In Eureka, Montana near the Canadian border, a telehealth initiative brings together a veteran with a physician five hours away. In Pittsburgh, a Department of Veterans Affairs (VA) oncologist conducts video visits with patients 100 miles to the east, coordinating care with a technician who helps ease patients into this new approach. And across the country, veterans have flexibility to see specialists outside VA thanks to a new law with provisions on everything from telemedicine to increased patient choice.

These are among many new developments to enhance specialty care for veterans, particularly those living in less-populated areas and those who face more complex challenges or deal with new challenges as they age. Spanning more than 20 disciplines, VA’s specialty care includes cardiology, critical care, dermatology, diabetes, eye care, infectious disease, neurology, nutrition, and oncology, and other areas described in full at www.patientcare.va.gov/specialtycare.asp.

With many new activities underway, one common thread across these initiatives is the goal “to ensure that veterans are spending their time getting care instead of driving to it,” said Lesly Roose, a program manager at the VA’s Office of Connected Care.

 

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VA specialty care is changing under the MISSION Act, the comprehensive legislation signed into law in 2018 that took effect in June 2019. Among other provisions, the law set new guidelines for how veterans can see specialists outside the VA system. Under the act, a veteran can seek private-sector care if he or she must wait more than 28 days for a VA appointment or drive more than 60 miles to a VA facility. The agency says this policy may mean 1.5 million veterans will gain access to private care, up from 560,000 under previous department choice initiatives.

So far, VA leaders say the law has produced gains for specialty care. “Ninety percent of the increase in consultations going out to the community are in specialty care,” Richard Stone, MD, administrator of the Veterans Health Administration, told a Capitol Hill audience in February 2020. With these options now more readily available, he said, “It appears veterans have improved access to specialty care.”

 

 

However, there is still ample evidence – despite the new flexibility – that many veterans prefer to use VA facilities and staff for their specialty care. “The MISSION Act has afforded the veterans the opportunity to receive speedier care,” said Terrence Hayes, a spokesman for the Veterans of Foreign Wars (VFW). “However, our members’ preference remains the VA medical centers and clinics, where they believe they will receive more specialized care due to their military service needs.”

Research has shown that veterans were able to access VA specialists at the same or faster rates than they could secure such care in the community. A 2019 study in the Journal of the American Medical Association found no statistically significant difference between private sector and VA wait times for primary care and two major areas of specialty care: cardiology and dermatology. While the VA had statistically significant longer wait times for a third area of specialty care included in the study – orthopedics – compared with private providers, researchers said the findings “should help to disabuse the unfortunate yet widely held belief that access in the VA is substantially inferior to that in the private sector.”

However, regional variations within the large VA system mean the situation can look different on the ground depending on the location. Recently, the VA’s Office of Inspector General (OIG) found the process of obtaining care in the community was particularly difficult in the southern U.S. region including Florida, Puerto Rico, and parts of Georgia. The OIG said it took 10 days to refer potential outside consultations and another 18 days to process the request.

 

 

That meant “28 days of administrative wait before a veteran was able to begin the scheduling and appointing process,” said William “Doc” Schmitz, VFW’s national commander in chief. “With standards of 20 days for primary care and 28 days for specialty care, the access standards were surpassed before the process of scheduling and receiving care could begin.” At one site, ophthalmology referrals took 66 days to complete care delivery, with 34 days spent waiting to create authorizations. If community care is to succeed for a large segment of the veteran population, he added, “it must work seamlessly and quickly to deliver needed care.”

One reason behind the delays is the many VA staff vacancies that go unfilled. In fall 2019, the OIG reported that 131 of 140 VA medical facilities had severe shortages of medical officers and 102 had severe nurse shortages. The inspector cited lack of qualified applicants, non-competitive salaries, and staff turnover among the reasons for the large number of vacancies.

In specialty care, shortages also can lead to overworked staff who remain on the job. For example, data showed that nurses who specialize in spinal cord injury or disorder (SCI/D) worked more than 105,000 overtime hours in one year, David Zurfluh, national president of Paralyzed Veterans of America, said at a March 2020 hearing. Such trends also indicate that underqualified staff must provide more care.

“A system that relies on floating nurses, not properly trained to handle SCI patients, overworks existing SCI/D nursing staff,” Zurfluh said. “This leads to burn out, injury, and loss of work time or staff departure and is unacceptable. In some circumstances, it even jeopardizes the health care of veterans.”

At recent 2020 hearings, members of Congress chimed in with their concern about VA staff shortages. “Vacancies continue to be the biggest barrier to primary, specialty, and mental care for veterans across the country,” said Sen. Jon Tester, D-Mont., a member of the Senate Veterans’ Affairs Committee.

 

VA spinal cord injury (SCI) nurses and veterans on Veterans Day Weekend at the VA Boston Healthcare System. Staff shortages in specialty care areas can lead to overworked staff and delays in veterans’ access to care.

 

One potential answer to these challenges is greater use of technology to deliver high-quality specialty care. One such innovation is the Specialty Care Access Network – Extension for Community Healthcare Outcomes (SCAN-ECHO) program, which links primary and specialty care physicians to improve patient care in the VA system. SCAN-ECHO is a provider-to-provider connection, where specialists provide professional development to increase the knowledge and skills of primary care physicians in rural or isolated communities. Webinars, small-group training, and even mini-residencies are options used to deliver the training.

