.S. Department of Veteran Affairs, 2012). In this project, the participating geriatric research, education and clinical centers (GRECCs) are centers of excellence in geriatric care within the VA system located in urban VA medical centers that act as the resource site for geriatric consultation using various telehealth modalities currently in use in VHA. We have included a case-based conference educational program for primary care providers similar to the ECHO model to enhance provider knowledge and skills and to go hand-in-hand with the implementation of the clinical consultation components of the program. The rationale of the approach is to enhance visibility and promote implementation of the clinical program, while building relationships with providers to identify potential barriers and facilitators for telehealth outreach. Here we describe our project and experience in establishing the connection between GRECC and rural clinics efforts, called “GRECC-Connect,” while discussing how educational approaches can be used to aid implementation efforts.
METHOD Project Goal and Setting Recognizing the lack of access to geriatric care in rural settings, the goal of GRECC-Connect is to improve health care for older adult veterans at rural VHA clinics with support from multiple GRECCs and to establish a model of collaboration and excellence for care in rural clinics without geriatrics expertise through the provision of telehealth modalities. Project interventions were built upon the current clinical and administrative infrastructures of the four GRECCs and the current network of geriatric scholars. The VA Geriatric Scholars Program has engaged participants from all regions within the VHA networks including 276 health care providers (122 physicians, 88 nurse practitioners or physician assistants, 33 pharmacists, and 33 social workers) from 195 facilities. The program has provided condensed training in geriatric care
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to equip rural primary care providers and their staff with skills to deliver basic geriatric care and has empowered them to diagnose and manage common geriatric syndromes. Establishing the GRECC-Connect project using GRECCs and under the umbrella of the Geriatric Scholars Program allowed for leveraging the resources of already established geriatric centers of excellence and of engaged rural scholar clinicians. These health care providers are well positioned to be champions in creating clinical partnerships with GRECCs to access geriatrics consultation for their sites through an array of teleconferencing and telemedicine strategies; they can also serve to recruit additional providers at their respective clinical sites as well. The objectives are (a) to establish and enhance the infrastructure from GRECCs to support rural primary care providers who have participated in the VA Geriatric Scholars Program (and other providers who have not engaged in the Geriatric Scholars Program) so that they can deliver highquality geriatrics care to older Veterans at rural clinics; (b) to provide expert interprofessional clinical consultation via teleconferencing to enhance geriatric care for medically complex older Veterans; and (c) to provide ongoing case-based training in geriatrics for PCPs practicing in rural clinics. VHA has already made investments in telecommunications equipment and network which the project utilizes in establishing linkages with the rural clinics. These outreach modalities include virtual medicine where Veterans are seen by geriatric providers located at distance sites, provider to provider consultation via electronic consultation through electronic consult request and chart review (E consults in the VA system), and provider to provider teleconference or huddles where clinical issues for multiple patients can be discussed in a teleconference meeting. The target population served by this project is older rural Veterans, particularly those with complex medical problems, geriatric syndromes, and those who are vulnerable and at risk for institutionalization. To supplement the implementation of these new consultative services within the rural clinic setting, we have established a regularly scheduled case-based conference with multiple clinics linking up with a GRECC site using teleconferencing. Cases are brought to the conference by rural primary care providers to be discussed by the geriatric interdisciplinary team at the GRECC. The rationale to include this program element is that these case conferences can educate primary care providers on best practices of geriatric medicine, while building relationships between GRECC-based teams and clinic providers and staff. At each session, a patient case with difficult to manage geriatric issues or syndromes, such as dementia, is presented by the provider, whereas the GRECC-based geriatric team focuses on specific issues in diagnosis or management with the participants in the conference. To assess the needs of targeted providers, a needs assessment was conducted across the rural sites to identify topics of interest and perceived priority areas of education.
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Evaluative Strategy When considering the potential impact of our educational initiative and proposing possible outcomes, we have adapted the SCAN-ECHO logic model from VA (VA Office of Specialty Care Transformation, 2013) that has summarized the approach for VA SCAN-ECHO programs. We have modified it to include items on the clinical interventions and anticipated outcomes related to the implementation of the clinical interventions (Figure 1) to guide our efforts. The model outlines the inputs, outputs, and potential outcomes of the intervention. Utilization of a logic model allows for consideration of a comprehensive approach to assess intervention resources and determine its potential processes and outcomes. The resources (inputs) include GRECC sites with geriatric teams, rural clinics with primary care providers and team members from Patient Aligned Care Teams (PACT) (which is similar to a patient-centered medical home model), teleconferencing equipment, and resources. The output would be case-based conferences and other clinical telemedicine modalities that may affect patient care. Proposed outcomes are related to the evaluation of geriatric issues by the various clinical modalities, with short-term outcomes including provider knowledge, skills and attitudes, satisfaction, and others. Long-term outcomes include retention of providers and GRECC teams, reliance of patients on VA system care, and the demonstration of overall change in patient care outcomes within the system served by the program.
Implementation Issues Across Sites GRECC-Connect is a collaboration of four GRECC sites and a medical center with geriatric resources (five sites altogether). The rationale for the multisite collaboration is to expand the reach of the program to rural clinics in multiple regions, allowing each site to involve multiple rural providers who have participated in the nationwide VA Geriatric Scholars Program. Furthermore, each GRECC can contribute to the collaborative with specific expertise in geriatrics, which also allow for learning from each others’ processes during the set-up of the intervention. As each site has different contexts and settings, implementation of modalities of outreach varied across sites. During the implementation process, we have considered facilitators and encountered barriers in the implementation efforts, with GRECC and rural clinic sites that are at various stages of readiness, and organizational settings for adopting particular methods of outreach to rural clinics. These included clinical video telehealth (direct telemedicine consultation between geriatric specialists and patients), electronic consultation (provider-to-provider consultation via electronic chart review) or telehuddle approaches (also provider-to-provider contact with face-to-face discussion via teleconferencing).
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Identification of patients by PCP, case finding
Clinical care by trained PCPs—use of consults and telehealth modalities
Educate primary care providers
Case Presentations and discussions
Outputs
Rural/ nonrural geriatrics
Older primary care patients
PCPs PACT team members
Functional ability Cognitive assessment Nutritional status Condition specific symptom presence Geriatric conditions Use of non-VA care Social situation
Evaluation of relevant issues in older patients:
Patients
Processes
FIGURE 1 Proposed logic model for GRECC Connect project (color figure available online). Note: CVT: clinical video telehealth.
