PACT Demonstration Labs - 16 -Department of Veteran Affairs

PACT-112112

**Department of Veterans Affairs**

**Patient Aligned Care Teams Demonstration Labs**

**Telehealth in the PADRECC:**

**The Key to the Patient-Aligned Care Team?**

**A Randomized – Controlled TrialJayne R. Wilkinson, M.D.**

**November 21, 2012**

Molly:  As we are at the top of our hour, I'd like to introduce our speakers, speaking first, we have Dr. Jayne Wilkinson.  She is the associate clinical director at the Parkinson's Disease Research Education and Clinical Center.  This is PVAMC, I believe is Philadelphia VA Medical Center.  I apologize if I have that wrong, Jayne, please correct me.  We have Dr. John Piette, the director for the program on quality improvement for complex chronic conditions at the VA Center for Clinical Management and Research.  So at this time, I'd like to turn it over to Dr. Wilkinson.  You will see a popup on your screen that says "Show my screen," go ahead and click on that.  Excellent and we're set to go.  Thank you.

Jayne Wilkinson:  Well, Mollie, thank you so much for that introduction and it's really my pleasure to be here and talk about my work as it relates to telehealth and the PADRECC, it's usually a topic near and dear to what I do each day and I do want to acknowledge that this work was spearheaded and very generously funded through a grant that I received from the [C-BOC] here in Philadelphia.  

So I'm going to talk about telehealth and the PADRECC: is it the key to the patient's fine care chain and review my study, which is currently underway.  So just briefly to outline what I'm going to talk about: I'd like to touch on the notion of PACT in specialty care and specifically in the PADRECC, our Parkinson's Disease center here in Philadelphia, and then sort of as a background, touch on telehealth and the VA Medical Center in general and what we're doing here in the PADRECC, and in that vein, discuss the study that we're doing and we're so excited about and sort of end with some future clinical educational and research directions that I think are relevant.

So I'm sure most on the call are familiar with the Patient Aligned Care Team, for anyone that isn't and knows that it's also synonymous with the patient-centered medical home model, I just wanted to bring that up, but as it goes or as we think about specialists using this model, I included an adaptation of the PCMH tenets and I think in reviewing them, you might imagine cases where it could apply to specialists particularly those that treat chronic disease and I'm not going to read them, but I just sort of want to make that point.

I will touch on this article in the next slide in a bit more detail, but the New England Journal of Medicine published an interesting survey that was conducted a couple years ago on this topic kind of querying specialists and their opinion of their role and do you in fact feel that you are a primary care provider in some cases?

There aren't a great number of specialty examples in the literature, but there are certainly a few and I included one about a mental health program and I just wanted to include this comment that Dr. [Ruff], our chief of neurology, made a couple years ago in a newsletter.  "Is there Room for the Neurologist in the Patient-Centered Medical Home?"  So I think this sort of gives us a lot to think about with respect to: can specialists function in this role?

So that article I mentioned that was published in the New England Journal of Medicine was pretty interesting, basically they carried out a phone survey of 372 leaders or directors of various clinical practices and they asked a very specific question and I'll read it to you: "In some cases specialists also serve as the primary care physician for their patients, to the best of your knowledge for approximately what percentage of patients, if any, do the physicians in your practice serve as the primary care physician as well as specialist?"  I think the bottom line maybe not to many surprise is that most don't, most providers responded that very few of their patients do they provide primary care service, but there certainly were some that did.  You might look here, the endocrinologist perhaps felt that they did more frequently.

So it's interesting that many don't, but that some obviously do and another I thought interesting fact about this article was that it received a fairly large number of letters to the editor from other specialists, including ob/gyn providers, mental health providers, a nephrology group and some cardiologists kind of saying, "Hey, wait.  What about me?  I think I provide primary care for my patients as well."  So I just wanted to share that.

Can the specialist provide PACT-type care?  Can the PACT model work in neurology?  Can it work in Parkinson's Disease, so I just want to take a quick minute to talk about Parkinson's Disease as many of you know, it is a neurodegenerative disorder that affects about 385 per 100,000 patients.  The prevalence certainly increases with age, it's widely recognized for its four cardinal motor signs of bradykinesia or slowness, rigidity, stiffness, resting tremor and postural instability, which is imbalance.  As you might imagine these cause significant physical disability to this patient population.  

There's also numerous somewhat less recognized non motor signs and these include things like depression, anxiety, fatigue, cognitive impairment, incontinence, really just to name a few and these are often even reported as more disabling to patients.  

So we have a patient population that's really in dire need of frequent sub specialty medical care, faced with a lot of obstacles to access that care, so that people that need us the most you could argue have the most trouble getting to us.  So how do we fix this problem?  That was sort of the driving force for my interest in this study.  How can we increase access to patients and Veterans specifically afflicted with Parkinson's Disease?

I think part of the solution actually took place about 10 years, really 11 years ago when the PADRECCs were established.  There are six PADRECCs they were developed in 2001, with a primary mission to provide comprehensive state-of-the-art multidisciplinary care to Veterans afflicted with PD and we really do try to provide comprehensive medical team approach during each visit and often there is a primary clinical care coordinator for each Veteran.  In our case it's often a sub specialty nurse, who works in conjunction with a physician and this one person really does orchestrate the myriad of ongoing aspects of care that are required to effectively treat this very disabling and multifactorial disease.

