Overview

The VA Greater Los Angeles Healthcare System adapted SCAN-ECHO to provide primary care providers (PCPs) with Women’s Health (WH) education and virtual consultations in an effort to improve care of female patients.

Organization Name

Veterans Health Administration (VA) Greater Los Angeles Healthcare System

Organization Type

• Government organization
• Integrated healthcare system/network

National/Policy Context

• The VA mandates that every primary care clinic have at least one primary care provider (PCP) who is proficient in women’s health (WH) to whom women can be preferentially assigned. These clinicians are referred to as WH PCPs.
• A deficit in WH PCPs in community-based outpatient clinics (CBOCs) causes women patients to travel long distances to VA medical centers or to seek care outside of the VA.
• Many VA PCPs have small female patient caseloads, which makes WH skills practice and knowledge acquisition challenging. Data shows that women Veterans rate the WH skills of PCPs lower at CBOCs with fewer women patients, relative to the scores of VA sites with higher women Veteran caseloads.

Local/Organizational Context

• The VA Greater Los Angeles Healthcare System is comprised of facilities and clinicians from Greater Los Angeles, San Diego, and Oklahoma City.
• Like other VA systems, VA Greater Los Angeles Healthcare System faces challenges meeting the WH needs of women Veterans, a growing population. Approximately 9% of veterans in the Golden State are women and this percent is expected to increase in the next two decades.
• The VA has implemented multiple initiatives to improve capacity among its workforce for WH and other specialities (i.e. geriatrics) that provide care for Veteran sub-populations.
• WH Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) is an adaptation of  ECHO’s original use to build PCPs’ capacities to  treat Hepatitis C in rural New Mexico.

Patient Population Served and Payor Information

• The VA Greater Los Angeles Healthcare System serves a diverse population of Veterans. LA and San Diego Counties have the largest population of veterans within California.
• Veterans can pay for healthcare with a combination of  VA Health Benefits, Tricare, Medi-Cal (Medicaid’s name in California), Medicare, and private insurance depending on their income, age, and other eligibility requirements.

Leadership

• Drs. Kristina M. Cordasco MD, MPH, MSHS and Donna L. Washington MD, MPH are investigators at The VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), physicians for The VA Greater Los Angeles Healthcare System, and professors of medicine at UCLA. They led the implementation of this pilot.
• Medical directors at the three pilot sites were in support of the project.

Funding

• The project was funded by the VA Health Services Research and Development (HSR&D) and the VA Patient Care Services.

Research + Planning

• WH Medical directors at the three pilot sites (VA Greater Los Angeles, VA San Diego, and VA Oklahoma City) provided the emails addresses of their sites’ PCPs to the WH SCAN-ECHO lead team at VA Greater Los Angeles.
• The lead team sent email invitations to 53 PCPs across the sites. PCPs were also encouraged to attend presentations about the intervention during meetings.  
• To understand whether the timing of WH SCAN-ECHO would affect PCP participation, one of the three pilot sites allocated specific time for PCPs to attend SCAN-ECHO sessions, whereas two sites held the sessions during PCPs’ lunch hours

Tools or Products Developed

• SCAN-ECHO: Speciality Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) is a model that uses video teleconferencing to connect several primary care providers (PCPs) with a specialist for consultations about specific cases and education. SCAN-ECHO sessions can be used for CME credit.

Tech Involved

• Email
• Video conferencing

Team Members Involved

• NPs
• PAs
• Physicians

Workflow Steps

• The WH SCAN-ECHO pilot consisted of 14 monthly sessions.
  • The team leaders used an internal needs assessment, conversations with WH medical directors, and cases submitted by PCPs to determine which topics to cover and therefore which specialists to schedule to lead the sessions.
  • Interviews with PCP participants began October 2012 and ended four months after pilot completion so that assessment occurred during implementation.
• The lead team sent email invitations to 53 PCPs. One site specified time for the sessions and two sites hosted the sessions during lunch.
• Each hour-long session was divided into two parts:
  • The first 15 minutes of WH SCAN-ECHO was dedicated to advanced education on a selected topic led by specialists.
  • The latter 45 minutes were spent on patient consultations or case examples.  
• After each session, the project leads emailed evaluative surveys to PCPs who attended. Survey completion was necessary for CME credit.