External Factors Funding for GRECC sites
Telehealth/ CVT equipment
Cases
Patient Aligned Care Team (PACT) team members
Primary care providers (PCPs)
Care Sites
Primary
GRECC Sites Geriatric interdisciplinary teams
Inputs
Consult workload Waiting time for consults Use of other telemedicine Modalities
System
Clinical indicators Patient satisfaction Location of care and by whom Appropriate medications Caregiver satisfaction Caregiver stress
Patients
Satisfaction with this type of care delivery Consult workload
GRECC Geriatrics Team
Knowledge change Attitude change Change in skills and behaviors→adoption of consult recommendations Referral to other noninstitutional modalities for older adults Satisfaction
PCPs
Outcomes Short
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Utilization/policy Demonstration of Improved care
System
Continued VA Utilization Long term outcomes (eg. institutionalization, maintenance of function)
Patients
Retention
GRECC Geriatrics Team
Retention Satisfaction
PCPs
Long
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Facilitators and barriers are summarized in Table 1. From the systems perspective, the project was funded by VA as VHA has placed significant emphasis in improving care for older adults, particularly within rural areas, and in extending care to rural areas through various telehealth modalities. Thus, information technology and telehealth equipment has already been deployed to rural areas in preparation for this type of expansion of care. Another facilitating factor is the organization and infrastructure already in place as GRECCs are centers with geriatric interdisciplinary staff that can be mobilized to implement the rural outreach and are centers that serve a particular geographic region with a number of affiliated clinics and medical centers. Some GRECCs already have relationship with the rural providers, either as consultants that providers would send patients to or as educational resources. Utilizing geriatric clinical resources to serve rural providers and patients through telehealth means would be a natural extension of these relationships. The Geriatric Scholar Program also helps to facilitate the project as there are already scholars that have been trained through the program that serve as champions at rural sites where the interventions would be delivered. TABLE 1 Facilitators and Barriers for Establishing and Sustaining the GRECC-Connect Program Facilitators
Barriers
System VA emphasis on rural health VA emphasis on expansion of telehealth modalities Performance measures for telehealth (though not specific to geriatrics) Funding Support from regional and local offices Available GRECC infrastructure
System Competing programs and resources Initial funding for one year only Obtaining support from regional and local offices
GRECC Established geriatric teams and expertise Expertise on specific geriatric topics Information technology equipment and support Familiarity with evaluative strategies Experience in clinical demonstration projects Existing relationship of referrals with rural providers
GRECC Competing programs Limited staff time Familiarity and comfort with telehealth use Administrative steps for setup of clinic Delays in hiring new staff
Rural clinics Provider interest Champions (geriatric scholars) Information technology equipment and support
Rural clinics Provider staff time and effort Variable level of knowledge and skills, and attitude Familiarity and comfort with telehealth use
Note: GRECC = Geriatric Research, Education, and Clinical Centers; VA = Veterans’ Administration.
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However, barriers to implementation are also significant. As the current federal funding climate is tight, the initial project funding lasts for only one year, with the expectation that the project would be sustained through other means within VA (thus require resources committed in advance by VA regional and local centers). Obtaining future support for the program at the regional and local level requires clear demonstration of potential benefits that must be weighed by local offices against competing programs and services. In addition, rural providers are full-time clinicians for rural Veterans; finding time to participate in an educational program is a challenge. Other significant barriers include hiring delays and administrative steps needed to set up a particular clinical modality—even within a single VA health care system, each medical center, or regional systems have unique established policies which further complicates how these modalities can be set up. To further identify and confirm needs from the provider perspective, we conducted a preprogram survey.
Needs Assessment (Preprogram Survey) The needs assessment was conducted via online survey collected anonymously. The survey was developed to assess provider knowledge, attitude, and provider comfort in using telehealth modalities. Questions on provider training included educational degrees and type of prior geriatric training. Level of interest (on a scale of 0–10) on specific geriatric topics was also included. Providers were questioned whether they had referred patients for geriatric consultation; and also if geriatric consultation were to become available, how often would providers be referring patients for consultation. Providers were asked to indicate their top three consult questions. To determine provider comfort level in using telemedicine modalities, providers were asked to indicate on a 5-point Likert-type scale (ranging from 1 [very uncomfortable] to 5 [very comfortable]) their comfort in using telemedicine modalities for clinical care and for education. Staff was also asked to identify the time within the week that they would be free to participate in a case-based conference.
Postprogram Survey The program was initiated in February 2013. Case conferences were conducted on a twice monthly schedule. After 6 months, a survey was sent to providers who participated in the case conferences to gauge their participation, satisfaction, and perceived impact of the program. Providers were asked to rate their satisfaction using a 5-point Likert-type scale, ranging from 1 (very unsatisfactory) to 5 (very satisfactory). Also providers were asked if they perceived any improvement in their knowledge on managing older adults, and in another question, if they perceived that their skills on managing older adults had improved.
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Analysis Characteristics and responses of providers surveyed were summarized with counts, proportions, means, and standard deviations as appropriate. Case conference topics and activities were described. Results of the needs assessment survey and the postprogram survey were summarized. Analysis was performed using Stata version 11.0.
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RESULTS The GRECC-Connect project has included four GRECCs located in various regions in the United States including Eastern region (Bronx, NY; Pittsburgh, PA), Midwest (Madison, WI), and Pacific region (Puget Sound, WA), and additionally included one VA Medical Center with geriatric resources (Canandaigua Rochester VA Medical Center, NY) located within a VA region without a GRECC. Together these five centers have implemented various modalities within their catchment area including clinical video telehealth in two centers, electronic consultation in three centers, and telehuddles in two centers. Case conferences have been established in two centers with a total of 14 regularly scheduled twice monthly sessions since February 2013. The differences in how the interventions have been set up at different sites can be explained by factors unique to each site. For example, at the Pittsburgh VA and the Puget Sound VA, where the geriatric teams at the GRECC have already developed existing relationships with rural providers and have been performing consultations on rural patients (though requiring significant travel time), clinical video telehealth was set up as the main modality to support rural providers. For centers (Bronx and Canandaigua) without existing clinical consultation with rural providers, case conferences were established first as educational modalities and a method of outreach to extend other clinical support and services. Because of the behavioral health expertise and resources at the Puget Sound GRECC, with psychiatry and psychology as the primary clinical staff in the project, the intervention focused mainly on mental health issues including dementia in older adults. On the other hand, Madison VA GRECC has a number of geriatric scholars within their catchment area and was able to mobilize a geriatric interdisciplinary team at their GRECC that can focus on comprehensive assessments; their main modality is telehuddle and electronic consultation with rural providers. Before project initiation, 21 providers from four sites completed the preprogram assessment (Table 2). Approximately 50% were physician providers (medical doctors or doctors of osteopathy) and approximately 50% were nurse practitioners. A minority (39%) reported having some training in geriatrics including fellowship, residency, or certificate program. Eighty percent of the providers reported that more than 50% of patients they are
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Multisite Geriatric Education Program for Rural Providers TABLE 2 Baseline PreProgram Survey Results Conducted Priort the Start of the Project
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Item Proportion of providers reported referring number of patients to geriatric consultation within past month (%) None 1–2 3–5 6–10 More than 10 Proportion of providers reported referring number of patients to geriatric consultation if geriatric consultation available through telemedicine (%) None 1–2 3–5 6–10 More than 10 Mean score of level of interest in various topics on a scale of 0–10 Dementia care Late life mental health issues Chronic care with complex needs Palliative care Delirium Falls and fall assessment Frailty Management of common medical problems in elderly Urinary incontinence Multiple chronic conditions Comfort level in using telemedicine modalities for clinical care (%) Very comfortable Comfortable Neutral Uncomfortable Very uncomfortable Comfort level in using telemedicine modalities for education (%) Very comfortable Comfortable Neutral Uncomfortable Very uncomfortable Professional degree (%) Medical doctor or doctor of osteopathy Nurse practitioner Physician’s assistant Prior training in geriatrics (%) Fellowship Residency Certificate Providers’ report of proportion of patients that they encounter aged 65 or older (%) 0%–25% 26%–50% 51%–75% 76%–100%
N = 21