So I just wanted to share this map here of the PADRECCs and our service area and you can see the Philadelphia service area, it's fairly large, but we're fortunate enough, as part of this network to work in conjunction with our consortium centers and there are 50 Parkinson's Consortium Centers and these centers have also a movement disorder neurologist seeing patients as well.  I just wanted to share that and I'll talk about applying the PACT tenets to the PADRECC.  I think there already are some similarities to PACT, but how can we make it better?  How can we come closer to reaching the goals and fulfilling the tenets and missions of the  PACT model?

I think we currently do provide each patient with an ongoing relationship with a personal physician or nurse who's trained to be first contact and provide comprehensive care.  I think we certainly provide care for acute chronic conditions, preventative services.  Unfortunately, we do deal with a lot of end-of-life care and if we can't provide those services, we're very facile at referring to providers in our facility that can.  

We coordinate care across many elements of the healthcare system and I think working in the VA and having access to the electronic medical record makes that slightly easier.  When we talk about enhancing access and other ways to do so beyond just the network that currently exists, I really started thinking, "Well, how can we enhance communication and what are some other options," and that's where telehealth first came to mind in kind of tying all this together and is that maybe the key for us at least and perhaps other providers that treat chronic disease to function as a PACT despite being a specialist.  

So just as background, I wanted to review a bit about telehealth in the VA Medical Center.  It began in 1968 with a mental health endeavor out in Nebraska, so it's been around for a long time, but obviously gained a lot of momentum in just the last few years.  It's overseen by the Office of Telehealth Services and the chief of that being Dr. Adam Darkins, he's also done a fair amount of very nice work, showing the benefits of telehealth, particularly for a Veteran population.

The mission: Provide the right care in the right place at the right time.  I mean it seems to make perfect sense and sound like a good thing to spend time and effort in.

 Our telehealth in the VA currently is divided into three general divisions: Care Coordination Home Telehealth, which involves the use of health informatics to transmit things from the patient's home like remote blood pressure readings, glucose levels, weight management.  Our CVT or Clinical Video Telehealth programs include really a myriad of programs, ours one of them, but basically any program whereby videos being implemented and then care coordination stored forward, which is the storing and transmission of still images.  So as you might imagine, things like dermatology, pathology and radiologists would develop programs that would fall under this division.

The VA Telehealth program is the largest in the country.  We had 380,000 Veterans involved in clinic-based telehealth in the last year and 100,000 involved in home telehealth.  There's approximately 140 VA medical centers and 500 CBOCs currently participating.  Obviously this number is counting.

Just to review some semantics because I think we hear telehealth and we hear telemedicine, at least I had prior to really getting involved in this.  So telemedicine is really defined as the use of electronic information and communication technologies to providing support healthcare, the clinical care, when distance separates participants.Whereas the term telehealth and sometimes e-health appeared later and really include all of the many allied healthcare activities that occur, such as patient education, CME or grand rounds, remote residence supervision, medical training over distances, healthcare administration via videoconferencing and connecting patients to each other over distances and support groups or other similar venues.

Given that, in 2003, in recognition of this interdisciplinary nature of tele [modes] the VA really began to use the broader more inclusive term of telehealth and thinking of telemedicine rather as a sub set of that broader category.

This is not an inclusive list, but I did want to mention some of the more commonly used pieces of equipment in the facilities themselves.  Obviously I think many of us know what a Webcam is.  Many providers can easily have these set up in their office, clinic or otherwise.  There's a number of types of specialty or primary care carts that have a camera as well as a computer and you can hook up a number of peripherals to these, so you can monitor things like blood pressure.  You can check other things like reflexes and there's sort of a growing list of technological additions to this equipment that will enhance your ability to examine someone remotely.

As far as home telehealth equipment goes, unfortunately, at the time that I was designing the study and writing the protocol, the VA had not approved a Web-based video application.  We're all probably familiar with Skype, well, because of security reasons that was not available.  So we had to seek out some useful equipment and had gotten some good reviews from colleagues that have used the Intel Health Guide that provides video.  We focused on the video connection, but just as a note that the health guide had other--and continues to have other functionality that includes a blood pressure cuff, scales, again peripheral equipment that can enable you to gather more information from the patient's home.

As a note the Health Guide's been updated and is now on a tablet format, but the functionality remains otherwise fairly similar.  I just put up a picture here of the Viterion 100, which is an example of one of the pieces of equipment used in the CCHT program, the health informatics program where they're transmitting data.  

I put this slide up here just to really emphasize for all the listeners that this is really something--if you're not involved in it now, there's a good chance you will be in the future.  telehealth is part of what the VA is now calling virtual care that will also include secure messaging via MyHealthyVet and the metrics on our performance goals are very lofty, but I think definitely attainable.  We did meet--at least turn our vision, our 15 percent goal for fiscal year 2012, but by 2014 there's an expectation that 50% of Veterans will be involved in some sort of virtual care. 

In the past year there was even a metric that included the PACT  that 1 1/2% of PACT's panel would be involved in some sort of Home Telehealth.  So I do think there's some national recognition that Telehealth can be an enhanced piece of the PACT-type care model.