Budget Details

• Compensation for specialists
• Continuing Medical Education (CME) accreditation costs
• Software licensing costs for SCAN-ECHO
• Video conferencing technology costs.

Where We Are

• This pilot ran for fourteen months between October 2012 through December 2014.
• WH SCAN-ECHO program expansion is being considered within the three pilot sites and in two other VA health care systems.

Outcomes

• PCP attendance: Participation logs identified how many PCPs attended each session and from which site.

• The sites that did not allocate specific time for WH SCAN-ECHO had lower participation than the site which did since clinical work often runs into the lunch hour.

• Participation Barriers and Facilitators: Between October 2012 and April 2014, 18 PCPs were interviewed about barriers and facilitators to participation and the perceived usefulness of the sessions. The interviews were transcribed and thematically coded.

• Session Quality: The lead team used a survey with 10 Likert scale and 2 open-ended questions to assess the sessions’ speaker and content quality and relevancy to how PCPs practice. Survey responses were required to receive CME credit.
  • More than half of the PCPs who filled out the surveys indicated that WH SCAN-ECHO would change their ordering of diagnostic studies, treatment plans, and prescription practices.

Benefits

• The pilot met its goal to improve how PCPs deliver care to women Veterans.
• WH SCAN-ECHO improves the primary-speciality care relationship and care coordination.

Unique Challenges

• The sites that did not allocate specific time for WH SCAN-ECHO had lower participation than the site which did since clinical work often runs into the lunch hour. Sites need to allocate specific time for education in order to increase PCP participation.
• The temporal mismatch between submitting cases and scheduling specialists for the sessions led to providers finding sessions interesting, but less relevant to their present cases. The rotation of specialists also limited case submissions.

Sources

• California Legislative Analyst’s Office. Understanding the Veterans services landscape in California. Retrieved from https://lao.ca.gov/Publications/Report/3525#The_Demographics_of_California.2019s_Veterans
• Cordasco, K. M., Zuchowski, J. L., Hamilton, A. B., Kirsh, S., Veet, L., Saavedra, J. O., … & Washington, D. L. (2015). Early lessons learned in implementing a women’s health educational and virtual consultation program in VA. Medical care, 53(4 Suppl 1), S88.
• Kaiser Family Foundation. Medicaid’s role in covering Veterans. Retrieved from https://www.kff.org/infographic/medicaids-role-in-covering-veterans/
• Kirsh, S., Su, G. L., Sales, A., & Jain, R. (2015). Access to outpatient specialty care: solutions from an integrated health care system. American Journal of Medical Quality, 30(1), 88-90.
• University of New Mexico. Our story: Project ECHO. Retrieved from https://echo.unm.edu/about-echo-2/our-story/
• U.S. Department of Veteran Affairs. California. Retrieved from https://www.va.gov/vetdata/docs/SpecialReports/State_Summaries_California.pdf
• U.S. Department of Veteran Affairs. VA health care. Retrieved from https://www.va.gov/health-care/
• U.S. Department of Veteran Affairs. VA Research on Women’s Health. Retrieved from https://www.research.va.gov/pubs/docs/va_factsheets/WomensHealth.pdf
• U.S. Department of Veteran Affairs. SCAN-ECHO: An effective way to provide patient-centered care. Retrieved from https://www.sanfrancisco.va.gov/features/SCAN_ECHO.asp
• Washington, D. L., Bean-Mayberry, B., Mitchell, M. N., Riopelle, D., & Yano, E. M. (2011). Tailoring VA primary care to women veterans: association with patient-rated quality and satisfaction. Women’s Health Issues, 21(4), S112-S119.