Enhancing Veterans' Access to Care through Video Telehealth Tablets

背景。2016年，VA的农村卫生办公室（ORH）和互联医疗办公室（OCC）开始分发

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.