Now I want to transition to Telehealth and the PADRECC with respect to Parkinson's Disease.  Telehealth in treating PD has not really been looked at in any great detail.  There are definitely a handful of smaller studies, generally looking at feasibility or very specific programs or perhaps educational endeavors.  A colleague, Ray Dorsey, at Johns Hopkins is developing a lot more programs as we speak and we frequently talk about these different things, but given the success of telehealth in the general literature, it certainly made sense to apply this technology to our current PADRECC [inaudible] population.  It seemed to be a very useful clinical resource for Parkinson's Disease because many of our symptoms are assessed by observation and what we see.  So although we might lose a bit of our exam, we're still going to be able to capture the majority of it.  There's certainly evidence that it can provide cost effective care and certainly it can make care more accessible.  

So we began to implement our program and at the same time, which in retrospect maybe was a little bit too much to try to do at once, we thought well let's launch a research study and look at this.  So the overall goal of our study was to compare using video telehealth and treating Parkinson's Disease and compare it to the usual in-person care.  The research design is very similar for two separate arms.  You can almost think of them as two separate studies with identical protocols.  One is the facility telehealth program where the provider remains at the Philadelphia VA Medical Center and the patient would go to the community-based outreach center and then facility to home telehealth.

The primary aim--despite having many interesting ideas about what we could look at we sort of settled on--let's focus our primary aim in this study at least on patient satisfaction between subjects in telehealth and those that aren't, but then we [inaudible] included a number of descriptive or secondary aims, such as clinical outcomes, healthcare utilization and patient travel costs and these are our hypotheses that compared with usual care, the use of telehealth will be associated with increased patient satisfaction and that compared with usual care, the 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.  The idea being if they can access us more easily perhaps we'll see them before the wheels fall off the cart or things deteriorate to a greater degree.

Our methodology--this is a randomized control trial, as I said the sites will include the Philadelphia VA Hospital, local VA outpatient centers and the patient's home.  Our source population are current PADRECC patients, so these are patients that we are familiar with, they have a clear diagnosis and they'll have the reference point of their past care in person if they are selected into the exposure group.  As I said, the exposure will be CBT, either at the C-BOC or in their home.  

Just to talk about the exposure in a little more detail, we've tried very hard to make it as similar to the current visit in the clinic that the provider will not change the duration--and frequency of the visit will not change and that the elements will not change.  Obviously the exam may be modified slightly, but we've been really fortunate enough to have some very talented telehealth clinical technicians or TCPs at each of the C-BOCs who were kind enough to come to our center, spend some time with us, learn about our exam, so that they can do some pieces of it and relay that information back to us.  The telehealth visits would, if necessary, also enable patients to see other providers.  We have a multidisciplinary team here and we certainly don't want to break down that aspect of our PADRECC model, using telehealth.  So that is still part of it.  Obviously the control group in this study would be those that continue to come.

So the inclusion criteria is pretty intuitive, diagnosis of Parkinson's Disease.  In order to enroll in the facility aspect you must live closer to one of those facilities than the Philadelphia clinic, the idea being that there will be less travel time et cetera.  If they're going to be recruited into the home telehealth, they needed to have an Internet connection in the home in order to support the Healthguide equipment and its installation.

We did have to exclude patients that require in-person visits.  currently, I think this will change some day.  Deep brain stimulation programming must occur in person and certainly we inject some of our patients for drooling and other things with botulinum and toxins and that we would have to do in person as well.

Our data collection is occurring primarily by questionnaires that will be administered directly after the visit.  Certainly some elements will be gleaned from the electronic medical record, some of the data we're going to collect include baseline demographics, various disease characteristics, duration, time since diagnosis, presenting signs and baseline scores.  We are collecting outcomes at two points and patients are seen frequently enough that most would be seen normally at these time points.  

We're really interested in 12 months data, but because this is a new endeavor and we weren't completely sure if people would like it, given the fact that we have an aging population and attrition due to nursing home placement, homebound state and unfortunately death, we thought we would collect data at six months as well.  We're collecting again a number of end points, but our primary outcomes--so we're going to collect our patient satisfaction a couple of ways.  It's sort of ironic that the name of this questionnaire is called the PACT, this was a questionnaire developed by some telehealth colleagues, it's a self-administered questionnaire that really tries to get at the visit convenience, the physician's patient-centered communication, clinical competence and interpersonal skills.  This was developed actually by a number of folks, but including our chief of staff here, Dr. Shapiro, who did and will be doing work in telehealth in pulmonology and then for the study actually we designed seven items for a clinical survey that again will assess patient's opinion on the convenience, quality of communication and overall visit.

Our secondary outcomes, our clinical outcomes are fairly standard measures to collect and research for Parkinson's Disease, our clinical rating scales, the UPDRS and Hahn and Lahr staging, quality of life will be assessed by a well-validated questionnaire called the PDQ-8 and we're also going to collect some information about mood, using the geriatric depression scale.

Our patient travel outcomes will be done by a questionnaire administered to the patient, asking things such as travel time, mileage, time off of work for them and/or a companion, meal cost and then factoring in any travel reimbursement.  To some extent we realize that this will be captured in the patient satisfaction and isn't a formal cost analysis, but more of an exploratory endeavor, to just sort of get a starting point on that.

