Improving Wound Care Access and Coordination Between Home, VA Primary and Tertiary Care Medical Centers

1. Improving Wound Care Access and Coordination Between Home, VA Primary andTertiary Care Medical Centers

2. VISN 11 Wound Care Teleconsultation Program Julie Lowery, PhD and Leah Gillon, MSW DM QUERI, Ann Arbor VAMC Developing a Home Telehealth Program to Manage Pressure Ulcers in Spinal Cord Injury/Disorder Marylou Guihan, PhD, Chester Ho, MD and Christine Woo, MS SCI QUERI/Cleveland VAMC Diabetic Foot Ulcer Treatment and Amputation Prevention in Non-Tertiary VA Care Facilities Greg J. Raugi, MD, PhD; Gayle E. Reiber, MPH, PhD Seattle VAMC

3. Overview of Telehealth • VA has been increasing access to care by building CBOCs. • Via the Office of Care Coordination (OCC), VHA has taken the lead in developing telehealth programs to serve veterans who would otherwise lack access to care. • Telehealth enables patients to receive specialty care at remote sites.

4. Defining Telehealth • Telehealth is the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants.

5. Telehealth Levels

6. Video telephones Data messaging devices Video tele-monitor devices Optional medical peripheral devices Home Telehealth Equipment

7. Care Coordination Home Telehealth • In CCHT, patients are assessed and monitored in their homes using telehealth technologies for preventive care, intervention and/or treatment management purposes.

8. Advantages: Low cost Easy to use Disadvantages: Performance varies Sporadic connection & transmission of images Limited use (mostly mental health) Videophones • Plain Old Telephone (POTS) with camera for video display • Some programs have used videophones for wound care

9. Advantages Easy to use Low-cost Portable Home Telehealth Data Messaging Devices Disadvantages • Time gap between patient data entry and clinician review • Provider must depend on accuracy of patient response to questions

10. Glucose Meter Video Tele-monitor – Patient Station • Desktop devices with video display screens, as well as camera and various biometric peripherals (some wireless) • Allows for real-time two-way interactive monitoring and management of disease between patient and provider • Wound care management limited by camera specifications and connectivity options Pulse Oximeter

11. Video Telemonitor – Clinician Station • During scheduled appointment, provider reviews video, audio or text data from patient • Data can be reported directly by patient or automatically via peripheral device connected to patient station • Data transfer from home to clinic via telephone line • Data (e.g., wound photos) received at clinician station can be placed in patient’s electronic medical record

12. Advantages Visual interaction Real-time data review Provider supervision of information collection /transmission Video Telemonitor and Peripherals Disadvantages • High equipment cost • Video images marginal over POTS telephone line • More complex to operate

13. Telemonitor and Peripherals: Real-time videoconferencing Multiple medical peripherals Data Messaging: Assignment of customized health management programs Advice messages for patients Schedules and reminders for medications, measurements, and questions Graphical display of results/trends Server access to educational materials Combination Video Telemonitor, Messaging and Peripheral Devices

14. VHA Clinic-to-Clinic Telehealth • Care coordination: general telehealth • Real time 2-way interaction between patient and health care provider at two different locations • Provider at remote site can collect real-time data from peripheral devices, (e.g., digital camera, camcorder, pressure mapping) • View and guide procedures or activities performed real-time from a remote clinical setting, (e.g., wound measurement)

15. Store-and-Forward Telehealth • Data collected at primary care site • Data transmitted to remote storage device • The encounter typically involves digital images, diagnostic testing or other clinical data captured during a clinical visit at remote site • Data retrieved and reviewed at the convenience of reviewing medical practitioner(s) • Feedback is provided to PCP at remote site

16. Developing a Home Telehealth Program to Manage Pressure Ulcers in Spinal Cord Injury/Disorder Marylou Guihan, PhD1, Chester Ho, MD2, Christine Woo, MS3 1 Assistant Director, SCI QUERI, Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, IL 2 Chief, SCI Center, Louis Stokes Cleveland VAMC, Cleveland, OH 3 Program Manager, SCI Telehealth Program, Louis Stokes Cleveland VAMC, Cleveland, OH

17. Background Spinal Cord Injury/Disorders (SCI/D) is the most costly condition in VA. PrUs account for about 1/3 of all VHA SCI/D admissions and 87% of hospital days. PrUs are a serious condition because: Very common Often preventable Cause increased morbidity/mortality, and decreased quality of life.

18. Background • Patients with SCI and severe PrUs are admitted to regional centers for treatment. • Healing often takes months to resolve. • Promoting prevention and/or early detection and reporting of PrUs in the community setting are important goals for the VHA SCI/D system of care. • One tool to promote these goals is the home telehealth data messaging device.

19. VISN 10 Hub and Spokes OHIO

20. Study Objectives To develop the tools necessary for implementing a new home telehealth disease management protocol (DMP) to manage community-dwelling veterans with SCI/D at high risk for developing PrUs.

