Virtual Specialty Care QUERI Program: Implementing and Evaluating Technology Facilitated Clinical Interventions to Improve Access to High Quality Specialty Care for Rural Veterans

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 DESCRIPTION (provided by applicant): Anticipate Impacts on Veterans' Healthcare: The Veterans Health Administration (VHA) provides care to 3.3 million Veterans living in rural areas, comprising 36% of all VHA enrollees. In 1995, VHA began expanding its system of Community Based Outpatient Clinics (CBOCs) in order to improve access for the geographically dispersed Veteran population. There are now approximately 900 CBOCs delivering a range of services to approximately 64% of VHA enrollees. While these CBOCs have dramatically improved access to first class primary care services, it has been more challenging to deliver specialty care to rural Veterans. Evidence based specialty care practices developed for large VA Medical Centers are often not feasible to deploy in small CBOCs and thus not accessible to rural Veterans. The proposed QUERI Program will implement and evaluate technology-facilitated clinical interventions designed to improve outcomes for rural Veterans. Project Background: The Office of Rural Health's (ORH) Resource Centers are funded to examine the unique health care needs of rural Veterans and develop a pipeline of "promising practices" to better meet these needs. In order to improve access, these promising practices often utilize virtual care technologies (e.g., telehealth, eHealth, mHealth) developed by Telehealth Services (TS) and the Connected Health Office (CHO). Due to the remote locations of rural Veterans and the rapidly evolving technologies used in interventions designed to better serve them, it is extremely challenging to conduct traditional randomized controlled trials (RCTs). Consequently, there are relatively few RCTs establishing the evidence based for interventions designed to improve outcomes for rural Veterans. Even when the logistics of recruitment and data collection in rural remote settings can be overcome, the length of time it takes to conduct a RCT usually renders the technology used in the intervention obsolete. Consequently, ORH, TS and CHO need rigorous methods to evaluate promising practices as they are being initially deployed into the field and as they evolve over time. Project Objectives: The goal of the proposed QUERI Program is to implement and evaluate promising clinical practices incorporating virtual care technologies in order to improve access to high quality care for rural Veterans. To achieve this goal the proposed Virtual Specialty Care QUERI has three specific aims. The first aim is to develop, evaluate, and refine implementation strategies for the ORH, TS and CHO to roll out promising clinical practices that incorporate teleheath, ehealth, and mhealth virtual care technologies. The second aim is to evaluate and refine promising clinical practices that incorporate telehealth, ehealth, and mhealth virtual care technologies that have been developed at VHA Rural Resource Centers and elsewhere designed to improve access to high quality care for rural Veterans. The third aim is to measure implementation costs and assess the budget impact of rollout for operational partners. Project Methods: The projects proposed as part of the Virtual Specialty Care QUERI will compare enhanced implementation strategies to standard implementation strategies used by the ORH, TS and CHO. Enhanced implementation will include a variety of strategies including ethnographic methods to assess the existing clinical workflow at implementation sites, and modification of both the existing clinical workflow and the new clinical intervention to maximize fit. Evaluation of the implementation strategies will be assessed using qualitative and quantitative methods to measure provider adoption and sustainability. Population level effectiveness of the clinic intervention will be assessed using qualitative and quantitative methods to measure reach and outcomes. Given the dynamic nature of technology and the high degree of variability in context across clinics, we will employ methods that enable the new clinical intervention to be adapted from setting to setting and to be refined over time rather than focusing on fidelity to a manualized protocol.