As far as healthcare utilization, some of these things were of interest to me: patient-initiated appointment cancellations.  How compliant are our patients with routine visits?  Then looking at unplanned clinical services, hospital admissions, emergency room visits, non-routine provider visits and provider phone calls.  We in the PADRECC often have patients that because they can't see us, you see a very long and growing list of phone calls in the medical records, so measuring those things between the two groups, we're certainly going to track the number of routine visits and then, as part of the PACT model with respect to referring and orchestrating care, we're also going also to track the number of referrals that our providers make to other providers.  

I certainly don't want to minimize a very interesting and exciting portion of our study that will occur at the end of it.  We're working with great qualitative researchers, Gala True, in our [inaudible].  At the end of the study, she's going to lead a number of focus groups, both with patients and providers, to gain more information about their experience, using telehealth.

As far as my study, we're roughly halfway.  Unfortunately, we experienced significant difficulties early on getting approvals, given natural concerns of patient safety and information security, getting that equipment that's going to be put in the home situated, but we are about halfway through, we're completing recruitment shortly and then the study will last 12 months for each participant.  

So our current enrollment, we have 32 patients in the home telehealth arm and 47 in the C-BOC or the facility arm.  We have had some drop out, we're trying to keep track of that, think about that as well, but our goal for each arm when we did our power calculations at best guess anyhow would be 50--25 in each of the intervention and the control.

Some of the imitations--I think the biggest limitation with this study is just the logistics of rolling out a program at the same time that you're trying to study it and despite the generosity of pilot funding that implementing programs like this are expensive and take a tremendous amount of time.  We're limited by our geography, equipment and census, there will only be so many patients that are really eligible for the study.  As I mentioned earlier, there will be naturally some dropouts.  The study may be underpowered, the effect size isn't known.  Hopefully, if nothing else, we can perhaps determine that.  There'll be some bias that we'll need to think about with respect to recall.  The patients will be asked to complete some questionnaires, particularly when it comes to some of those healthcare utilization pieces, where they were perhaps seen at another facility, where we can't get that information from the electronic medical record in the VA system.  Perhaps there will be some selections that our own tier bias is those willing to participate could potentially overstate the benefits, given perhaps they're more technically savvy and obviously the fact that the study is not blinded could potentially introduce some bias.

Confounding, hopefully will be largely addressed by the fact it is an RCT, but we are going to measure some possible confounders like disease stage duration, the age and depression and then the generalizability.  Then when we get this data will it be applicable just to our PADRECC population, PD patients at large, perhaps we can consider it, looking at chronic disease care.  So that's one thing to think about and then as I mentioned, the cost analysis is not complete and we have to appreciate the fact that cost savings for the patient will be captured in some respects in their satisfaction scores.

Future directions: I'm hopeful that this data will really guide development of telehealth programs in treating PD and again perhaps in other fields as well.  Expanding the use of telehealth in multidisciplinary fields I think is very critical to getting everyone sort of in one place doesn't necessarily have to mean that literally anymore.  

Using telehealth and educational programs and other non- clinical venues, we've had the fortune of already launching this in our support group venue and even doing just some general educational endeavors with patients that may not be able to come to Philadelphia, we can broadcast it through the C-BOCs and we've done that and found that the attendance has increased substantially and certainly the use of telehealth in conducting research.  There has been a study or a number of which actually that indicate patients--of course, if they didn't have to go as far would be more likely to participate in clinical trials.

I think most importantly I'm hopeful that this study will provide pilot data for us to do broader, more national level studies, looking at PD telehealth programs and clinical trials.

So in summary I would just like encourage all the listeners out there to consider telehealth, particularly as it may relate to the  model PACT and understand that this is a learning process.  That there will be a lot of things that are obviously good and easy about it, but that it won't always be easy and there'll be some tough moments.  Hopefully not as bad as what George is experiencing there, but that there's not a whole lot in the literature about using telehealth and the PACT and I think, though, it would clearly enhance it, so I'll leave that at that.  I certainly again want to acknowledge the C-PACT  here and Rachel Werner the direct in PI there, Michele Lempa for all her help.  Steve Marcus, our biostatistician, innumerable PADRECC colleagues and patients.  John McHale here who does a lot of work and [Stephanie Pilowski], who is our research coordinator and last but not least our facility now has a full-time telehealth coordinator, Len Watson, who really helps with the logistics and I'll just say for those of you that aren't yet involved in telehealth this person will be really critical to helping the provider.  You sort of can see what you want to do clinically and then this coordinator is really designed to help execute that for you and help you.  So that's all I have to say.  I do encourage anyone to contact me directly either by e-mail or telephone.  I also co-chair our facilities' telehealth committee, so I have a really broader interest in Telehealth's success outside of what we're doing in the PADRECC and really would welcome any collaboration or be happy to answer any questions outside of the venue of this seminar, so that's it and thank you very much for inviting me to do this.

Molly:  Great.  Thank you very much, Dr. Wilkinson and without further ado, I will turn it over to Dr. Piette now.

Dr. John Piette:  Thank you very much and happy pre-Thanksgiving to everyone.  Thank you for being here--

Molly:  I'm sorry to interrupt.  Great.  We're all set.