65 30 5 0 0 17 44 33 6 0 8.6 8.3 8.3 8.2 8.0 7.3 7.2 7.0 7.0 6.9 25 44 31 0 0 20 53 27 0 0 50 50 0 5 10 24 0 20 60 20
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encountering in their clinics were age 65 and older. For referrals to geriatric consultation, 65% reported that they had not referred any patients to geriatric consultation in the previous month; 83% reported that they would do so if geriatric consultation would become available via telemedicine modalities. Comments from providers indicated that reasons for not referring more patients for geriatric consultation included distance and time for travel to medical centers where geriatric consultation is based and long waits to obtain an appointment. One provider noted that as a provider serving in a rural area her practice is very independent, without much access to other providers to review cases or ask questions; the “connection would be very helpful to me to have a connection with other providers who may have similar experiences and offer additional insights and suggestions.” Providers indicated that their top consult questions included cognitive assessment and dementia management, polypharmacy and medication management, and support services for elderly Veterans including palliative care. Top five topics of interest for further education included dementia care, late-life mental health issues, chronic care with complex needs, palliative care, and delirium. Overall, providers indicated that their comfort level with using telehealth modalities were high, with 69% reporting feeling comfortable or very comfortable in using telehealth modalities for clinical care and 73% reporting feeling comfortable or very comfortable in using telehealth modalities for education. However, finding a common time for conducting case conference was difficult as providers and PACT team members already have established clinic schedules for patient care. For one site, a time slot was identified that was time already protected for an hour-long continuing education activity throughout the region. The case conferences were implemented for a total of 14 sessions (Table 3). In each session, a clinical case was discussed, with the majority TABLE 3 Case Conference Topics and Participation Item Number of sessions Number of clinic sites per conference, mean (SD) Number of participants per conference, mean (SD) Number of sessions that covered the topics listed Dementia management including behavioral symptoms Discussion of patient preferences Cognitive assessment in older adults Medication management including polypharmacy Falls assessment Late life mental health problems such as depression Management of multiple chronic diseases with competing risks Care transitions in older adults Hip fracture Delirium
N = 30 (unique providers) 14 4.4 (1.3) 13.0 (4.3) 3 3 2 2 2 2 2 2 1 1
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of cases brought by PCPs at remote clinics, the rest were supplemented by cases from GRECC staff when cases were not identified by other participants in advance. The average number of remote sites that connected to GRECC for the case conference was 4.3 (SD = 1.3), and the average number of providers per conference was 13 (SD = 4.4). Cases included Veterans with dementia, multiple chronic diseases, heart failure, and automatic implantable cardioverter defibrillator management, recurrent hospital admissions with hospital acquired infections, and the topics discussed included dementia assessment and management, care planning, discussion of patient preferences, management of multiple medications, falls and risk factors for falls, palliative care and considerations for referrals to palliative care, transitions of care, and use of screening tools for geriatric problems such as for depression. In the postprogram survey, we received a total of 14 responses from a pool of 30 participants (response rate = 46.7%). A total of 15% of providers reported participating in case conferences more than 10 times, 54% reported participating three to five times, and 15% reported one to two times (Table 4). Self-reported use of other telehealth modalities included electronic consultation in 14% of providers and 29% reported using telehuddles. For provider TABLE 4 Postprogram Survey Results on Geriatric Research, Education, and Clinical Centers (GRECC) Connect Project Item Providers reporting improved skills on managing older adults (%) Yes No Missing Providers reporting improved knowledge on managing older adults (%) Yes No Missing Proportion of providers reporting participation in case-based conference (%) None 1–2 times 3–5 times 6–10 times More than 10 times Self-reported use of telehealth modalities to connect with the GRECC (%) E-consult Telehuddle Satisfaction in utilizing telemedicine modalities for education (%) Very satisfied Satisfied Neutral Unsatisfied Very unsatisfied
N = 14 79 14 7 57 36 7 15 15 54 0 15 14 29 17 50 33 0 0
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satisfaction among those who responded, 50% reported that they were satisfied and 17% reported being very satisfied. Approximately 57% of providers perceived that they had improved their knowledge in managing older adults, and 79% of providers reported having improved skills in managing older adults in their practice.
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DISCUSSION This report describes our experience in implementing a clinical intervention utilizing telehealth modalities in rural areas where geriatric care is lacking. As part of our program we have integrated educational components to improve provider knowledge and skills. Case conferences also provided an avenue to promote the clinical components of the program while establishing connections to enhance the implementation phase of the project. The format of the case conference, with case presentations brought by participating providers enhanced the experience because providers were more engaged in the discussion of their own patients with the discussion brought directly back to their patients’ care. The additional component of a group educational experience, in this case, a case-based conference, may have synergistic effects on the implementation of the clinical components. Also, although the clinical components in GRECC-Connect such as consultation via electronic consults, huddles, or clinical video telehealth are not necessarily considered educational but rather clinical services, they do act to reinforce geriatrics concepts and facilitate a strong interpersonal teaching and learning relationship between the consultant and the primary provider. On the other hand, the case-based conference in a group setting is not only educational by design, but also has potential for real-time improvement in care in the specific cases discussed. Older adults who may otherwise have little access to geriatric care may have improved access to geriatric expertise via these types of conferences and clinical interventions. For Veterans who normally would need to travel to see geriatric consultants in urban VA medical facilities, they may avoid such trips while improving access to geriatric resources. This addressed a significant barrier for rural Veterans to receive geriatric care. Considering the challenge of implementing novel clinical programs in multiple locations across the country with multiple providers, this project was implemented under the umbrella of the Geriatric Scholars project, which was an already existing network of rural front-line PCPs. This facilitated collaboration as these providers served as champions to establish further working relationships with GRECCs within a short period of time. As the Geriatric Scholars project is an educational program that has been established for several years, the infrastructure and communication resources such as network SharePoint allowed for reaching out and efficiently distributing information to providers, engaging providers that understand the need for specialized care for older adults in rural areas, and enhancing connections
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with centers of geriatric care. These represent significant facilitating factors that may lead to the successful implementation of the ”virtual” collaboration. As a grant-funded project, the ability to sustain the project beyond the grant period relies on the demonstration of positive impact on patient care, such as health outcomes, patient and provider satisfaction, and costs. As this project improves access to geriatric care and consultation through telehealth modalities and promotes the development of geriatrics skill and expertise for rural providers, it also aimed to enhance the clinical competency of rural providers through the discussion of patient cases and evidence-based practices to target at-risk older Veterans. Also Veterans who have had to travel to see geriatric consultants in urban VA medical facilities in the past can now avoid significant mileage costs and travel time, which can improve overall access to geriatric care overcoming the distance barrier. The addition of geriatric expertise in rural clinics, either through direct clinical consultation or through provider education, may lead to better management of older rural Veterans who suffer from geriatric syndromes and multiple chronic diseases. In addition to consultations that may help providers with the management of patients, the clinical components themselves may also serve as an educational tool to improve providers’ ability to manage other patients with similar conditions not directly seen or discussed by consultants. Our report of the experience in including educational approaches to the implementation of clinical telehealth modalities has several limitations. Although our project utilizes multiple sites across the nation, our results may not be generalizable as our implementation program may not be transposable to other medical centers or health systems outside the VHA with different conditions and contexts. As this is a report of the early experience in the project, data on further effects of the educational components and data on the implementation of the project itself such as patient health outcomes are not yet available. Here we are limited to reporting the early experience together with the rationale for including educational approaches with clinical implementation efforts. In summary the GRECC-Connect project targeted the problem of limited access to geriatric care for patients and front line providers in rural settings, while utilizing telemedicine to bridge the gap of access and reach providers to implement geriatrics training. Our experiences demonstrate a potential role for including educational components within the implementation of clinical innovations.
