Enhancing Veterans' Access to Care through Video Telehealth Tablets

背景2016年，VA的农村卫生办公室（ORH）和连接护理（OCC）开始分发 视频平板电脑，以退伍军人的地理，临床和社会障碍，以个人护理。中 ORH资助的第一批5,000个VA发放的平板电脑的评估，我们发现，许多平板电脑接收者是高- 需要（例如，农村，社会孤立的退伍军人与心理健康状况）。然而，平板电脑的主动性 各设施的覆盖范围、采用和实施情况各不相同。此外，大约20%的片剂 接受者没有使用他们的平板电脑，这表明有机会评估实施战略， 优化这一有限资源的影响。2017年，VA从早期的平板电脑型号过渡到成本更低的型号， 用户友好的iPad，这一转变可能会促进平板电脑的采用和使用。我们建议在现有的基础上， 与ORH和OCC合作，开展合作评估计划， 有效性和实施平板电脑分配给高需要的退伍军人与访问障碍。 目标.这一合作评价的目标是：1）评价有效性， 实施VA向高需求退伍军人分发视频远程保健平板电脑倡议 障碍，以及2）测试增强的患者评估工具如何影响平板电脑的可及性和有效性。 方法.我们将在PRISM框架的指导下进行Hybrid II试验，重点关注以下目标： 目标1将专注于平板电脑的普及、采用和实施。在目标1.1中，我们将识别患者 这些特点可能是未来干预措施的重点，以加强平板电脑计划在 高需求患者在目标1.2中，我们将调查设施远程医疗协调员，以研究采用（即， 平板电脑分销量）受设施特征（例如，乡村性、远程医疗人员配备、领导力）的影响 参与）和实施战略。在目标1.3中，我们将采访机构领导，远程医疗 协调员、提供商和退伍军人，以确定具有增强平板电脑潜力的实施策略 分配和使用。在目标1.4中，我们将设计并试点测试一种增强型患者评估工具， 这是根据目标1的调查结果制定的，并将在目标2的设施中进行随机抽样评估。 在目标2中，我们将评估平板电脑对患者获取、临床结局和 经验，并评估随机选择的增强型患者评估工具（在目标1.4中开发） 设施目标2分析将纳入管理数据（目标2.1）和患者调查（目标2.2）。我们 与OCC的合作提供了一个机会，可以严格评估增强的患者是否 评估工具增加了片剂在高需求患者中的分发和使用。首先，我们将比较所有 片剂接受者与未接受片剂的患者的倾向评分匹配的对照组。 然后，在平板电脑接受者中，我们将比较来自具有通常实施条件的设施的患者 从使用增强评估工具的机构向患者提供信息。 在目标3中，我们将通过以下预算影响分析来检查平板电脑计划的维护潜力： 与实施和维持平板电脑计划相关的设施级成本。我们将使用 国际药物经济学和结局研究学会（ISPOR）预算影响分析 评估与平板电脑相关的设施级实施、干预和后续成本的指南 分布我们还将比较该计划对不同地方组织的预算影响 特别是在农村地区。 这项合作评估解决了ORH的使命，以改善农村退伍军人的健康和福祉 通过增加他们获得护理和服务的机会。研究结果将为ORH、OCC和 VA设施旨在利用视频远程医疗来扩大对高需求退伍军人的访问。

Background. In 2016, VA’s Offices of Rural Health (ORH) and Connected Care (OCC) began distributing video-enabled tablets to Veterans with geographic, clinical, and social barriers to in-person care. In an ORH-funded evaluation of the first 5,000 VA-issued tablets, we found that many tablet recipients were high- need (e.g., rural, socially isolated Veterans with mental health conditions). However, the tablet initiative’s reach, adoption, and implementation varied across facilities. Furthermore, approximately 20% of tablet recipients did not use their tablets, suggesting an opportunity to evaluate implementation strategies that will optimize the impact of this limited resource. In 2017, VA transitioned from early tablet models to lower cost, user-friendly iPads, a shift that may facilitate tablet adoption and use. We propose to build on our existing collaboration with ORH and OCC to conduct a Partnered Evaluation Initiative that examines the effectiveness and implementation of tablet distribution to high-need Veterans with access barriers. Objectives. The objectives of this partnered evaluation are to: 1) evaluate the effectiveness and implementation of VA’s initiative to distribute video telehealth tablets to high-need Veterans with access barriers, and 2) test how an enhanced patient assessment tool influences tablet reach and effectiveness. Methods. We will conduct a Hybrid II trial guided by the PRISM framework, focusing on the following aims: ▪ Aim 1 will focus on Reach, Adoption, and Implementation of tablets. In Aim 1.1, we will identify patient characteristics that could be the focus of future interventions to enhance the tablet initiative’s reach among high-need patients. In Aim 1.2, we will survey facility telehealth coordinators to examine how adoption (i.e., tablet distribution volume) is influenced by facility characteristics (e.g. rurality, telehealth staffing, leadership engagement) and implementation strategies. In Aim 1.3, we will interview facility leadership, telehealth coordinators, providers, and Veterans to identify implementation strategies with potential to enhance tablet distribution and use. In Aim 1.4 we will design and pilot test an enhanced patient assessment tool that draws on Aim 1 findings and that will be evaluated in a random sample of facilities in Aim 2. ▪ In Aim 2, we will evaluate the Effectiveness of tablets on patient access, clinical outcomes, and experience, and assess the enhanced patient assessment tool (developed in Aim 1.4) at randomly-selected facilities. Aim 2 analyses will incorporate administrative data (Aim 2.1), and a patient survey (Aim 2.2). Our partnership with OCC offers an opportunity to rigorously evaluate whether the enhanced patient assessment tool increases tablet distribution and use among high-need patients. First, we will compare all tablet recipients to a propensity score matched comparison group of patients who did not receive tablets. Then, among tablet recipients, we will compare patients from facilities with usual implementation conditions to patients from facilities using the enhanced assessment tool. ▪ In Aim 3, we will examine the tablet initiative’s Maintenance potential through a budget impact analysis of facility-level costs associated with implementing and sustaining the tablet program. We will use the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) budget impact analysis guidelines to assess facility-level implementation, intervention, and consequent costs associated with tablet distribution. We will also compare the program’s budget impact across different local organizational contexts, with a particular focus on rural sites. This partnered evaluation addresses ORH’s mission to improve the health and well-being of rural Veterans by increasing their access to care and services. Findings will provide practical guidance to ORH, OCC, and VA facilities aiming to harness video telehealth to expand access to high-need Veterans.