John Piette:  I'm happy to give this talk, both because I'm very excited about the topic and also I think this really provides a nice complement to the great talk that we just heard from Dr. Wilkinson.  When I think of telemedicine or telehealth, to me, the world breaks down into things that use special technology or special devices to monitor patients in the home or to allow clinicians to communicate via video cam or to communicate between clinician and patient.  The growing area of what we call mobile health and to me mobile health is when we're communicating with patients between face-to-face encounters with standard cell phones, with standard devices that don't require necessarily that the patient purchase any new equipment, that doesn't require that they have the ability to get online and doesn't even necessarily require that they have a Smart Phone, more and more apps or applications are being developed for people with Smart Phones and certainly the types of exciting advances that we just heard about with videoconferencing with patients or clinician-to-clinician communication are invaluable, but like as I said, this provides a nice complement in a way for  PACT to increase their ability to contact patients, to touch patients for monitoring and for self-management support between outpatient encounters and it really increases the Veteran's access to care.  So that's what I really like about this area.

So I'm going to talk in a general way about this area of mobile health, but really focus in on a suite of applications that we've developed over the last many years that we really call the CarePartner program, to help chronically ill Veterans, using IVR, with monitoring and self-management assistance and feedback to them and their family caregivers.  So here in Ann Arbor, we're one of the PACT laboratories and that means that one of our charges is to develop innovations that could be quickly scaled up and rolled out to help the PACTs, to help PACT clinicians and to help patients get care that is consistent with the goals of PACT.  

This is kind of an overall design of how our PACT laboratory functions.  We have this suite of self-management support programs.  Some of those involve peer-to-peer interventions that we've developed both with face-to-face peer interactions and ways to use new telecommunications platforms so that patients can communicate with one another between outpatient visits, without necessarily sharing personal information.

We have a big focus on transitional care or care for patients that are just leaving the hospital.  Of course, that's a big focus for all of the VA.  Then, as I said, there's these CarePartner programs that I'm going to be focusing on mainly for the rest of my talk that use IVR or automated telephone monitoring and self-management support calls to improve patient's access to monitoring and to self-management assistance and to improve the care team's ability to monitor those patients between outpatient encounters.  

As we said when we were introduced, I'm the director of a program called QUICCC.  QUICCC is a research group, it's a kind of a subset of our health services research program and also has a life at the University of Michigan and QUICCC stands for quality improvement for complex chronic conditions.  What we try to do is to develop and evaluate new services that are going to improve care across a variety of chronically ill patients, specifically with an emphasis on vulnerable patients.  So we're emphasizing the care of patients such as rural Veterans, patients with multi morbidity, patients with mental health disorders or co-morbid substance abuse disorders, patients with mild dementia, or things of that nature.

The thing that really drives most of our work is this concept that we just are more and more in the situation where patients need more help than they can get during face-to-face encounters, that's not news I know to anyone that's participating in this teleconference today.  

These two studies down at the bottom I just always highlight them because they had such an impact on my own thinking and on my own direction of my research in this area.  The first being a study by Lisa Rubenstein where she's really commenting on this problem.  Lisa Ruvenstein, as many of you may know, she's an outstanding VA investigator, who's been around a very long time and has developed amazing health system change interventions to help VA transform care for patients with depression and she's shown through very large, very rigorously designed studies that you can improve both the quality and the process and the outcomes of depression care by transforming the system according to the chronic care model in other standard principles.  

This is why we're into this discussion about translation and about dissemination, many of those things [aren't] happening, as you know, in VA.  So people like Steve Dobscha--the second paper here is another excellent VA health services researcher and a psychiatrist has done what many of us have tried to do and said, "Let's take Lisa Rubenstein's model and put it into a form where we can do it, given standard staffing patterns and workflows and budgets and did another large randomized study and found that it didn't work, which is to say that we have this gap.  We have some expensive interventions that are very effective but we can't seem to support a scale-up and then we have some things that we've tried to do that are light touch that are more affordable and they don't have the impacts we need, so that's the gap that we're working in and telehealth and mobile health services are a big part of the solution to that.

Part of the way we're thinking about these problems is that given this big gap and given that clinicians are just plain limited even with the additional resources that have come to bear through PACTs--we have to look beyond the traditional patient-clinician relationship.  We certainly have to develop models that connect patients with clinicians between standard outpatient contacts and that's where CCHT is a big part of that, some of the telehealth models we just heard about are an important part of that, but we're [inaudible] ongoing chronic disease management for this huge, huge number of patients that we have in the VA.  We have to look beyond that and develop things that can have patients be communicating more effectively between encounters with other patients so that they can share information, they can share emotional support.  They can help each other to problem solve and we have to empower patient's family caregivers and bring them in more formally to the system of care, to give them the resources that they need to know how their loved one is doing and what they can actually do to help.

So that's kind of the broader framework that we use in developing our [mhealth] programs.  

Most of the studies and interventions that we've developed, as I mentioned, have to do with IVR and we'll talk specifically about IVR in a minute, but most of the world of mobile health has had to do with text messaging and text messaging, I must admit, is something that I really didn't give much credit or didn't give much attention for a long, long time, but what you see in this big collage of different publications is this: these are not studies.  I'll tell you what they're not, they're not studies showing that text messaging works for chronic disease management, each of the articles here and there's about six or seven, is a review of studies, randomized trials, showing that text messaging interventions work to improve patient self-management behaviors and in some cases to improve physiologic outcome.