REFERENCES Arora, S., Kalishman, S., Dion, D., Som, D., Thornton, K., Bankhurst, A., . . . Yutzy, S. (2011). Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Affairs (Millwood), 30, 1176–1184. doi:10.1377/hlthaff.2011.0278hlthaff.2011.0278 [pii]
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Arora, S., Kalishman, S., Thornton, K., Dion, D., Murata, G., Deming, P., . . . Pak, W. (2010). Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care. Hepatology, 52, 1124–1133. doi:10.1002/hep.23802 Arora, S., Thornton, K., Jenkusky, S. M., Parish, B., & Scaletti, J. V. (2007). Project ECHO: Linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Reports, 122(Suppl. 2), 74–77. Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., . . . Qualls, C. (2011). Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine, 364, 2199–2207. doi:10.1056/NEJMoa1009370 Bratton, R. L., & Short, T. M. (2001). Patient satisfaction with telemedicine: A comparison study of geriatric patients. Journal of Telemedicine and Telecare, 7(Suppl. 2), 85–86. Brignell, M., Wootton, R., & Gray, L. (2007). The application of telemedicine to geriatric medicine. Age Ageing, 36, 369–374. doi:afm045 [pii]10.1093/ageing/ afm045 Cravens, D. D., Mehr, D. R., Campbell, J. D., Armer, J., Kruse, R. L., & Rubenstein, L. Z. (2005). Home-based comprehensive assessment of rural elderly persons: The CARE project. Journal of Rural Health, 21, 322–328. Edirippulige, S., Martin-Khan, M., Beattie, E., Smith, A. C., & Gray, L. C. (2013). A systematic review of telemedicine services for residents in long term care facilities. Journal of Telemedicine and Telecare, epub ahead of print. doi:10.1177/1357633x13483256 Esterle, L., & Mathieu-Fritz, A. (2013). Teleconsultation in geriatrics: Impact on professional practice. International Journal of Medical Informatics, 82, 684–695. doi:10.1016/j.ijmedinf.2013.04.006 Fisk, M. J. (1997). Telemedicine, new technologies and care management. International Journal of Geriatric Psychiatry, 12, 1057–1059. Glasgow, N., & Brown, D. L. (2012). Rural ageing in the United States: Trends and contexts. Journal of Rural Studies, 28, 422–431. Gruen, R. L., Weeramanthri, T. S., Knight, S. E., & Bailie, R. S. (2004). Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database of Systemic Reviews (1), CD003798. doi:10.1002/14651858.CD003798.pub2 Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press. Juretic, M., Hill, R., Luptak, M., Rupper, R., Bair, B., Floyd, J., . . . Dailey, N. K. (2010). Reaching out to older veterans in need: The Elko clinic demonstration project. Journal of Rural Health, 26, 325–332. doi:10.1111/j.1748-0361.2010.00302.x Lund, B. C., Charlton, M. E., Steinman, M. A., & Kaboli, P. J. (2013). Regional differences in prescribing quality among elder veterans and the impact of rural residence. Journal of Rural Health, 29, 172–179. doi:10.1111/j.17480361.2012.00428.x Luptak, M., Dailey, N., Juretic, M., Rupper, R., Hill, R. D., Hicken, B. L., & Bair, B. D. (2010). The Care Coordination Home Telehealth (CCHT) rural demonstration
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project: A symptom-based approach for serving older veterans in remote geographical settings. Rural and Remote Health, 10, 1375. Retrieved from http:// www.rrh.org.au/articles/subviewnew.asp?ArticleID=1375 National Center for Veteran Analysis and Statistics. (2012). Characteristics of rural veterans: 2010; Data from the American Community Survey. Retrieved from http:// www.va.gov/vetdata/docs/SpecialReports/Rural_Veterans_ACS2010_FINAL.pdf Peterson, L. E., Bazemore, A., Bragg, E. J., Xierali, I., & Warshaw, G. A. (2011). Ruralurban distribution of the U.S. Geriatrics physician workforce. Journal of the American Geriatrics Society, 59, 699–703. doi:10.1111/j.1532-5415.2011.03335.x Rosenthal, T. C., & Fox, C. (2000). Access to health care for the rural elderly. Journal of the American Medical Association, 284, 2034–2036. doi:jct00010 [pii] Rubegni, P., Nami, N., Cevenini, G., Poggiali, S., Hofmann-Wellenhof, R., Massone, C., . . . Fimiani, M. (2011). Geriatric teledermatology: Store-andforward vs. face-to-face examination. Journal of the European Academy of Dermatology and Venereology, 25, 1334–1339. doi:10.1111/j.14683083.2011.03986.x Scalvini, S., & Zanelli, E. (2002). Telecardiology: A new support for general practitioners in the management of elderly patients. Age & Ageing, 31, 153. Shah, M. N., McDermott, R., Gillespie, S. M., Philbrick, E. B., & Nelson, D. (2013). Potential of telemedicine to provide acute medical care for adults in senior living communities. Academic Emergency Medicine, 20, 162–168. doi:10.1111/acem.12075 Solomon, P. A., Torma, M. J., Strickland, R. M., Martin, P. S., Cason, V., Anderson, D., . . . Sterns, B. (1996). Dermatology screening with telemedicine. Journal of Family Practice, 42(1), 84–85. Tumosa, N., Fitzgerald, J. T., Wood, W. G., Thielke, S., Shay, K., Howe, J. L., . . . Horvath, K. (2011). Education partnerships between GRECCs and other VA organizations, non-VA governmental agencies, academic medical centers, and centers of excellence. Gerontology & Geriatrics Education, 32, 22–37. doi:10.1080/02701960.2011.550212933898160 [pii] Tumosa, N., Horvath, K. J., Huh, T., Livote, E. E., Howe, J. L., Jones, L. I., & Kramer, B. J. (2012). Health care workforce development in rural america: When geriatrics expertise is 100 miles away. Gerontology & Geriatrics Education, 33, 133–151. doi:10.1080/02701960.2012.661812 U.S. Census Bureau. (2009). American community survey. Retrieved from http:// www.census.gov/acs/www/ U.S. Census Bureau. (2013). Projected population of the United States, by age and sex: 2015 to 2060. Retrieved from http://www.census.gov/population/projections/ files/summary/NP2012-T2.xls U.S. Department of Agriculture. (2013). Rural poverty and well-being: Geography of poverty. Retrieved from http://www.ers.usda.gov/topics/rural-economypopulation/rural-poverty-well-being/geography-of-poverty.aspx# U.S. Department of Veteran Affairs. (2012). VA uses technology to provide rural veterans greater access to specialty care services. Retrieved from http://www.va.gov/ opa/pressrel/pressrelease.cfm?id=2353
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VA Office of Specialty Care Transformation. (2013). VA SCAN-ECHO logic model. Unpublished raw data. Wen, M., Browning, C. R., & Cagney, K. A. (2003). Poverty, affluence, and income inequality: neighborhood economic structure and its implications for health. Social Science & Medicine, 57, 843–860. doi:S0277953602004574 [pii] Williams, M. E. (1995). Geriatric medicine on the information superhighway: Opportunity or road kill? Journal of the American Geriatrics Society, 43, 184–186. Williams, M. E., Ricketts, T. C., & Thompson, B. G. (1995). Telemedicine and geriatrics: Back to the future. Journal of the American Geriatrics Society, 43, 1047–1051.
