Telehealth in the PADRECC: 

The Key to the Patient-Aligned Care Team?

A Randomized – Controlled Trial

November 22, 2012

Jayne R. Wilkinson, M.D.

Associate Clinical Director,

PADRECC, Philadelphia VAMC

Assistant Professor, Neurology

University of Pennsylvania School of Medicine
Outline

• PACT in specialty care

• PACT in PADRECC

• Telehealth in the VAMC 

• Telehealth in the PADRECC

– Study proposal and design

– Future clinical, education, research directions
Patient – Aligned Care Team & Specialists

(Patient – Centered Medical Home)

Casalino et al 2010
PACT & the Specialist

Casalino et al 2010
Background – Parkinson’s Disease

• Parkinson’s disease (PD) affects 385/100,000

• Prevalence increases with age: >70, 500/100,000

• Cardinal motor signs: bradykinesia, rigidity, resting 

tremor and postural instability  disability

• Numerous disabling, nonmotor signs/symptoms

• A population in need of extensive and often 

frequent subspecialty medical care; faced with 

numerous obstacles to access that care
PADRECC:

Parkinson’s Disease Research, 

Education, and Clinical Center
Is PADRECC a PACT? 
“VAMC Telehealth 101”

• Origin: Began in the VAMC in 1968

• Oversight: Office of Telehealth Services (OTS)

• Mission: “Provide the RIGHT CARE in the RIGHT PLACE at the RIGHT TIME!”

• Three (3) general divisions

– Care Coordination Home Telehealth (CCHT)

– Clinical Video Telehealth (CVT)

– Care Coordination Store-and-Forward Telehealth (CCSF) 

• Largest program in the country: 300,000 veterans 

annually; 140 VAMC and 500 CBOCs
Definition of Telehealth

• Telemedicine: "the use of electronic information and communications technologies 

to provide and support health care when distance separates the participants."

• The terms "Telehealth" and "e–health" appeared later to include allied healthcare 

activities such as:

– patient education; 

– continuing medical education/grand rounds; 

– remote resident supervision; 

– medical training over distance; 

– health care administration via video–teleconferencing; and 

– connect patients to other patients over a distance. 

• In recognition of the interdisciplinary nature of telemedicine, VA began using the 

broader, more inclusive term “Telehealth" in place of "telemedicine" in 2003. VA 

telemedicine is seen as a subset of VA telehealth.
VAMC Facility Telehealth Equipment

Primary Care & Specialty Carts

Web-cam
VAMC Home Telehealth Equipment

Intel Health Guide® 
National VAMC Telehealth Goals

Virtual Care

• Census goals

– 15% veterans FY 2012

– 30% veterans FY 2013

– 50% veterans FY 2014

• Secure Messaging via MyHealthyVet will be 

included in Virtual Care metric

• Enroll at least 1.5% of each PACT’s assigned panel 

in Home Telehealth
Telehealth in the PADRECC

• Telehealth in treating PD has not been studied 

in great detail; a few small studies looking at 

feasibility 

• Given success demonstrated in general 

telehealth literature, want to apply this 

technology to PADRECC patient population. 

• Useful clinical resource for PD: symptoms can be 

assessed by video, provides cost-effective 

accessible care  implementation 

Dorsey et al 2010
Research Study

Overall Goal

• Compare using video telehealth in treating 

Parkinson’s disease to usual, in-person care

• Research design similar for 2 separate arms:

1. Facility-to-facility telehealth (PVAMC CBOCs)

2. Facility-to-home telehealth
Primary Aim 

• Compare patient satisfaction between subjects 

enrolled in telehealth and those who are not. 
Descriptive / Secondary Aim

• Compare clinical outcomes, healthcare 

utilization, and patient travel costs between 

subjects enrolled in telehealth and those who 

are not.
Hypotheses

• Compared with usual care, use of telehealth will 

be associated with increased patient 

satisfaction.