So just what I'm trying to convey is that there's actually a very impressive body of evidence now, with some very large, rigorous studies with some very difficult outcomes things like smoking cessation, showing that we can improve patient self-management and we can improve their health even with something as simple as text messaging.  So it's a very exciting area for VA to be working in because it is low cost and can potentially have great impacts for large numbers of our Veterans.

Specifically in the area of IVR and that's interactive voice response or automated calls to patients, that's also--I won't review all of the evidence in this area, but it's also another area where there's just a huge body of literature showing that these things can be effective, specifically at gathering clinically important information about patients.  

So here I'm just highlighting a couple of studies that have been important to me because a lot of our work has been in mental health.  Of course, this first study, as you can see for yourself--they looked at 26,000 depression ratings in 17 randomized trials and found that these ratings of patients' depression scales that patients are reporting, using their touchtone phone and IVR are at least as reliable, at least as reliable and valid as the information that clinicians can get during a face-to-face encounter or during a telephone interview with a patient.  

Interestingly, we use the PHQ as another depression measure in our IVR patient monitoring and almost on the money, the reliability scores that they got in this large study are identical to the ones that we're getting among Veterans and among chronically ill patients who aren't Veterans.  

The second study, of course, here being where they showed that you can measure even very difficult outcomes like suicidal ideation can be measured via IVR, PTSD symptoms can be measured via IVR, eating disorders, substance abuse is very reliably reported via IVR.  So these very simple tools that have patients using their standard phone really can be a very powerful link between PACT teams and patients between outpatient visits.

We did a study that really made the case that we also need to involve family caregivers, not just spousal caregivers, adult children outside the home and other people in the patient's social network.  This study, of course, I'm happy to share any of these studies that I cite with you, just let me know at the end of the talk and I will send those to you, but what we found in this study is a couple of things that really made the case for involving a broader variety of caregivers in patients' self-management support.  First, 60% of Veterans are married, but, of course, that means that 40% of them are not, so if we only focus on spousal caregivers, we're really going to leave a lot of Veterans out of the solution.

Secondly, we often think of patients having a caregiver or Veterans having a spouse, usually typically a wife, who is their caregiver, but really that's not what we have in the world.  When you look at the chronic diseases that patients have and their caregivers, Veterans who have more chronic diseases or more co-morbidities have spouses that also are more likely to have co-morbidities, including mental health problems, chronic pain, which is to say that we really have an older couple that's growing old together and those spouses are really struggling with their own competing demands by other people in the family network, their own health challenges, relationship difficulties with their spouse, so looking beyond the spousal caregiver is something that's very possible and very important to do.  Most Veterans are in touch with adult children outside their home.  The majority of older adults say that they speak with at least one adult child at least weekly, so there are these other people that we can empower through information and that could help fill some of the gaps that I mentioned before in what PACT teams can provide.

So the CarePartner program is a program that uses IVR calls that go out to patients and it really is designed to use very, very simple IT tools to monitor patient status and give clinicians actionable information, no more information that they really want and need, but actionable information to improve someone's follow-up and prevent acute events.  It's designed to provide patients with additional tailored feedback and education, so when patients are getting these automated calls, they get tailored information about their depression scores, when they should seek follow-up care, their adherence to their heart failure medication or anti-hypertensive medication, diet, physical activity et cetera.  

In each of these programs, patients have the opportunity to enroll with an adult informal caregiver, often it's a caregiver outside of the home, typically an adult child or someone else in the family network who can receive structured feedback about how their loved one is doing, with suggestions for what they can to follow up and to support the person's self-management.

The general structure of these programs is that patients are enrolled over the telephone, the program is explained to them.  They are in our PACT program, we have a navigator who identifies patients that are at high risk for poor outcomes and offered the CarePartner program as being one of a suite of programs for supporting their self-management that they can use for between-visit care.  If they are eligible for a given program, they then are enrolled in the system, they receive automated calls that last between five and fifteen minutes.  Those calls are usually designed to come about once a week and they answer questions, using their touchtone phone.  Calls come at frequency and at specific times that the patient recommends are convenient for them and based on the feedback, there are automatic alerts, as I mentioned, that go back to the clinical team, using thresholds that those clinicians have told us are useful.  In other words, we're very, very sensitive to not having too much information overload to the PACT team, the idea is to really supplement and kind of empower those teams not to give them an unacceptable amount of additional work and as I said, based on patients' reports, family caregivers can get updates on their cell phone or structured e-mails, those come automatically.  If there's an urgent problem, those family caregivers do automatically get a report that comes via an IVR call to their cell phone,

We have gone to great lengths to make the program really road ready for widespread dissemination.  There's a variety of DVDs, written materials for patients and caregivers, there's instructional materials for clinicians who are participating.  So that everyone really understands what their role is in the program, how the information is going flow and what the program can and can't do for their self-care.

I'm a health services researcher and what I've really enjoyed about working in this program is that it's not a formal research study, so when we get feedback by a clinician or by a patient, asking us, "Can you make the program do this?"  We can incorporate that, that's something you usually don't do if you're doing an NIH study or a VA Health Services research randomized trial, where you want to be very rigorous and leave the intervention the same until the completion of the trial.  We're kind of--this is much more of a CQI, continual quality improvement mode, where we're constantly improving the program, so we've done things like added a function where automated messages go out to the PCP when patients enroll in the program.  CarePartners say, "Can I get an alert if my loved one isn't completing their calls," and that now happens automatically in most of our programs.

