VA Provides Specialty Care in Local Offices Across the Country

The U.S. Department of Veterans Affairs (VA) has launched a virtual model of medical education to deliver health care that is based on AHRQ's "Project Extension for Community Healthcare Outcomes" (Project ECHO). The VA created and implemented the nationwide program to provide specialized care at local VA offices across the country.

VA physicians and other care providers are now being trained in specialty care areas, including heart failure and diabetes, via telehealth technology. The goal is for patients to receive care locally for most of their chronic health conditions, without having to make often lengthy trips to see specialists.

The AHRQ-funded Project ECHO uses a telehealth approach to implementing best practices in disease management and providing distance-based training for rural clinicians. Sanjeev Arora, MD, Vice Chairman of the Department of Medicine at the University of New Mexico Medical School, was the driving force behind the creation of Project ECHO.

The VA's project is called Specialty Care Access Networks-Extension for Community Healthcare Outcomes (SCAN-ECHO). It has the potential to affect thousands of veterans and has already engaged several hundred primary care clinicians and specialist teams.

Susan Kirsh, MD, MPH, Clinical Consultant in the Office of Specialty Care at the VA's Central Office in Washington, DC, broadened the scope of the original SCAN-ECHO project to include a wide variety of health care providers, patients, and conditions. "The impact to the veteran is our main goal," she explains. "We want to be able to provide good care locally when appropriate so patients don't have to travel to receive care from a specialist, who can be distant. This is a particularly useful program for providers serving rural veterans."

Eleven VA centers were originally funded as Specialty Care Centers, with $5 million for each center over a 3-year period. At the beginning of the SCAN-ECHO project, nurse practitioners and physician assistants were the providers most commonly trained to treat four chronic health conditions. Conditions addressed include diabetes, hepatitis C, heart failure, and chronic pain. The curriculum for chronic pain management is a joint effort between the VA and the Department of Defense (DoD) and is based on the "VA/DoD Evidence-Based Clinical Practice Guidelines." Walter Reed National Military Medical Center has implemented Project ECHO around the world for chronic pain management and collaborates with the VA in this area regularly.

The VA's Office of Rural Health became involved, and in January 2012, more than $2 million in funding allowed primary care providers to participate in the new program. With this boost in funds and focus, training was expanded to include more primary care providers and their teams, along with additional disease states/conditions in areas serving rural veterans or in rural areas themselves. The centers cover additional conditions that primary care providers have often referred to specialists, including epilepsy, kidney disease/renal failure, general cardiology, HIV, women's health/gynecology, and chronic obstructive pulmonary disease (and in rural Ohio, preoperative care). Many rural clinicians seek collaboration and specialist input because they are located in areas with few specialists. This program offers an opportunity to enhance care and education for both patients and clinicians in rural areas of the United States.

"We have increased the numbers and types of providers who are being trained in basic specialty care. We've discovered that primary care providers love becoming increasingly knowledgeable and skilled in delivering some aspects of specialty care," Kirsh notes.

She continues, "The core content for training is designed as enduring case-based educational materials. All content for the 16 core didactic courses has been vetted by National Program directors and subject experts in each specialty." The standardized training curriculum became available for continuing medical education credit in early 2013.

While the new processes have already been shown to be good for patients, the program also has to be financially viable. "If we can improve patient care and the patient experience, that's excellent," Kirsh says. "But the project must demonstrate a positive return on investment in order to be sustainable."

To measure costs and effectiveness of the program, VA's Health Services Research and Development Service will look at quality metrics and utilization analyses. The project's evaluation team will interview primary care providers about the specialty side of their patients' care to get providers' perspectives. Some potential ways to evaluate this program may include geo-coding to identify the number of miles saved as a result of patients' ability to receive care near their home rather than driving to see specialists in distant cities. Geo-coding is the process of linking geographic information with other data. In this case, patient addresses are linked to locations where they see both primary care and specialty care VA providers.

The SCAN-ECHO program is creating a nationwide team of "mini-specialists," who apply their newly learned skills as they care for veterans. This has also created a ripple effect in local patient care. "For instance, pain experts will still see their own patients, but they will also apply their new knowledge in each patient interaction," Kirsh notes.

Within a fairly short time frame, Kirsh expects to see some measurable process changes. One example would be an increase in the number of patients with hepatitis C who receive HIV testing. All such patients should be tested, but as of 2012, only about 20 percent of all patients with hepatitis C both in and outside of the VA had been tested for HIV.

Kirsh adds, "The coding issues are massive, but we are working to create reports for measurement. We want to look across the entire program and compare treatments. For example, how is pain being managed? What is being done, what types of medication are being used, how much medicine is prescribed? This lets us examine variances in treatment throughout our community-based outpatient clinics."