• Compared with usual care, use of telehealth will 

be associated with similar clinical outcomes, 

decreased patient travel costs, and different 

patterns of healthcare utilization, with 

telehealth users having a lower degree of 

unplanned encounters with their providers.
Methods

• Study Design: Randomized Controlled Trial

• Study Sites: Philadelphia VAMC, local VA outpatient 

centers & patient homes

• Source Population: Current PADRECC patients

• Exposure: Clinical Video Telehealth (CVT) at 

outpatient centers of the Philadelphia VAMC or 

patient’s home
Exposure: Telehealth in the PADRECC

• Patient at home or local facility (CBOC)

• Similar to in-person visits

– Duration and elements of visit unchanged

• Exam: modified; TCTs facilitate

• Other providers available (psychiatry, social work, nursing 

staff)

Control: Continued in-person visits
Study Population

• Inclusion criteria: 

– Dx of PD (ICD9=332.0)

– Reside closer to another VA facility with telehealth 

technology, than the Philadelphia clinic

 or

– Internet connection (allowing Healthguide® installation)

• Exclusion criteria: 

– Patients requiring in-person visits (deep brain 

stimulation devices or botulinum toxin injections)
Data Collection

• Questionnaires and electronic chart review

• Baseline / demographic 

– Age, sex, race

– Disease characteristics:

• Duration of disease; time since diagnosis

• Presenting signs

• Baseline PD clinical scores

• Outcomes: 6 month & 12 month visits 

– Patient satisfaction

– Clinical outcomes

– Patient travel costs

– Healthcare utilization
Primary Outcome – Patient 

Satisfaction

• Patient Assessment of Communication of 

Telehealth (PACT) Questionnaire

• PADRECC Clinical Survey

Agha et al 2009
Secondary Outcomes

Clinical 

• Disease stage: UPDRS (Unified Parkinson’s 

disease Rating Scale); Hoehn & Yahr stage

• Quality of Life: PDQ-8 Questionnaire 

• Geriatric Depression Scale
Secondary Outcomes

Patient Travel Costs

• Travel time & mileage

• Time off of work: patient &/or companion

• Meal costs

• Travel reimbursement from VAMC
Secondary Outcomes

Healthcare Utilization

• Patient-initiated appointment cancellations

• Unplanned clinical services related to PD

– Hospital admissions 

– ED visits 

– Non-routine provider visits

– Provider phone calls

• Routine PD visits
Timeline

Event Study Month

0 3 6 9 12 15 18 21 24

RB approval 

btain equipment, if applicable

ecruitment/equipment training 

ctive study duration 

ata cleaning & analyses 

bstract / manuscript preparation

I

O

R

A

D

A
Limitations

• Recruitment / retention

– Limited by geography, equipment and PD census

– Drop-out (death, NH placement, home-bound)

– Study may be underpowered; effect size not known

• Bias:

– Recall 

– Selection / volunteer

– Outcome: not blinded to intervention

• Confounding: 

– RCT will address many unmeasured

– Possible measured: disease stage/duration, age, depression

• Generalizability: 

– Patient population

– Cost analysis is not complete; travel costs contribute to patient 

satisfaction
Current Study Enrollment

• Home telehealth: 32

• Facility-to-facility: 47

• Goal for each arm = 50 (25 telehealth; 25 control)
Future Directions

• Data will guide development of future telehealth 

programs in treating PD

– Expanding use in multi-disciplinary fields

– Use in educational and other non-clinical venues

– Use in conducting research (clinical trials)

• Provide pilot data for broader, national PD 

telehealth clinical trials
Summary

• Encourage providers to consider telehealth; 

particularly as it relates to PACT model
Acknowledgements

• CEPACT (Center for the Evaluation of the Patient –

Aligned Care Team) 

– Rachel Werner, MD, PhD: Director and PI

– Michele Lempa, Dr. PH: Administrative Director

– Steve Marcus, PhD: Biostatistician

• PADRECC colleagues & patients
The End –Thank you!

jayne.wilkinson@va.gov

Philadelphia PADRECC

215-823-5934
References 

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Nov;15(9): 830-9. 

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Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood ) 2010; 29(4):614-621.

Biglan KM, Voss TS, Deuel LM, Miller D, Eason S, Fagnano M et al. Telemedicine for the care of nursing home residents with Parkinson's disease. Mov Disord 

2009; 24(7):1073-1076.

Casalino LP, Rittenhouse DR, Gillies RR, Shortell SM. Specialist Physician Practices as Patient-Centered Medical Homes. N Engl J Med 2010; 362: 1555-1558.