Gerontology & Geriatrics Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wgge20
A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect) William W. Hung
a b
c
d
, Michelle Rossi , Stephen Thielke , Thomas
e
f
g
Caprio , Steven Barczi , B. Josea Kramer , Gary Kochersberger , Kenneth S. Boockvar
a b
, Abraham Brody
a b
& Judith L. Howe
e
a b
a
Department of Geriatrics and Palliative Medicine , Mount Sinai School of Medicine , New York , New York , USA b
Geriatrics Research, Education, and Clinical Center , James J. Peters Veterans Affairs Medical Center , Bronx , New York , USA c
Geriatrics Research, Education, and Clinical Center, Pittsburgh VA Medical Center , Pittsburgh , Pennsylvania , USA d
Geriatrics Research, Education, and Clinical Center, Puget Sound VA Medical Center , Seattle , Washington , USA e
Canandaigua/ Rochester VA Medical Center, University of Rochester , Rochester , New York , USA f
Geriatrics Research, Education, and Clinical Center, William Middleton VA Medical Center , Madison , Wisconsin , USA g
VA Greater Los Angeles Healthcare System Geriatric Research, Education, and Clinical Center , Los Angeles , California , USA Accepted author version posted online: 08 Jan 2014.Published online: 17 Jan 2014.
To cite this article: William W. Hung , Michelle Rossi , Stephen Thielke , Thomas Caprio , Steven Barczi , B. Josea Kramer , Gary Kochersberger , Kenneth S. Boockvar , Abraham Brody & Judith L. Howe (2014) A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect), Gerontology & Geriatrics Education, 35:1, 23-40, DOI: 10.1080/02701960.2013.870902 To link to this article: http://dx.doi.org/10.1080/02701960.2013.870902
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Gerontology & Geriatrics Education, 35:23–40, 2014 ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2013.870902
A Multisite Geriatric Education Program for Rural Providers in the Veteran Health Care System (GRECC-Connect)
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WILLIAM W. HUNG Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
MICHELLE ROSSI Geriatrics Research, Education, and Clinical Center, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA
STEPHEN THIELKE Geriatrics Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, Washington, USA
THOMAS CAPRIO Canandaigua/ Rochester VA Medical Center, University of Rochester, Rochester, New York, USA
STEVEN BARCZI Geriatrics Research, Education, and Clinical Center, William Middleton VA Medical Center, Madison, Wisconsin, USA
B. JOSEA KRAMER VA Greater Los Angeles Healthcare System Geriatric Research, Education, and Clinical Center, Los Angeles, California, USA
GARY KOCHERSBERGER Canandaigua/Rochester VA Medical Center, University of Rochester, Rochester, New York, USA
KENNETH S. BOOCKVAR, ABRAHAM BRODY, and JUDITH L. HOWE Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
This article not subject to U.S. copyright law. Address correspondence to William W. Hung, Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA. E-mail: [email protected]
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Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts. KEYWORDS geriatrics education, rural, telehealth intervention
INTRODUCTION The aging of the baby boomer cohort in the United States is expected to lead to an increasing proportion of older adults in the population in the near future—with an increasing proportion of adults age older than 65 from 13.7% currently to 21.9% in 2060, and for age 85 and over from 2% to more than 5% (U.S. Census, 2013). For rural areas, recent data from the American Community Survey found that the age 65 and over age group accounted for more than 15% of the nonmetropolitan population, compared with 12% of the metropolitan population (U.S. Census Bureau, 2009). Although it is challenging to predict shifts in elderly population in rural areas given multiple trends in migration and aging, it is expected that the older population will continue to be disproportionately higher in rural regions (Glasgow & Brown, 2012). Within the veteran health care system (VHA), Veterans living in rural areas are, on average, older than their urban counterparts. Almost one half of rural Veterans are between age 55 to 74 and another 26% are older than age 75 (National Center for Veteran Analysis and Statistics, 2012). Older adults living in rural areas often have more significant health care needs—with a higher proportion living in poverty, poorer health status, and higher burden of chronic diseases (Rosenthal & Fox, 2000; U.S. Department of Agriculture, 2013; Wen, Browning, & Cagney, 2003). These older Veterans living in rural areas often do not have access to specialized geriatric care, the availability of which is important to improve the quality of care for older adults living
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in rural areas (Gruen, Weeramanthri, Knight, & Bailie, 2004; Williams, 1995; Williams, Ricketts, & Thompson, 1995). Currently workforce in the United States and also in the VHA is not likely to be able to meet the needs of providing adequate care for this rapidly expanding segment of the population (Institute of Medicine, 2008). Currently, geriatric physician workforce is small, with approximately 7,412 physicians according to the most recent report in 2008, accounting for 1.07 geriatricians per 10,000 older adults; more than 90% practicing in urban areas (Peterson, Bazemore, Bragg, Xierali, & Warshaw, 2011). This disparity in rural and urban distributions of the geriatric health care workforce makes provision of adequate care for older adults in rural areas even more challenging (Lund, Charlton, Steinman, & Kaboli, 2013). Novel models of care are needed to best utilize the limited resources in geriatric medicine to provide care for older adults in rural areas (Edirippulige, Martin-Khan, Beattie, Smith, & Gray, 2013; Esterle & Mathieu-Fritz, 2013; Fisk, 1997; Juretic et al., 2010). Within the Veterans Administration (VA), prior and ongoing programs have targeted this disparity by developing the workforce and equipping rural primary care providers with skills in managing geriatric problems (Tumosa et al., 2011). The Geriatric Scholars Program allowed rural clinics to send primary care providers (PCPs) and staff to geriatric centers for a short, intensive geriatric training coupled with elements of ongoing quality improvement projects to educate rural PCPs on geriatric care (Tumosa et al., 2012). Although the VA Geriatric Scholars Program has provided condensed training in geriatrics to empower rural PCPs to diagnose and manage common geriatric syndromes, significant care gaps still exist as these providers still struggle to address more medically and psychosocially complex cases that are best managed with the real-time input of an interdisciplinary geriatric team. Telemedicine is an attractive modality to bring patient-centered care to Veterans particularly in rural areas where access to specialist care is limited by distance and travel (Shah, McDermott, Gillespie, Philbrick, & Nelson, 2013) Because telemedicine does not require providers to be on-site at rural areas, geriatric providers located in urban health care centers can be accessed for management of patients located in rural areas (Rubegni et al., 2011; Scalvini & Zanelli, 2002; Solomon et al., 1996). Despite limited reports on the application of telemedicine in geriatric medicine, the majority have suggested that telemedicine can be applied safely (Brignell, Wootton, & Gray, 2007). Several small projects have demonstrated that care relevant to older adults can be delivered using telemedicine modalities, such as dementia assessment and wound care, and has the potential to improve access and patient satisfaction (Bratton & Short, 2001; Brignell et al., 2007; Cravens et al., 2005; Luptak et al., 2010). Telemedicine modalities may include direct patient consultation, teleconferencing for provider-to-provider discussions or consultation via electronic means such as chart-based electronic consultation, a model that has been increasingly utilized in the VA. Another model that has been
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tested and found effective is the extension for community healthcare outcomes (ECHO) model (Arora, Thornton, Jenkusky, Parish, & Scaletti, 2007) that was developed in New Mexico, primarily as an educational model to discuss cases brought by PCPs at rural sites, to a consultation specialist located at the urban center (Arora et al., 2011). The goal of the ECHO model was to educate rural providers in the care of future patients with similar conditions. This model was first applied to the treatment of patients with hepatitis C infection and achieved similar disease control as a specialist-based clinic for hepatitis C (Arora et al., 2010; Arora, Thornton, et al., 2011). VHA has adapted the ECHO approach, called SCAN-ECHO (Specialty Care Access NetworkECHO), to serve Veterans in rural areas in a pilot effort in several specialties, such as hepatitis and pain management (U.S. Department of Veteran Affairs, 2012). In this project, the participating geriatric research, education and clinical centers (GRECCs) are centers of excellence in geriatric care within the VA system located in urban VA medical centers that act as the resource site for geriatric consultation using various telehealth modalities currently in use in VHA. We have included a case-based conference educational program for primary care providers similar to the ECHO model to enhance provider knowledge and skills and to go hand-in-hand with the implementation of the clinical consultation components of the program. The rationale of the approach is to enhance visibility and promote implementation of the clinical program, while building relationships with providers to identify potential barriers and facilitators for telehealth outreach. Here we describe our project and experience in establishing the connection between GRECC and rural clinics efforts, called “GRECC-Connect,” while discussing how educational approaches can be used to aid implementation efforts.
