# Presentation: 218269

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

## VISN 11 Wound Care Teleconsultation Program 

- 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, MS
- SCI 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.

## Telehealth Levels

|  | Level
 | Store-and-
Forward | Real 
Time | Type of data transmitted | Minimum
Bandwidth
Kbit/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) |
|  | 
II | a. High resolution still images | b. Low resolution video | Images, low resolution video | Low (128 kbit/s) |
| 

Pre-Telehealth | 
I | Email of text information | Faxing of text information | Electronic transmission of text information | Modem (<10 kbit/s) |
|  | 
0 | Postal mail | Verbal report by phone | Traditional, non-electronic methods of communication | Telephone network |

## 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

- 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, IL
- 2 Chief, SCI Center, Louis Stokes Cleveland VAMC, Cleveland, OH
- 3 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.

## 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

- 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

## Home Telehealth 

-  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. 

- 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 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

## 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.

## 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.

- 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?  
Nothing (medium risk).
Stay off Area
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? 
 Two months
 One month
 One week
 Several days
 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

**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

- 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.

## 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