COVID Lessons Learned: The Invaluable Need for Virtual CareSes s ion 16, Augus t 10 , 2021

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U.S. Department of Veterans Affairs

Chris t ina Arms t rong, Ph.D.

DISCLAIMER: The views and opinions expressed in this presentation are solely those of the author/presenter and do not necessarily represent any policy or position of HIMSS.

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Welcome

Connected Health Implementation Strategies, Office of Connected Care (OCC), Patient Care Services (12CC), U.S. Department of Veterans Affairs

Chris t ina Arms t rong, PhD

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Conflict of Interest

Christina Armstrong, Ph.D.

Has no real or apparent conflicts of interest to report.

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Agenda

• VA Virtual Care

• COVID: Changing VA & Healthcare

• Our Tools and Our Lessons

• What’s Next?

• Questions/Answers

• Resources and References

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Learning Objectives

• Learning Objective 1: Explain how VA’s virtual care strategy increased access to and utilization of virtual care technologies, built capacity to match clinical supply and demand, and reduced barriers to care

• Learning Objective 2: Demonstrate through data how the demand for virtual care technologies and delivery changed from before, during and after the pandemic and how VA is using information gleaned from that data to sustain clinical and Veteran adoption of virtual care tools

• Learning Objective 3: Identify lessons learned from the pandemic response and examples of increasing capacity, engaging clinicians, reducing barriers to adoption to improve Veteran’s patient outcomes during COVID

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VA Virtual Care:Filling the White Space and VA Priorities of Access, Capacity and Quality

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Filling the White Space

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Filling the White Space

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Veteran Testimonial

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VA Overview

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20MILLION

Veterans in the U.S.

9+MILLION

Receive VA care

(Department of Veterans Affairs, 2021)

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VA Mission

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U.S. Department of Veterans AffairsTo fulfill President Lincoln's promise - “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.

Veterans Health AdministrationHonor America’s Veterans by providing exceptional health care that improves their health and well-being.

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VA Virtual Care

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VA Virtual Care – Our Priorities

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Accessibility• Video care, secure email, telephone

care – available in all ambulatory services for Veterans and caregivers to access from their preferred location

• Asynchronous modalities of care that can be used between scheduled visits

• Enhanced Veteran communication channels with their care teams (e.g. clinical chat, secure messaging, text)

Capacity• Resource hubs for primary care, mental

health, and other high- volume specialty services, accessible as a shared telehealth service, delivered across VA facilities.

• Increased clinic efficiency, resulting from more efficient just-in-time resolution of simple health issues or transactions through virtual modalities.

Quality• Expert consultation & coordination of

services that are difficult to find, expensive to manage, or low volume in any given market.

• Promote self-management of health and proactively engage patients using digital health tools that leverage analytics

• Reduce hospitalizations & emergency visits through remote monitoring

Bringing care to the Veteran

Matching clinical supply and demand

Providing the right care at the right time

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COVIDChanging VA & Healthcare

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Encounters Before and During Pandemic

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Growth in VA Connected Care Services

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0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20*

Total EncountersNote: RPM-HT data not available prior to FY12

Telehealth

(Department of Veterans Affairs, 2021)

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Growth in VA Connected Care Services

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My HealtheVet

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020

Rx Refills/Month MHV Users - Cumulative

(Department of Veterans Affairs, 2021)

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Growth in VA Connected Care Services

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0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

FY 18 FY 19 FY 20

New Annie Users per Week Total Active Annie Users

Annie

(Department of Veterans Affairs, 2021)

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Increase in Provider Utilization

• 64% to 94% - % of VA primary care providers that had

conducted at least 1video telehealth visit before and after

COVID

• 67% to 98% - % of VA mental health providers that had

conducted at least 1video telehealth visit before and after

COVID

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Patients Value Telehealth

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“My HealtheVet is great! I use it to message my provider and order my meds. I also promote the use of My HealtheVet and mobile apps at my VFW post.”

“Annie contacts me at 8 every morning. It’s almost like saying that she has my back. I have other PTSD apps, but I don’t go to them. Annie comes to me.”

“Home Telehealth was the best move I ever made. For me, my blood pressure is very important, and using telehealth, they are able to monitor that from home.”

“With TeleMental Health, I’m able to receive the help I need in a comfortable setting, without the stress of traffic and hospital waiting rooms. My doctor brings me back into focus and helps me deal with a very dark time.”

"VA Video Connect really is a timesaver for Veterans. With VA Video Connect, I can receive my care, no matter where my specialist is.”

“The VA telehealth program really saved my life when I had COVID-19, because every single day, I had someone who was checking on me at home. My telehealth nurse checked on my symptoms and encouraged me through my feelings of helplessness and depressive episodes.”

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Our Tools and Our Lessons

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Innovation Under Quarantine: VA COVID Tools and Technologies

• In the first three months of the pandemic VA grew capacity, developed new

tools and provided additional services in areas hardest hit.