METHOD Project Goal and Setting Recognizing the lack of access to geriatric care in rural settings, the goal of GRECC-Connect is to improve health care for older adult veterans at rural VHA clinics with support from multiple GRECCs and to establish a model of collaboration and excellence for care in rural clinics without geriatrics expertise through the provision of telehealth modalities. Project interventions were built upon the current clinical and administrative infrastructures of the four GRECCs and the current network of geriatric scholars. The VA Geriatric Scholars Program has engaged participants from all regions within the VHA networks including 276 health care providers (122 physicians, 88 nurse practitioners or physician assistants, 33 pharmacists, and 33 social workers) from 195 facilities. The program has provided condensed training in geriatric care
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to equip rural primary care providers and their staff with skills to deliver basic geriatric care and has empowered them to diagnose and manage common geriatric syndromes. Establishing the GRECC-Connect project using GRECCs and under the umbrella of the Geriatric Scholars Program allowed for leveraging the resources of already established geriatric centers of excellence and of engaged rural scholar clinicians. These health care providers are well positioned to be champions in creating clinical partnerships with GRECCs to access geriatrics consultation for their sites through an array of teleconferencing and telemedicine strategies; they can also serve to recruit additional providers at their respective clinical sites as well. The objectives are (a) to establish and enhance the infrastructure from GRECCs to support rural primary care providers who have participated in the VA Geriatric Scholars Program (and other providers who have not engaged in the Geriatric Scholars Program) so that they can deliver highquality geriatrics care to older Veterans at rural clinics; (b) to provide expert interprofessional clinical consultation via teleconferencing to enhance geriatric care for medically complex older Veterans; and (c) to provide ongoing case-based training in geriatrics for PCPs practicing in rural clinics. VHA has already made investments in telecommunications equipment and network which the project utilizes in establishing linkages with the rural clinics. These outreach modalities include virtual medicine where Veterans are seen by geriatric providers located at distance sites, provider to provider consultation via electronic consultation through electronic consult request and chart review (E consults in the VA system), and provider to provider teleconference or huddles where clinical issues for multiple patients can be discussed in a teleconference meeting. The target population served by this project is older rural Veterans, particularly those with complex medical problems, geriatric syndromes, and those who are vulnerable and at risk for institutionalization. To supplement the implementation of these new consultative services within the rural clinic setting, we have established a regularly scheduled case-based conference with multiple clinics linking up with a GRECC site using teleconferencing. Cases are brought to the conference by rural primary care providers to be discussed by the geriatric interdisciplinary team at the GRECC. The rationale to include this program element is that these case conferences can educate primary care providers on best practices of geriatric medicine, while building relationships between GRECC-based teams and clinic providers and staff. At each session, a patient case with difficult to manage geriatric issues or syndromes, such as dementia, is presented by the provider, whereas the GRECC-based geriatric team focuses on specific issues in diagnosis or management with the participants in the conference. To assess the needs of targeted providers, a needs assessment was conducted across the rural sites to identify topics of interest and perceived priority areas of education.
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Evaluative Strategy When considering the potential impact of our educational initiative and proposing possible outcomes, we have adapted the SCAN-ECHO logic model from VA (VA Office of Specialty Care Transformation, 2013) that has summarized the approach for VA SCAN-ECHO programs. We have modified it to include items on the clinical interventions and anticipated outcomes related to the implementation of the clinical interventions (Figure 1) to guide our efforts. The model outlines the inputs, outputs, and potential outcomes of the intervention. Utilization of a logic model allows for consideration of a comprehensive approach to assess intervention resources and determine its potential processes and outcomes. The resources (inputs) include GRECC sites with geriatric teams, rural clinics with primary care providers and team members from Patient Aligned Care Teams (PACT) (which is similar to a patient-centered medical home model), teleconferencing equipment, and resources. The output would be case-based conferences and other clinical telemedicine modalities that may affect patient care. Proposed outcomes are related to the evaluation of geriatric issues by the various clinical modalities, with short-term outcomes including provider knowledge, skills and attitudes, satisfaction, and others. Long-term outcomes include retention of providers and GRECC teams, reliance of patients on VA system care, and the demonstration of overall change in patient care outcomes within the system served by the program.
Implementation Issues Across Sites GRECC-Connect is a collaboration of four GRECC sites and a medical center with geriatric resources (five sites altogether). The rationale for the multisite collaboration is to expand the reach of the program to rural clinics in multiple regions, allowing each site to involve multiple rural providers who have participated in the nationwide VA Geriatric Scholars Program. Furthermore, each GRECC can contribute to the collaborative with specific expertise in geriatrics, which also allow for learning from each others’ processes during the set-up of the intervention. As each site has different contexts and settings, implementation of modalities of outreach varied across sites. During the implementation process, we have considered facilitators and encountered barriers in the implementation efforts, with GRECC and rural clinic sites that are at various stages of readiness, and organizational settings for adopting particular methods of outreach to rural clinics. These included clinical video telehealth (direct telemedicine consultation between geriatric specialists and patients), electronic consultation (provider-to-provider consultation via electronic chart review) or telehuddle approaches (also provider-to-provider contact with face-to-face discussion via teleconferencing).
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Identification of patients by PCP, case finding
Clinical care by trained PCPs—use of consults and telehealth modalities
Educate primary care providers
Case Presentations and discussions
Outputs
Rural/ nonrural geriatrics
Older primary care patients
PCPs PACT team members
Functional ability Cognitive assessment Nutritional status Condition specific symptom presence Geriatric conditions Use of non-VA care Social situation
Evaluation of relevant issues in older patients:
Patients
Processes
FIGURE 1 Proposed logic model for GRECC Connect project (color figure available online). Note: CVT: clinical video telehealth.
