Improving Access Through Targeted Delivery of Telemedicine

通过有针对性的远程医疗提供改善获取服务

• 批准号: 10178548
• 负责人: Charlie M Wray
• 金额: --
• 依托单位: VETERANS AFFAIRS MED CTR SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-02-01 至 2026-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10178548
• 关键词: Address; Appointment; Area; Caring; Cellular Phone; Characteristics; Clinic; Clinic Visits; Computers; Data; Devices; Elements; Ensure; Environment; Evaluation; Failure; Feedback; Goals; Health Personnel; Health Services Accessibility; Heart failure; Homelessness; Housing; Improve Access; Intervention; Location; Machine Learning; Measures; Medical; Medical Records; Mental Health; Methodology; Methods; Modality; Modeling; Online Systems; Outpatients; Patients; Persons; Phenotype; Population; Primary Health Care; Probability; Process; Provider; Quality of Care; Recording of previous events; Reporting; Research; Research Personnel; Resources; Risk; Risk Estimate; Risk Factors; Schedule; Services; Structure; Substance abuse problem; Tablets; Techniques; Technology; Telemedicine; Telephone; Testing; Text Messaging; Veterans; Veterans Health Administration; Videoconferencing; Violence; Visit; Voice; Vulnerable Populations; Work; base; care delivery; career; clinical phenotype; cohort; connected care; cost; design; effectiveness implementation design; effectiveness implementation study; formative assessment; high risk; improved; innovation; marginally housed; meetings; novel; predictive modeling; preference; programs; regression trees; risk prediction model; satisfaction; social; social vulnerability; targeted delivery; telehealth; tool

Background: Improving access to care is a high priority within the VA. While improvements to access have been made in recent years, gaps and inefficiencies still exist, particularly around missed clinic visits, or `no- shows'. The VA reports that approximately 15-18% of scheduled outpatient primary care appointments are not completed and that 9.2 million appointments were lost because of no-shows in FY2017. In preliminary work, we demonstrated the importance of social risk factors on VA no-show rates. These findings suggest that a no- show prediction model that incorporates patient-level factors could predict missed clinic rates and provide clinical phenotypes (i.e. an aggregate description of a Veterns' social vulnerabilities) of Veterans at greatest risk of no-showing. VA Video Connect (VVC) is a newly developed telemedicine application that provides video conferencing services as a means to connect Veterans with their VA medical providers. With VVC, Veterans can access their VA provider from any mobile or web-based device (e.g. smartphone, tablet, or computer) and do not need to be located at a satelite clinic. Previous work supports the idea that VVC could be targeted to those at elevated risk of no-showing clinic appointments. This CDA proposes a risk-based, targeted use of VVC in patients with social vulnerabilities as a means of decreasing clinic no-shows. Significance: This proposal aims to improve access to care by identifying, describing and engaging Veterans who would most benefit from alternative methods of primary care, specifically VA Video Connect. Innovation: This research has several innovative aspects to it. First, we will utilize machine-learning predictive techniques to identify and describe Veterans who are at highest risk of no-showing based on their social risk. This methodology has never been utilized in addressing no-shows. Second, we will actively engage Veterans in a formative assessment of how to optimize the use of VVC as an alternative method to obtaining primary care. Engaging Veterans throughout this proposal will ensure that Veterans' voices are properly integrated into the final product. Finally, this proposal utilizes novel telemedicine technologies (i.e. VVC) as a means of improving access for Veterans who are at high risk of missing clinic visits. Specific Aims & Methodology: (1) Use regression tree analysis to phenotype Veterans based on their estimated risk of no-showing clinic appointments. Hypothesis: Social risk factors are associated with no- shows in the ambulatory VA population and certain phenotypes will have higher no-show rates compared to others. (2) Use a sequential exploratory mixed methods design to engage phenotyped Veterans at high risk for no-showing and assess Veteran suitability and capability of using VVC. Hypothesis: Certain phenotypes of Veterans will be optimally served by VVC, while other phenotypes will require higher intensity primary care programs or continued in-person care. (3) Pilot the targeted use of VVC among 50 Veterans at-risk of no-showing primary care clinic appointments at the SFVA using a Type I hybrid effectiveness-implementation design. We will collect formative implementation data about local adaptability, acceptability, and fidelity. Hypothesis: VVC will be an acceptable alternative modality of primary care for both Veterans and providers. Next Steps: Following the effective implementation of this CDA, we will work with operational partners (Office of Connected Care and Telehealth) and perform a multisite assessment of the focused use of VVC on Veterans at high risk of missing clinic appointment.

背景：改善获得护理的机会是退伍军人事务部的一个高度优先事项。虽然改善了准入， 近年来，仍然存在差距和效率低下的问题，特别是在错过诊所就诊或“不- 演出。VA报告说，大约15-18%的计划门诊初级保健预约没有 2017财政年度，由于没有出现，920万个预约被取消。在初步工作中， 我们证明了社会风险因素对VA未就诊率的重要性。这些发现表明，一个不- 显示包含患者水平因素的预测模型可以预测错过诊所率，并提供 退伍军人的临床表型（即退伍军人社会脆弱性的综合描述） 没有显示的风险。VA视频连接（VVC）是一个新开发的远程医疗应用程序，提供视频 会议服务作为一种手段，连接退伍军人与他们的VA医疗提供者。随着VVC，退伍军人 可以从任何移动的或基于网络的设备（例如智能手机、平板电脑或计算机）访问其VA提供商， 不需要在卫星诊所。以前的工作支持VVC可以针对 那些没有出现诊所预约的风险较高的人。本CDA建议基于风险，有针对性地使用 VVC在社会脆弱患者中作为减少门诊不出现的一种手段。 意义：该提案旨在通过识别、描述和吸引退伍军人， 谁将最受益于初级保健的替代方法，特别是VA视频连接。 创新：这项研究有几个创新方面。首先，我们将利用机器学习预测 技术来识别和描述退伍军人谁是在最高的风险，没有显示基于他们的社会风险。 这种方法从未被用于解决未出现的问题。第二，我们将积极吸引退伍军人 在形成性评估中，如何优化VVC的使用，作为获得主要 在乎在整个提案中让退伍军人参与进来将确保退伍军人的声音适当地融入到 最终产品。最后，该提案利用新型远程医疗技术（即VVC）作为一种手段， 改善退伍军人谁是在错过诊所访问的高风险的访问。 具体目的和方法：（1）使用回归树分析，根据退伍军人的表型， 估计的风险没有显示诊所预约。假设：社会风险因素与无- 在门诊VA人群中显示，与 他人(2)使用序贯探索性混合方法设计， 未出现的风险，并评估退伍军人使用VVC的适用性和能力。假设：确定 退伍军人的表型将通过VVC得到最佳服务，而其他表型将需要更高的强度 初级保健计划或持续的个人护理。(3)在50名退伍军人中试点有针对性地使用VVC 在SFVA使用I型混合型时，存在未出现初级保健诊所预约的风险 有效实施设计。我们将收集有关本地适应性的形成性实施数据， 可接受性和忠诚度。假设：VVC将是一种可接受的初级保健替代方式， 退伍军人和供应商。 下一步：在有效实施这一全面发展议程之后，我们将与业务伙伴（办事处）合作， 联网护理和远程医疗），并对VVC的重点使用进行多站点评估， 退伍军人错过诊所预约的高风险。