Overview

The Vet Connect Project aims to increase access to specialty care through video conferencing for veterans living in long-term care facilities in Oklahoma and Colorado. 

Organization Name

The Veterans Health Administration (VA) was responsible for the intervention. They contracted with Community Nursing Homes (CNHs) to coordinate care for veterans.

Organization Type

• Government organization
• Integrated healthcare system/network
• Veteran's Affairs

National/Policy Context

• Telehealth services are successful in rural communities because they increase access and decrease costs and travel time. 
• In 2013, the Veterans Health Administration provided over 600,000 Clinic Based Video Telehealth (CVT) appointments and real-time video consultations. 
• Another VA program called the Care Coordination and Home Telehealth program (CCHT) was successful in reducing inpatient bed days, hospital admissions, and cost. 
• The 2013-2018 VA Strategic Plan was passed, which states that veterans should receive personalized, patient-driven, proactive health care. The VA Mission Bill was also passed to increase access to telehealth.

Local/Organizational Context

• The Denver VAMC’s nursing home (called Community Living Center or CLC) closed in April 2017. 
• The Vet Connect project was created to provide long-term follow-up for Eastern Colorado Health Care System veterans residing in contracted Community Nursing Homes.
• The Vet Connect project focuses on specialty medical care and mental health support via telehealth.

Patient Population Served and Payor Information

• Veterans who used to receive care from the Denver VAMC’s nursing home

Leadership

• Anne Hale, Leah M. Haverhals, Chelsea Manheim, and Cari Levy designed the project. Anne Hale and Leah M. Haverhals implemented the project and developed process maps.
• The Denver VAMC leadership, consisting of the director of palliative care, facility telehealth coordinator, chief of psychology, and the VA-based CNH program social work supervisor, provide leadership for the project on an ongoing basis. Frequent team communication and collaboration helps keep the project organized and improving.

Funding

• The Office of the Under Secretary for Health (USH) and the Office of Rural Health (ORH) in collaboration with the Office of Veterans Access to Care (OVAC) funded the project. 

Research + Planning

•  The project leaders had to gain key stakeholders such as the CNHs by visiting them in person. 
• Telehealth leadership at the Denver VAMC also helped create clinics appropriate for telehealth (CVT tablets and computers with Jabber software were added). They also trained and credentialed providers to implement telehealth services.

Tools or Products Developed

• Process mapping: Documents were created over the span of a year to identify barriers and facilitators to implementation. The innovators created process mapping by mapping out the administrative, staff, and clinical aspects of the implementation. 

Training

• Eight Denver VAMC specialty care providers and three project nurses were trained to review charts of CNH veterans, use the Clinical Based Video Telehealth (CVT) tablets and video cameras, and coordinate care. 

Tech Involved

• Tablet
• Video conferencing

Team Members Involved

• RNs
• Specialists

Workflow Steps

• Project nurses first identify patients eligible for video visits (those who are in VA CNHs and whose provider agrees to a video visit instead of a face to face visit). 
• The appointments are coordinated between team nurses, patients, and provider and then scheduled. 
• Team nurses arrive at the CNH an hour before the scheduled time to take patients’ vitals and medical history in a private and quiet setting.
• The provider then calls into the CVT tablet using Jabber software for the visit. 
• After the visit, team nurses update the electronic medical records. Any referrals or follow-up appointments are scheduled. The team nurses then communicate recommendations from the VA providers via fax or in person with the CNH staff.

Budget Details

• Cost of staffing time for coordinating travel 
• Cost of scheduling appointments 
• Cost of transportation for staff
• Cost of video visit technology (CVT tablets, provider video cameras)
• Cost of office space

Where We Are

• Date Project Described Started: June 2017
• Date Paper Published: September 2018

Outcomes

• Clinical utilization: follow-up visits accounted for 22.2% of visits to specialties including hospice and palliative care, geriatrics, and mental health. 
• Cost analysis: cost of delivering a face-to-face visit was $187.34 for the VA and $171.01 for CNH. In comparison, the cost of delivering a video visit was $30.67 for the VA and $5.70 for the CNH. The VA and CNH saved a total of $310 for each video visit.
• Technical success: Vet Connect visits have an 83.3% technical success rate, which is defined as a visit with no dropped calls or poor connectivity.  

Future Outcomes

• This ongoing project will include qualitative interviews with VA specialty care providers, team nurses, and VA and non-VA staff to better determine barriers and facilitators of the program. 
• The innovators also plan to disseminate lessons learned during project implementation to influence best practices nationally.

Benefits

• Video visits cost less than in-person visits which allows patients to have more affordable access to specialty care. 
• Follow-up visits increased because of improved access to specialists for veterans.

Unique Challenges

• Administrative tasks took longer than initially expected.
• Delegating workload credit to providers was difficult because modifying new clinics for providers took time and persistent follow-up. 
•  The project was one of the first VA to non-VA facility telehealth programs in Denver VAMC, so there was increased need for collaboration between the facilities and team problem solving. 
• The high turnover of staff in charge of multiple collateral duties made building relationships with the CNHs difficult. 
• Veterans also had trouble hearing providers during visits because of technical connection issues or hearing impairments.

Sources

• Hale, A., Haverhals, L., Manheim, C., & Levy, C. (2018). Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes. Geriatrics, 3(3), 57.