External Factors Funding for GRECC sites
Telehealth/ CVT equipment
Cases
Patient Aligned Care Team (PACT) team members
Primary care providers (PCPs)
Care Sites
Primary
GRECC Sites Geriatric interdisciplinary teams
Inputs
Consult workload Waiting time for consults Use of other telemedicine Modalities
System
Clinical indicators Patient satisfaction Location of care and by whom Appropriate medications Caregiver satisfaction Caregiver stress
Patients
Satisfaction with this type of care delivery Consult workload
GRECC Geriatrics Team
Knowledge change Attitude change Change in skills and behaviors→adoption of consult recommendations Referral to other noninstitutional modalities for older adults Satisfaction
PCPs
Outcomes Short
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Utilization/policy Demonstration of Improved care
System
Continued VA Utilization Long term outcomes (eg. institutionalization, maintenance of function)
Patients
Retention
GRECC Geriatrics Team
Retention Satisfaction
PCPs
Long
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Facilitators and barriers are summarized in Table 1. From the systems perspective, the project was funded by VA as VHA has placed significant emphasis in improving care for older adults, particularly within rural areas, and in extending care to rural areas through various telehealth modalities. Thus, information technology and telehealth equipment has already been deployed to rural areas in preparation for this type of expansion of care. Another facilitating factor is the organization and infrastructure already in place as GRECCs are centers with geriatric interdisciplinary staff that can be mobilized to implement the rural outreach and are centers that serve a particular geographic region with a number of affiliated clinics and medical centers. Some GRECCs already have relationship with the rural providers, either as consultants that providers would send patients to or as educational resources. Utilizing geriatric clinical resources to serve rural providers and patients through telehealth means would be a natural extension of these relationships. The Geriatric Scholar Program also helps to facilitate the project as there are already scholars that have been trained through the program that serve as champions at rural sites where the interventions would be delivered. TABLE 1 Facilitators and Barriers for Establishing and Sustaining the GRECC-Connect Program Facilitators
Barriers
System VA emphasis on rural health VA emphasis on expansion of telehealth modalities Performance measures for telehealth (though not specific to geriatrics) Funding Support from regional and local offices Available GRECC infrastructure
System Competing programs and resources Initial funding for one year only Obtaining support from regional and local offices
GRECC Established geriatric teams and expertise Expertise on specific geriatric topics Information technology equipment and support Familiarity with evaluative strategies Experience in clinical demonstration projects Existing relationship of referrals with rural providers
GRECC Competing programs Limited staff time Familiarity and comfort with telehealth use Administrative steps for setup of clinic Delays in hiring new staff
Rural clinics Provider interest Champions (geriatric scholars) Information technology equipment and support
Rural clinics Provider staff time and effort Variable level of knowledge and skills, and attitude Familiarity and comfort with telehealth use
Note: GRECC = Geriatric Research, Education, and Clinical Centers; VA = Veterans’ Administration.
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However, barriers to implementation are also significant. As the current federal funding climate is tight, the initial project funding lasts for only one year, with the expectation that the project would be sustained through other means within VA (thus require resources committed in advance by VA regional and local centers). Obtaining future support for the program at the regional and local level requires clear demonstration of potential benefits that must be weighed by local offices against competing programs and services. In addition, rural providers are full-time clinicians for rural Veterans; finding time to participate in an educational program is a challenge. Other significant barriers include hiring delays and administrative steps needed to set up a particular clinical modality—even within a single VA health care system, each medical center, or regional systems have unique established policies which further complicates how these modalities can be set up. To further identify and confirm needs from the provider perspective, we conducted a preprogram survey.
Needs Assessment (Preprogram Survey) The needs assessment was conducted via online survey collected anonymously. The survey was developed to assess provider knowledge, attitude, and provider comfort in using telehealth modalities. Questions on provider training included educational degrees and type of prior geriatric training. Level of interest (on a scale of 0–10) on specific geriatric topics was also included. Providers were questioned whether they had referred patients for geriatric consultation; and also if geriatric consultation were to become available, how often would providers be referring patients for consultation. Providers were asked to indicate their top three consult questions. To determine provider comfort level in using telemedicine modalities, providers were asked to indicate on a 5-point Likert-type scale (ranging from 1 [very uncomfortable] to 5 [very comfortable]) their comfort in using telemedicine modalities for clinical care and for education. Staff was also asked to identify the time within the week that they would be free to participate in a case-based conference.
Postprogram Survey The program was initiated in February 2013. Case conferences were conducted on a twice monthly schedule. After 6 months, a survey was sent to providers who participated in the case conferences to gauge their participation, satisfaction, and perceived impact of the program. Providers were asked to rate their satisfaction using a 5-point Likert-type scale, ranging from 1 (very unsatisfactory) to 5 (very satisfactory). Also providers were asked if they perceived any improvement in their knowledge on managing older adults, and in another question, if they perceived that their skills on managing older adults had improved.
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Analysis Characteristics and responses of providers surveyed were summarized with counts, proportions, means, and standard deviations as appropriate. Case conference topics and activities were described. Results of the needs assessment survey and the postprogram survey were summarized. Analysis was performed using Stata version 11.0.
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RESULTS The GRECC-Connect project has included four GRECCs located in various regions in the United States including Eastern region (Bronx, NY; Pittsburgh, PA), Midwest (Madison, WI), and Pacific region (Puget Sound, WA), and additionally included one VA Medical Center with geriatric resources (Canandaigua Rochester VA Medical Center, NY) located within a VA region without a GRECC. Together these five centers have implemented various modalities within their catchment area including clinical video telehealth in two centers, electronic consultation in three centers, and telehuddles in two centers. Case conferences have been established in two centers with a total of 14 regularly scheduled twice monthly sessions since February 2013. The differences in how the interventions have been set up at different sites can be explained by factors unique to each site. For example, at the Pittsburgh VA and the Puget Sound VA, where the geriatric teams at the GRECC have already developed existing relationships with rural providers and have been performing consultations on rural patients (though requiring significant travel time), clinical video telehealth was set up as the main modality to support rural providers. For centers (Bronx and Canandaigua) without existing clinical consultation with rural providers, case conferences were established first as educational modalities and a method of outreach to extend other clinical support and services. Because of the behavioral health expertise and resources at the Puget Sound GRECC, with psychiatry and psychology as the primary clinical staff in the project, the intervention focused mainly on mental health issues including dementia in older adults. On the other hand, Madison VA GRECC has a number of geriatric scholars within their catchment area and was able to mobilize a geriatric interdisciplinary team at their GRECC that can focus on comprehensive assessments; their main modality is telehuddle and electronic consultation with rural providers. Before project initiation, 21 providers from four sites completed the preprogram assessment (Table 2). Approximately 50% were physician providers (medical doctors or doctors of osteopathy) and approximately 50% were nurse practitioners. A minority (39%) reported having some training in geriatrics including fellowship, residency, or certificate program. Eighty percent of the providers reported that more than 50% of patients they are
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Multisite Geriatric Education Program for Rural Providers TABLE 2 Baseline PreProgram Survey Results Conducted Priort the Start of the Project
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Item Proportion of providers reported referring number of patients to geriatric consultation within past month (%) None 1–2 3–5 6–10 More than 10 Proportion of providers reported referring number of patients to geriatric consultation if geriatric consultation available through telemedicine (%) None 1–2 3–5 6–10 More than 10 Mean score of level of interest in various topics on a scale of 0–10 Dementia care Late life mental health issues Chronic care with complex needs Palliative care Delirium Falls and fall assessment Frailty Management of common medical problems in elderly Urinary incontinence Multiple chronic conditions Comfort level in using telemedicine modalities for clinical care (%) Very comfortable Comfortable Neutral Uncomfortable Very uncomfortable Comfort level in using telemedicine modalities for education (%) Very comfortable Comfortable Neutral Uncomfortable Very uncomfortable Professional degree (%) Medical doctor or doctor of osteopathy Nurse practitioner Physician’s assistant Prior training in geriatrics (%) Fellowship Residency Certificate Providers’ report of proportion of patients that they encounter aged 65 or older (%) 0%–25% 26%–50% 51%–75% 76%–100%
N = 21
