improving wound care access and coordination between home, va primary and tertiary care medical...
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Improving Wound Care
Access
and Coordination Between
Home, VA Primary and
Tertiary Care Medical
Centers
VISN 11 Wound Care Teleconsultation Program
Julie Lowery, PhD and
Leah Gillon, MSW
DM QUERI, Ann Arbor 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
Developing a Home Telehealth Program to Manage Pressure Ulcers in Spinal Cord Injury/Disorder
Marylou Guihan, PhD,
Chester Ho, MD and
Christine Woo, MSSCI QUERI/Cleveland VAMC
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.
Defining Telehealth
Telehealth is the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants.
Level Store-and-Forward
Real Time
Type of data transmitted
MinimumBandwidthKbit/s per
Connection
Advanced
IV
Convergence of traditional telehealth, integration with EMR,
makes distinctions between traditional
medicine and telehealth meaningless
Convergence: Images, high
resolution video, EMR
High, (512kbits/s or greater)
Modern Telehealth
III Hybrid with high resolution video and
image
Images, high resolution video,
Medium (364 kbit/s)
IIa. High
resolution still images
b. Low resolution
video
Images, low resolution video
Low (128 kbit/s)
Pre-Telehealth
IEmail of
text information
Faxing of text
information
Electronic transmission of text information
Modem (<10 kbit/s)
0Postal mail Verbal
report by phone
Traditional, non-electronic
methods of communication
Telephone network
Telehealth Levels
Home Telehealth Equipment
Video telephones Data messaging devices Video tele-monitor devices Optional medical peripheral
devices
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.
Videophones
Advantages: Low cost Easy to use
Disadvantages: Performance varies Sporadic connection
& transmission of images
Limited use (mostly mental health)
Plain Old Telephone (POTS) with camera for video display
Some programs have used videophones for wound care
Home Telehealth Data Messaging Devices
Advantages Easy to use Low-cost Portable
Disadvantages Time gap between
patient data entry and clinician review
Provider must depend on accuracy of patient response to questions
Video Tele-monitor – Patient Station
Glucose Meter Pulse Oximeter
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
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
Video Telemonitor and Peripherals
Advantages Visual interaction Real-time data review Provider supervision of
information collection /transmission
Disadvantages High equipment
cost Video images
marginal over POTS telephone line
More complex to operate
Combination Video Telemonitor, Messaging and Peripheral Devices
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
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)
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
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, IL2 Chief, SCI Center, Louis Stokes Cleveland VAMC, Cleveland, OH3 Program Manager, SCI Telehealth Program, Louis Stokes Cleveland VAMC, Cleveland, OH
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.
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.
VISN 10Hub and Spokes
OHIO
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.
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
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
Adaptation of Telehealth Equipment for Veterans with Disabilities
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.
Home Telehealth Data Messaging Devices
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.
Developing the PrU DMP
PrU DMP ItemsDMP 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
Developing the PrU DMP
Consensus was obtained for following:
1. Purpose, goal and comprehension of questions/content items,
2. Determination of frequency with which each item should be administered,
3. Identification and assignment of weights to responses (high, medium, or low risk),
4. Strategy for reporting triggered alert items to local clinicians.
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.
Developing the PrU DMP
Sample Behavior Question
Category Type of Question
Question with Follow-up Response
Daily Skin Care
Behavior What do you do if you see a color change, dark, or red area on your skin?
1. Nothing (medium risk).2. Stay off Area3. Continue with normal activities (medium risk)
F/U Responses
Medium risk: You must immediately stay off the area to minimize the chance of developing a pressure ulcer. Check your skin every 15 minutes. If you do not see any changes in the color of your skin after 1 hour, please contact your care coordinator.
Low risk: Good.
Sample Knowledge Question
Category Type of Question
Final Version of Question with Follow-up Response
Prevention Knowledge How much time does it take for a pressure ulcer to develop?
1. Two months2. One month3. One week4. Several days5. Half an hour
For all responses: When blood cannot circulate past areas where the blood vessels are choked by the pressure of your weight on a surface, the cells that are fed by those blood vessels die and a sore develops. This can happen in as short a time as 30 minutes.
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
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.
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
Interim Results
Alert Trigger by Type
PrU Safety Issues
22%
Equipment Issues
22%
Daily Skin Care56%
Keeping Skin Dry 20%
20%
Dragging across
surfaces20% Regular
Pressure Relief40%
Skin Inspection
20%
Daily Skin Alert Triggers
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.
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.
Future Directions
1. Use information/experience from this study to guide larger DMP.
2. Develop a larger prospective study to assess outcomes associated with patient use of PrU DMP in SCI.
Acknowledgements
Expert Panel MembersFred Cowell (PVA)Susan Garber MA, OTMichael Priebe, MDSusan Thomason, PhD, RN
DMP Development
GroupKaren Farrell, CNPCarol Gill, MDMarylou Guihan, PhDChester Ho, MDSadie Hughes-Young, CNPChristine Woo, MSKristina Young, MOT OTR/L
OCC RepresentativePatricia Ryan, MS, RN
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