Chumbler NR, Haggstrom DA, Saleem J. Implementation of Health Information Technology in Veterans Health Administration to Support Transformational 

Change: Telehealth and Personal Health Records. Med Care 2010.

Cradduck TD. Sustainability--the Holy Grail of telehealth? J Telemed Telecare 2002; 8 Suppl 3:S3-S8.

Darkins A. Changing the location of care: management of patients with chronic conditions in Veterans Health Administration using care coordination/home 

telehealth. J Rehabil Res Dev 2006; 43(4):vii-xii.

Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B et al. Care Coordination/Home Telehealth: the systematic implementation of health informatics, 

home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health 2008; Dorsey ER, 

14(10):1118-1126.

Deuel LM, Voss TS, Finnigan K, George BP, Eason S, Miller D, Reminick JI, Appler A, Polanowicz J, Viti L, Smith S, Joseph A, Biglan KM. Increasing access to 

specialty care: a pilot, randomized controlled trial of telemedicine for Parkinson’s disease. Mov Disord. 2010 Aug 15;25(11):1652-9.

Fincher L, Ward C, Dawkins V, Magee V, Willson P. Using telehealth to educate Parkinson's disease patients about complicated medication regimens. J Gerontol 

Nurs 2009; 35(2):16-24.

Finkelstein SM, Speedie SM, Potthoff S. Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemed J E Health 2006; 12(2):128- 136.

Hopp F, Whitten P, Subramanian U, Woodbridge P, Mackert M, Lowery J. Perspectives from the Veterans Health Administration about opportunities and 

barriers in telemedicine. J Telemed Telecare 2006; 12(8):404-409.

Hubble JP, Pahwa R, Michalek DK, Thomas C, Koller WC. Interactive video conferencing: a means of providing interim care to Parkinson's disease patients. Mov 

Disord 1993; 8(3):380-382.

Noel HC, Vogel DC, Erdos JJ, Cornwall D, Levin F. Home telehealth reduces healthcare costs. Telemed J E Health 2004; 10(2):170-183.

Ruff RL. Is there a room for Neurology in the Patient-Centered Medical Home? Neurology FAC Quarterly Newsletter 2[1]. 2010.

Samii A, Ryan-Dykes P, Tsukuda RA, Zink C, Franks R, Nichol WP. Telemedicine for delivery of health care in Parkinson's disease. J Telemed Telecare 2006; 

12(1):16-18.

Scholle SH, Pawlson LG, Solberg LI, Shih SC, Asche SE, Chou AF et al. Measuring practice systems for chronic illness care: accuracy of self-reports from clinical 

personnel. Jt Comm J Qual Patient Saf 2008; 34(7):407-416.

Schrag A, Barone P, Brown RG, Leentjens AF, McDonald WM, Starkstein S et al. Depression rating scales in Parkinson's disease: critique and recommendations. 

Mov Disord 2007; 22(8):1077-1092.

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Improving Support for Chronic Illness Care: 

The CarePartner Approach

John D. Piette, Ph.D.

VA Senior Research Career Scientist

Director, VA Ann Arbor Program on Quality Improvement for Complex Chronic Conditions

jpiette@umich.edu

PR11SM Demo Lab

PACT Research Inspiring Innovation and Self Management
What is QUICCC?

QUICCC is a research group supported by the 

Ann Arbor HSR&D, the University of Michigan 

Health System, and outside grants

QUICCC’s purpose is to develop and evaluate 

new services that improve care for chronically 

ill patients in ‘real-world’ settings
PR11SM DEMO LAB INNOVATION

FACILITATED SELF- PATIENT IDENTIFIED MANAGEMENT

REGISTRIES PATIENTS • CarePartners

• Diabetes • Diabetes, CHF, Depression

• Heart Failure • Transitions

• Depression

• Hospital & ED NAVIGATOR ENHANCED 

Transitions

• Chronic Pain SYSTEM: MANAGEMENT • Systematic • Social Work 

Assessment • RN Case Management 

• Recommendations • CCHT 

Based on Patient • MOVE/TeleMOVE

Priorities • Diabetes Classes

 

 PRIMARY CARE PACT REDESIGN

 
Many patients need 

more help than 

clinicians can ever 

realistically provide 

during standard 

encounters.