65 30 5 0 0 17 44 33 6 0 8.6 8.3 8.3 8.2 8.0 7.3 7.2 7.0 7.0 6.9 25 44 31 0 0 20 53 27 0 0 50 50 0 5 10 24 0 20 60 20
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encountering in their clinics were age 65 and older. For referrals to geriatric consultation, 65% reported that they had not referred any patients to geriatric consultation in the previous month; 83% reported that they would do so if geriatric consultation would become available via telemedicine modalities. Comments from providers indicated that reasons for not referring more patients for geriatric consultation included distance and time for travel to medical centers where geriatric consultation is based and long waits to obtain an appointment. One provider noted that as a provider serving in a rural area her practice is very independent, without much access to other providers to review cases or ask questions; the “connection would be very helpful to me to have a connection with other providers who may have similar experiences and offer additional insights and suggestions.” Providers indicated that their top consult questions included cognitive assessment and dementia management, polypharmacy and medication management, and support services for elderly Veterans including palliative care. Top five topics of interest for further education included dementia care, late-life mental health issues, chronic care with complex needs, palliative care, and delirium. Overall, providers indicated that their comfort level with using telehealth modalities were high, with 69% reporting feeling comfortable or very comfortable in using telehealth modalities for clinical care and 73% reporting feeling comfortable or very comfortable in using telehealth modalities for education. However, finding a common time for conducting case conference was difficult as providers and PACT team members already have established clinic schedules for patient care. For one site, a time slot was identified that was time already protected for an hour-long continuing education activity throughout the region. The case conferences were implemented for a total of 14 sessions (Table 3). In each session, a clinical case was discussed, with the majority TABLE 3 Case Conference Topics and Participation Item Number of sessions Number of clinic sites per conference, mean (SD) Number of participants per conference, mean (SD) Number of sessions that covered the topics listed Dementia management including behavioral symptoms Discussion of patient preferences Cognitive assessment in older adults Medication management including polypharmacy Falls assessment Late life mental health problems such as depression Management of multiple chronic diseases with competing risks Care transitions in older adults Hip fracture Delirium
N = 30 (unique providers) 14 4.4 (1.3) 13.0 (4.3) 3 3 2 2 2 2 2 2 1 1
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of cases brought by PCPs at remote clinics, the rest were supplemented by cases from GRECC staff when cases were not identified by other participants in advance. The average number of remote sites that connected to GRECC for the case conference was 4.3 (SD = 1.3), and the average number of providers per conference was 13 (SD = 4.4). Cases included Veterans with dementia, multiple chronic diseases, heart failure, and automatic implantable cardioverter defibrillator management, recurrent hospital admissions with hospital acquired infections, and the topics discussed included dementia assessment and management, care planning, discussion of patient preferences, management of multiple medications, falls and risk factors for falls, palliative care and considerations for referrals to palliative care, transitions of care, and use of screening tools for geriatric problems such as for depression. In the postprogram survey, we received a total of 14 responses from a pool of 30 participants (response rate = 46.7%). A total of 15% of providers reported participating in case conferences more than 10 times, 54% reported participating three to five times, and 15% reported one to two times (Table 4). Self-reported use of other telehealth modalities included electronic consultation in 14% of providers and 29% reported using telehuddles. For provider TABLE 4 Postprogram Survey Results on Geriatric Research, Education, and Clinical Centers (GRECC) Connect Project Item Providers reporting improved skills on managing older adults (%) Yes No Missing Providers reporting improved knowledge on managing older adults (%) Yes No Missing Proportion of providers reporting participation in case-based conference (%) None 1–2 times 3–5 times 6–10 times More than 10 times Self-reported use of telehealth modalities to connect with the GRECC (%) E-consult Telehuddle Satisfaction in utilizing telemedicine modalities for education (%) Very satisfied Satisfied Neutral Unsatisfied Very unsatisfied
N = 14 79 14 7 57 36 7 15 15 54 0 15 14 29 17 50 33 0 0
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satisfaction among those who responded, 50% reported that they were satisfied and 17% reported being very satisfied. Approximately 57% of providers perceived that they had improved their knowledge in managing older adults, and 79% of providers reported having improved skills in managing older adults in their practice.
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DISCUSSION This report describes our experience in implementing a clinical intervention utilizing telehealth modalities in rural areas where geriatric care is lacking. As part of our program we have integrated educational components to improve provider knowledge and skills. Case conferences also provided an avenue to promote the clinical components of the program while establishing connections to enhance the implementation phase of the project. The format of the case conference, with case presentations brought by participating providers enhanced the experience because providers were more engaged in the discussion of their own patients with the discussion brought directly back to their patients’ care. The additional component of a group educational experience, in this case, a case-based conference, may have synergistic effects on the implementation of the clinical components. Also, although the clinical components in GRECC-Connect such as consultation via electronic consults, huddles, or clinical video telehealth are not necessarily considered educational but rather clinical services, they do act to reinforce geriatrics concepts and facilitate a strong interpersonal teaching and learning relationship between the consultant and the primary provider. On the other hand, the case-based conference in a group setting is not only educational by design, but also has potential for real-time improvement in care in the specific cases discussed. Older adults who may otherwise have little access to geriatric care may have improved access to geriatric expertise via these types of conferences and clinical interventions. For Veterans who normally would need to travel to see geriatric consultants in urban VA medical facilities, they may avoid such trips while improving access to geriatric resources. This addressed a significant barrier for rural Veterans to receive geriatric care. Considering the challenge of implementing novel clinical programs in multiple locations across the country with multiple providers, this project was implemented under the umbrella of the Geriatric Scholars project, which was an already existing network of rural front-line PCPs. This facilitated collaboration as these providers served as champions to establish further working relationships with GRECCs within a short period of time. As the Geriatric Scholars project is an educational program that has been established for several years, the infrastructure and communication resources such as network SharePoint allowed for reaching out and efficiently distributing information to providers, engaging providers that understand the need for specialized care for older adults in rural areas, and enhancing connections
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with centers of geriatric care. These represent significant facilitating factors that may lead to the successful implementation of the ”virtual” collaboration. As a grant-funded project, the ability to sustain the project beyond the grant period relies on the demonstration of positive impact on patient care, such as health outcomes, patient and provider satisfaction, and costs. As this project improves access to geriatric care and consultation through telehealth modalities and promotes the development of geriatrics skill and expertise for rural providers, it also aimed to enhance the clinical competency of rural providers through the discussion of patient cases and evidence-based practices to target at-risk older Veterans. Also Veterans who have had to travel to see geriatric consultants in urban VA medical facilities in the past can now avoid significant mileage costs and travel time, which can improve overall access to geriatric care overcoming the distance barrier. The addition of geriatric expertise in rural clinics, either through direct clinical consultation or through provider education, may lead to better management of older rural Veterans who suffer from geriatric syndromes and multiple chronic diseases. In addition to consultations that may help providers with the management of patients, the clinical components themselves may also serve as an educational tool to improve providers’ ability to manage other patients with similar conditions not directly seen or discussed by consultants. Our report of the experience in including educational approaches to the implementation of clinical telehealth modalities has several limitations. Although our project utilizes multiple sites across the nation, our results may not be generalizable as our implementation program may not be transposable to other medical centers or health systems outside the VHA with different conditions and contexts. As this is a report of the early experience in the project, data on further effects of the educational components and data on the implementation of the project itself such as patient health outcomes are not yet available. Here we are limited to reporting the early experience together with the rationale for including educational approaches with clinical implementation efforts. In summary the GRECC-Connect project targeted the problem of limited access to geriatric care for patients and front line providers in rural settings, while utilizing telemedicine to bridge the gap of access and reach providers to implement geriatrics training. Our experiences demonstrate a potential role for including educational components within the implementation of clinical innovations.
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