CarePartners can call in to get updates, so if they don't have access to e-mail, they can use the program, using just their cell phone.  In our depression program patients can automatically transfer to a suicide hotline if they report suicidal ideation and different sorts of automatic alerts happen, based on the feedback from our psychiatry advisory team.  So there's a bunch of features that have made the program very, very acceptable and not something that clinicians feel like it adds burden to their work in managing their PACT patients.

We've developed content for the CarePartner programs in a wide variety of areas at this point.  Some of it has been through HSR&D studies.  Some of it has been with funding from the Office of Rural Health, that's ORH there.  Some of it has been to non-VA interventions and randomized trials, where we've been able to move those interventions into the VA.  For example, for patients that are in transitional care, that's a new module that we're very, very excited about.  The Depression CarePartner program has been rolled out in the 18 clinics affiliated with the University of Michigan, so that's 20,000 patients with depression, that could potentially use that program and we've--given the recruitment rate, we expect that the actual number of users will probably be around 8,000.  We're just rolling out a program for patients with decompensated cirrhosis.  What I love more than anything is when a clinician learns about what we're doing and they come to us, for example, our colleagues in the liver clinic at the University of Michigan and they say, "You know what this would be great for this area, decompensated cirrhosis," that's an area I knew nothing about, but to kind of have that collaboration, to expand the portfolio of services that we're able to offer and really collaborate on new programs that could serve Veterans, I think is really, really wonderful and so far that's been very effective.

This is a paper that's about to come out in the journal Medical Care, where we pulled together data on almost 1,300 patients that have been using our CarePartner program in one context or another, including patients with heart failure, depression, diabetes and cancer.  Most patients enroll with a CarePartner.  In a couple of these programs that's been mandatory, in other words, we really are looking at developing a program, evaluating a program only for people that have the feedback to the CarePartner, but what we've found is that in programs, including programs for depression, diabetes, our cirrhosis program, when you offer patients the opportunity to have this regular feedback to a loved one, including an adult child, most of them will take you up on that.  Most of them say yes, so despite the important concerns that we have about data security, patients really want to involve their family caregivers in their care and the family caregivers are really appreciating this opportunity to get regular updates and feel more empowered to do something to help their loved one.

As I mentioned, in most of our programs, patients get calls about once a week and in this particular analysis, we had a total of almost 29,000 patient weeks of follow-up and overall the assessment completion rates have been very, very high.  Patients complete about 83% of their assessments.  They complete about 90% of their assessments if they're a VA patient with heart failure. The rate is lower, probably understandably so, for patients with depression.  We found that patients are more likely to be engaged and remain engaged in these programs over a long period of time if they enroll with a family caregiver.  So that has already that important function of making patients feel that this program isn't just a robot call, it's a way that they're communicating with their loved ones, with their social network as well as with their clinical team.  

Another thing that has surprised us is that patients' completion of these automated assessments, these IVR assessments keeps going up with age.  We really didn't find a point where we said these patients are too old to do this.  If anything, older adults, Veterans who are 75, 80 years old are actually a little bit more likely to complete these assessments consistently than their younger counterparts.  For people--and some of these are VA, some of these are non-VA patients, who are under 35, who are under 30, in their mid-20s, that's the population we might start to expand more to [inaudible] or text message, where the IVR call doesn't necessarily fit as well in their busy life, but it's specifically for patients that are older, patients with limited education we found, racial and ethnic minorities, we really haven't seen any barrier to using these systems happily.  We're looking a lot at how predictive the information is that patients report.  What this slide shows is the probability that someone is going to report suicidal ideation in their subsequent IVR call, based on their most recent depression scores and what you can see here is that you can really predict who's going to be expressing suicidal ideation if you have a series of their recent IVR calls.  We continue to look at this because it's so important that we know that we're gathering information that's useful to the PACT teams as well as to the patients.

Patients have been very, very satisfied with these programs, 90% would recommend the program to a friend, 84% said the program helped them deal more effectively with their condition.  Even though the calls come weekly and some people think that that might be a lot of contact with the system, patients find that very, very supportive and useful to them.   The family caregivers or CarePartners also have by and large been very, very accepting of the program, very enthusiastic about remaining in the program.  Eighty percent said that almost all of their needs were met.  For example, in our depression program, this was one thing where we constantly hear that the program really opened up an opportunity to talk between the patient and the family caregiver.  Like with Dr. Wilkinson's study, we're really looking a lot at the qualitative data, it's really taught us an enormous amount of what Veterans want, what their families want, what clinicians really need, what information is actionable and what is additional workload that they really can't deal with and we're continually trying to improve these programs so that we can make them more useful to everyone involved.

Patients are telling us it's more useful and there are interactions with their clinicians in the face-to-face encounters and we're starting to expand in programs, for example, with our collaborations with people in New Haven with the pain center, to kind of integrate the information that patients are reporting between visits as a basis for more effective communication during those visits, to kind of bring it all together.