Rubenstein LV et al. Improving care for depression: there’s no free lunch. Annals of Internal Medicine 

2006;145:544-546.

Dobscha SK et al. Depression decision support in primary care: a cluster randomized trial. Annals of Internal 

Medicine 2006;145:477+.
Other Patients Informal Caregivers

Patient

Care Managers Primary Providers Pharmacy

Communication Targets for New Services

5 
mHealth 


Why Focus on “Informal Caregivers”?

• Research suggests that informal caregivers can 

improve chronic illness outcomes

• Family already are involved in many patients’ care

• Many physicians want more family involvement

• Informal caregivers often lack the support they need 

to be effective 

Martire LM, Lustig AP, Schulz R, Miller GE, Helgeson VS. Is it beneficial to involve a family member? A metaanalysis of psychosocial interventions for chronic illness. Health Psychology 2004;23(6): 599-611.
10 
• Use a simple IT tool to enhance clinicians’ ability to monitor 

patients’ status via automated telephone assessments with 

feedback to the clinical team

• Provide patients with additional tailored feedback and education 

based on their self-management needs

• Provide structured feedback and education to patients’ active 

and potential ‘informal caregivers’ e.g., adult children living 

outside of their household

• Keep clinician workload to a minimum

CarePartner Program Goals
12 
Website 
Materials for Patients and their CarePartners

Patient CarePartner 

In-Home Caregiver

User-Requested Features

• Automated message to the PCP when patients enroll

• Alerts to CarePartners when patients miss a call

• The CarePartner can call in to get their updates

• If patient reports an urgent health problem, the system will 

call the CarePartner and let them know

• Clinics can tailor their own desired fax alert menu
CarePartner Programs Have Been 

Implemented for Patients with a Variety of 

Conditions

• VA Patients with CHF (ORH and HSR&D)

• VA Patients Undergoing Cancer Chemotherapy (HSRD)

• VA Patients with Chronic Pain (HSRD) 

• VA and Non-VA Patients with Diabetes (ORH, PACT, NIH)

• VA and Non-VA Patients in Transitional Care (PACT, AHRQ, NIH)

• VA and Non-VA Patients with Depression (PACT, UMHS, PGIP, NIH)

• Non-VA Patients with Decompensated Cirrhosis (UMHS)
Piette JD, Rosland Am, Marinec NS, Striplin D, Bernstein SJ, Silveira MJ. Engagement in automated 

patient monitoring and self-management support calls: experience with a thousand chronically-ill 

patients. Medical Care, in press.
19 
20

Probability of Call Completion by Patient Age
0 

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

1 6 11 16 21 26

Probability of a Suicide Alert by Most Recent 

IVR-Reported PHQ-9 

Patient Satisfaction

• 90% would recommend the program to a friend

• 90% satisfied with the amount of help they received 

from the program

• 84% said the program helped them to deal more 

effectively with their condition

• 79% would return to the program
CarePartner Satisfaction 

• 69% of Care Partners said they talk with the patient more 

frequently in general and discuss self-management more 

frequently 

• 98% would recommend the program to a friend

• 85% said the information in the weekly updates helped them to 

provide assistance more effectively

• 80% said that most or almost all of their needs were met in 

assisting the patient with their depression
Patient Feedback 

• “The program made me acknowledge the consequences of not taking 

meds.”

• “A few times I was really down, and got a call from a nurse, which was 

very comforting and reassuring.”

• “One time I accidentally pressed the wrong number, and my doctor's 

office called that night - it was reassuring to have that system in place. 

It would be very hard to avoid even when I isolate myself.”

• “I had been dealing with this for so long that I almost wasn’t paying 

attention. I don't think I would have gone back to therapy to address 

these things without the phone calls making me see how much I 

needed it.”
Effects on Doctor/Patient Relationships

– 62% agree that “Since being in the program, I feel better 

able to ask questions when I visit my doctor” 

– 64% agree that “Since being in the program, I have a better 

understanding of the importance of follow-up visits with 

my primary care provider”

– 76% agree that “Since being in the program, I understand 

better when I should contact my provider about a problem 

I may be having with medications or self-care”
27