In a 2019 report, the Department of Health and Human Services (HHS) cited a study finding that veterans with chronic liver disease showed much stronger outcomes if their primary care physicians participated in the program. “Those receiving the intervention were much less likely to die than those who had no SCAN-ECHO consultation over the same time period,” the agency reported. Other research showed that providers with at least one SCAN-ECHO consultation improved treatment for patients with hepatitis C. Overall, HHS said based on the most recent data, SCAN-ECHO was used most heavily to improve care for diabetes, pain management, and hepatitis C.

 

While SCAN-ECHO is a long-time tool of VA, more recent advances in telehealth – with patients interacting directly with specialists via video – are driving a rapid expansion in remote patient consultations. Telehealth provided 2.6 million episodes of care to more than 900,000 veterans in fiscal year 2019, an increase of 17 percent over the previous year, the VA reported. “This extraordinary progress gives veterans more convenient care options without traveling to their provider’s office,” VHA’s Stone wrote in a post in January 2020 on VAntage Point, the VA’s blog.

The MISSION Act also contains many provisions to support telehealth. It specifically authorizes “anywhere to anywhere” telehealth, which in effect “can bring provider expertise across state lines and into veterans’ own living rooms,” Stone added.

Such innovations include the nation’s first remote chemotherapy clinic from the VA Pittsburgh Healthcare System. From their base in Pittsburgh, oncologists monitor the care of patients as they visit the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania, two hours to the east. Staff in Altoona use a camera to send images and live video to the oncology team in Pittsburgh. The Altoona clinic can conduct lab work, testing, and radiology services, and clinic staff work with oncologists to create a patient’s individualized treatment plan.

 

A treatment room at the nation’s first remote chemotherapy clinic, located at the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania.

 

“Patients and caregivers tell me, ‘We love this technology because it saves us so much travel, time, and money,’” said Vida Passero, MD, an oncologist and head of VA Pittsburgh’s hematology and oncology division, in a recent post on the VA’s blog. One key element to success is having a welltrained, caring technician on site in Altoona to introduce the patients and their families to the concept of visiting with a physician via a TV screen.

Oncology is just one of many initiatives underway to enhance specialty care via telehealth:

• Later this year, the VA Pittsburgh Healthcare System also plans to roll out tele-gynecology for outpatient clinics in western Pennsylvania and eastern Ohio, part of an effort to deliver care to a fast-growing population of women veterans.
• VA teledermatology solutions are helping patients get quicker access to board-certified dermatologists. Under this program, a primary care provider on site orders imaging, which is then transferred to a remotely located dermatologist via the VA’s electronic health record. Mobile app solutions also are underway to enhance care in this specialty.
• A Tele-ICU program allows specialty providers to access intensive care unit rooms via video to improve care. Rooms in the tele-ICU typically include TV screens, cameras, and call buttons used to contact specialists. Providers review charts, speak with patients, make notes, and confer with on-site care teams to chart patient care.
• A TeleStroke initiative supports VA facilities without round-the-clock acute stroke coverage. Under this initiative, neurologists can examine patients through a video tool and help local providers diagnose conditions and propose treatments.

Another emerging innovation is the Accessing Telehealth through Local Area Stations (ATLAS) initiative, where VA and partners are creating dedicated space in local communities for veterans to visit with their health care providers. One of the new locations is 7 miles from the Canadian border in Eureka, Montana, where veterans face a five-hour drive to the nearest VA hospital. At its office in Eureka, VFW Post 6786 provided a dedicated office space plus an internet connection so that veterans can communicate with their medical providers.

“By providing convenient locations for veterans to access VA care in their communities, ATLAS saves veterans travel time and transportation costs, increases their access to care, and provides a convenient solution for aging, underserved, or rural veterans,” said Roose, the ATLAS program manager within the Office of Connected Care.

 

 

The VFW, the American Legion, and veterans’ service organizations offer locations for these local stations, and Philips Healthcare has donated telehealth equipment and expertise to make them fully operational. Aside from Eureka, Phase 1 ATLAS sites include Linesville, Pennsylvania, and Los Banos, California. For each site, Philips created an exam room that was customized based on feedback from veterans who participated in role-play activities to determine the best layout and structure to promote patient ease and comfort. ATLAS pods have blood pressure cuffs, glucose meters, electronic scales, and other resources to facilitate a quality health care visit.

The local VA facility associated with the ATLAS site determines the clinical services offered at each site. Each site has the ability to link veterans with VA providers through VA Video Connect, a secure video conferencing software. Patients also have no co-pay for VA Video Connect appointments.

For the next phase of the project, the VA is working with other partners to stand up exam rooms in more sites such as local Walmart stores. Leaders recently cut the ribbon on a new ATLAS facility inside a Walmart in Asheboro, North Carolina. The retailer also will provide space for ATLAS sites in Boone, North Carolina; Howell, Michigan; Keokuk, Iowa; and Fond du Lac, Wisconsin.

“ATLAS is enhancing the veteran experience by offering a convenient and personalized health care option for veterans that face long travel times to VA facilities or have limited internet connectivity at home,” Roose said.

Overall, the VA says nearly 1.9 million veterans have sought care via the MISSION Act’s various initiatives since June 2019. A recent survey of 7,000 VFW members also found that 74 percent saw improvements at their local VA facility, up from 64 percent in 2018. Overall, Roose added, “The MISSION Act has greatly expanded the choices veterans have when it comes to their health care.”

 

This story originally appears in Veterans Affairs & Military Medicine OUTLOOK.