So just to emphasize a few things in summary: (1) we really are trying to develop programs that help PACT teams.  We know in our own environment that PACT team members are feeling a bit stressed.  They're feeling overwhelmed by the additional responsibilities that they have, they're enthusiastic about the transformation to PACT, but it's a lot to do and what we would like to do is to provide some additional resources that can help people meet those demands without increasing workload and while at the same time, improving the outcomes for patients between outpatient encounters through using this accessible technology.  The programs that we've developed now again they're really for to be rolled out.  It's all kind of on a case-by-case basis how we make those available, but we certainly are hoping to make them available, so if you're in a site that would like to discuss using one of these programs, don't hesitate to get in touch with me and if you have an idea, for another type of patient for whom something like this might be of assistance, we always are happy to hear about that too.

Another thing to mention to Dr. Jayne Wilkinson, someone just approached me last week about using our depression program for patients post stroke because I'm sure Jayne knows very well depression is one of the most common consequences of stroke and one of the most remedial or addressable risk factors for poor outcome, so people here at the university are going to be evaluating whether this works with stroke patients.  We'd love to see that same sort of thing happen in VA and I'll leave it there, so that we have a few minutes for questions.  Thank you for listening.

Molly:  Great.  Thank you very much, Dr. Piette.  We do have a few questions pending and I know a lot of our attendees joined us after the top of the hour, so if you're wondering how to submit a question or a comment, simply go to the Webinar dashboard located on the right-hand side of your screen, type your question in under the question section and press send.  We will get to it in the order that it is received.  The first one is for Dr. Wilkinson: "Can we get a copy of the  questionnaire?"

Jayne Wilkinson:  Yeah.  I think so.  I would just double-check with the people I got permission to use it from, but I'm sure they'd be happy to share it definitely.  As I said, it was really unique--I think I said this or meant to that even though the title includes telehealth, you can actually administer it to your control group and that was one of the problems we faced that there are some nice [DVT] patient satisfaction questionnaires, but you wouldn't obviously be able to administer them to your control, so yeah, I'll double-check and be happy to provide that,

Molly:  Thank you.  This question is for Dr. Piette: "Are the ongoing projects with telehealth for complex chronic pain management within PACT?"

John Piette:  Yes.  It's the project that's just getting up and going with the people in the New Haven Pain Center.  We'll have patients in LA--PACTs in LA, here in Michigan and then in New Haven and it's a create, so it's one of these efforts to do research that's explicitly linked with PACT, so it has one element of feedback about people's pain scores to their PACT team.

Molly:  Thank you very much for that response.  This next question: "Can you address the feasibility of using text messaging in VA, considering VA IRB issues regarding communication with patients?  

John Piette:  That's another hour-long talk, but let me say this:  First of all IRB VA data rules vary around the country, some places are more reasonable, some places are still kind of figuring out what's allowable and what's not.  I do tend to feel that people self-censor too much.  In other words they say, "Well, we can't do this," and so they don't even try and I would encourage engaging in a productive, persistent dialog in your local environment to say what exactly would make this something that everyone is comfortable with and is in compliance with the rules, given that we all absolutely want to improve between-visit support with patients.  So rather than assuming it's not possible, I'd say consider that it might be possible, making those communications itemized is helpful.

In other words, to the extent that you cannot mention the person's disease, which is often possible and certainly not mention their first and last name in the text message that already gets you a leg up.  So there are some things you can do to the message to make it more feasible, but then the devil's in the details, but like I said, I would be persistent and see there are some things that you can do.

Molly:  Excellent.  Thank you.  The final question: "Will the health [text] in the C-BOC sites be the one to take hold of this mainly?"

Jayne Wilkinson:  The program in general I mean--they, I think, work as the provider and the program feel necessary, so they'll do quite a bit, but it will sort of be dictated by sort of the clinical leader for that particular program and so they're doing a lot of different things.  Their job may be varied, so they'll have a lot of responsibility, but I don't think they'll be called on to develop things in that sense, they report directly to each facility's telehealth coordinator.  She works with the provider to kind of talk about how they may or may not be useful in that provider's telehealth program.  They're very critical, but their job will vary, depending on what the program entails.

Molly:  Great.  Thank you for that response.  Well, that ends the final question that has come in, so at this time I'd like to give either of the two of you the opportunity to make any concluding comments you'd want to and, Dr. Wilkinson, why don't we begin with you?

Jayne Wilkinson:  No.  That's it.  I just really hope that folks consider telehealth in the future.  Definitely I think it is the wave of the future and again I'm happy to talk with anyone and just Happy Thanksgiving.

Molly:  Great.  Dr. Piette?

John Piette:  I second that Happy Thanksgiving and the only other comment I would make is that our office is moving in the next month or two and so you will be much more successful if you do want to get in touch with me by e-mail to use my university e-mail than my VA e-mail and that is: jpiepte@umich--like University of Michigan, umich.edu and thank you very much.

Molly:  Thank you.  We do have some comments coming in, saying thank you both for outstanding programs and wonderful talks today, so I'd like to echo that, thank you both for sharing your expertise and thank you to our attendees for joining us.  As you exit today's cyber seminar, you will have a feedback survey that will populate on your screen, please take just a moment to fill out those questions, it helps us improve our program and also gets topics of interest to you up on our calendar, so thank you once again and Happy Thanksgiving everyone.  This does conclude our cyber seminar for today.

**[End of Recording]**

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