21. Home Telehealth Data Messaging Devices • Currently used by patients throughout VHA • Compact device displays text • Multiple chronic health management programs available • Q & A covers patient: 1) knowledge, 2) behavior, and 3) symptoms regarding key aspects of care • Built-in education reinforcement and reminders that prompt patient action • Daily sessions take about 10-15 minutes

22. Adaptation of Telehealth Equipment for Veterans with Disabilities • Telehealth equipment is not designed for use by functionally impaired persons and may need to be adapted • Therapist can assess physical limitations • Provide adaptive devices (mouth stick, head pointer and typing aids) • Recommend home environment adaptation • Privacy issue with caregiver assistance

23. Home Telehealth Data Messaging Devices • Patient responses are sent from the patient’s home to a data center via telephone line. • Clinicians review patient responses in a spreadsheet on a secure VHA web site. • Patient responses are risk stratified-color coded as “high” “medium” or “low” risk answer. • Clinician makes decision regarding follow-up on patient response.

24. Developing the PrU DMP • In collaboration with VHA SCI/D Field Workgroup and VHA Office of Care Coordination, clinicians at Cleveland SCI/D Specialty Center developed a draft Pressure Ulcer Disease Management Program (PrU DMP). • Sources of DMP items • 1) the SCI Clinical Practice Guideline (CPG) • 2) the SCI PrU Consumer Guide • 3) “Yes I Can” - a patient guide to self-care that is used at all VA SCI Centers as part of the rehabilitation process after SCI.

25. PrU DMP Items DMP categories • General Medical Status (including co-morbidities) • General Psychosocial Status • Safety Issues • Prevention (PrU specific) • General knowledge about prevention • Daily skin care • Risk factors • Nutrition • Equipment • Treatment (PrU specific) • General knowledge about treatment of PrU • Monitoring, complications, recurrence

26. Developing the PrU DMP Consensus was obtained for following: • Purpose, goal and comprehension of questions/content items, • Determination of frequency with which each item should be administered, • Identification and assignment of weights to responses (high, medium, or low risk), • Strategy for reporting triggered alert items to local clinicians.

27. Developing the PrU DMP • Final versions of the DMP and responses with follow-up education were developed in collaboration with an expert clinician panel to validate PrU DMP items. • Follow-up clinical care guideline responses for alert triggers were developed based on PrU question/content risk level and patient response risk level.

28. Sample Behavior Question

29. Sample Knowledge Question

30. High Priority Items (n=9) • Quality of care provided by caregiver • Able to communicate with caregiver • Daily skin inspection • Notice new skin reddened areas on skin • Problems with equipment • Able to change position in bed • Able to keep skin clean and dry • Able to do pressure relief or weight shifts • Able to take care of skin

31. Study Design • PrU patients who about to be discharged from Cleveland SCI Center are screened for eligibility to participate in the study. • Patients with open or closed skin may participate. • Inclusion/exclusion: Cognitively intact and has a phone. • Design: Patients randomly assigned to receive daily (5 days a week) or weekly (1 day a week) calls implementing the proposed PrU DMP. • Study Status: Currently enrolling patients.

32. Study Data Analysis Study data will be used to determine • the appropriate frequency with which each item should be asked • whether certain items should be dropped • whether the items that the patients respond to should be determined by patient or SCI factors, (e.g., history of previous ulcers, Braden risk, open vs. closed skin, etc) We will make the following comparisons • daily vs. weekly interviews • closed vs. open skin • those who do/do not develop open skin during the study

33. Alert Trigger by Type Interim Results Daily Skin Alert Triggers

34. Resolving Triggered Alert Items • When a high or medium risk response item is triggered, the study research assistant contacts the Cleveland SCI clinic nurse that day who may: • provide advice or education to patient, • refer patient to Cleveland VA or local specialty clinic and/or • contact spoke site PCP to address/resolve the issue. • Study RA will follow-up with Cleveland RN, review CPRS notes or contact spoke site PCP to determine what actions and/or care (if any) was received.

35. Triggered Alert Issues We have identified problems with provider ability to communicate via CPRS about the resolution of clinical alerts between the hub-and-spoke sites. Providers within a site are more accustomed to using interdisciplinary team notes. We have observed differential ability among providers to use CPRS remote notes.

36. Future Directions • Use information/experience from this study to guide larger DMP. • Develop a larger prospective study to assess outcomes associated with patient use of PrU DMP in SCI.

37. Acknowledgements Expert Panel Members Fred Cowell (PVA) Susan Garber MA, OT Michael Priebe, MD Susan Thomason, PhD, RN DMP Development Group Karen Farrell, CNP Carol Gill, MD Marylou Guihan, PhD Chester Ho, MD Sadie Hughes-Young, CNP Christine Woo, MS Kristina Young, MOT OTR/L OCC Representative Patricia Ryan, MS, RN