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COVID Coach

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Managing Stress related to COVID

Education

Resources

Tools for Managing Stress

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Automated text messages for COVID“Annie” is the VA’s automated text message platform

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Let’s Test Annie

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VA Coronavirus Chatbot Get answers to questions about COVID, VA benefits and services.

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VA Video Connect NowStreamlined access

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Connected Care AcademyOne stop access to all virtual care training

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Telehealth Expansion in 2020 –Advancing in Realtime and Maintaining Quality• Maintaining continuity of care – quickly shifting to remote delivery of care and remote

work for staff

• Increasing access to tools/resources – quickly deploying necessary hardware and

software for staff and patients

• Expanding workforce trained in virtual care – quickly ramping up virtual care training

for healthcare staff

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VA Tele-Critical CareResource sharing across the enterprise to increase access and quality

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Clinical Resource HubsResource sharing across the enterprise to increase access and quality

Lessons Learned – Before & After COVID

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Pre-COVID Building Virtual Care Infrastructure

• Design technology with patients in mind, put patients & caregivers at the center

• Provider-centered design is essential. Your staff matters

• Optimize adoption, systems need investments in people

• Think from a system perspective, capacity & responsiveness

• Leave no patient (Veteran) behind, mind the digital divide

During COVID – Rapid Enhancements For Providers & Patients

• Provider training is not one-sized fits all – rapid training, peer networks, provider supports

• Understand what policies & procedures are holding your system back

• Partnerships & community-based agreements help move the needle

• Execute VA’s “4th mission” improve the nation’s preparedness for response to war, terrorism, national emergencies, and natural disasters

VA Emergency Response during COVID

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Supporting VA’s “4th Mission”

• Deployed personnel to more than 50 states and territories, including Navajo nation support

• Distribution of personal protective equipment, acute and intensive care beds, and medical equipment

• Admitting non-Veteran citizens into VA medical centers

• Vaccinated 3,311,795 people, including 2,877.037 million Veterans, 313,046 employees, 70, 947 family or caregivers through the SAVE LIVES Act, 49,793 others including federal partners (as of June 11, 2021

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What’s Next?

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Beyond video visits: Getting more out of the White Space

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The healthcare system is forever changed

• The healthcare system will be feeling the direct

impact for the next five to ten years we’re going to

continue feel the effects. To prepare we need:• Further the development and integration of emerging

virtual care tools • Changes in policies and practices to ensure continuity

of operations and prepare for future emergencies• To invest in workforce expansion trained in virtual care

and in infrastructure improvements to support virtual care

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Developing and Implementing Virtual Care Technologies

• Sensors, Wearables, and Remote Patient Monitoring

• Patient-Generated Health Data

• Prescribing Virtual Care

• Rolling out new EHR and creating interoperability with

existing infrastructure

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Changes in Policies and Practices

Pre-pandemic• MISSION Act

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During pandemic• CARES Act

• VHA Directive 1914

• SAVES Lives Act

• VHA Directive 6506

• American Recovery

Plan Act

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“

Dr. Carolyn ClancyActing Deputy Secretary, Veterans Health Administration

It’s critical that we do everything we can to empower our people, unleash their ingenuity, unify their efforts and therefore expand their capacity. “

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Questions

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References

• Armstrong, C. M., McGee-Vincent, P., Juhasz, K., Owen, J., Avery, T., Jaworski, B., Jamison, A., Cone, W., Gould, C., Ramsey, K., Mackintosh, M. A., & Hilty, D. M. (2021). VA Mobile Health Practice Guide (1st ed.). U.S. Department of Veterans Affairs. Washington, DC. https://connectedcare.va.gov/sites/default/files/va-mobile-health-practice-guide.pdf

• Chao, G. F., Li, K. Y., Zhu, Z., McCullough, J., Thompson, M., Claflin, J., Fliegner, M., Steppe, E., Ryan, A., & Ellimoottil, C. (2021). Use of telehealth by surgical specialties during the COVID-19 pandemic. JAMA Surg, e210979. doi:10.1001/jamasurg.2021.0979.

• Clancy, C. M. & Kirsh, S. (2021). Virtual care and the pandemic: are we reaching all patients? Ann Intern Med, 174(1), 116-117. doi: 10.7326/M20-5593

• Congressional Research Service (May 20, 2020) Delivery of VA Telehealth Services During COVID-19. https://crsreports.congress.gov/product/pdf/IF/IF11554

• Connolly, S. L., Stolzmann, K. L., Heyworth, L., Weaver, K. R., Bauer, M. S., & Miller, C. J. (2021). Rapid Increase in telementalhealth within the Department of Veterans Affairs during the COVID-19 pandemic. Telemed J E Health, 27(4), 454-458. doi: 10.1089/tmj.2020.0233

• Department of Veterans Affairs. (2018). VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSON) Act. https://www.congress.gov/congressionalreport/115th-congress/house-report/671/1. Accessed April 15, 2021.

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References (continued)

• Department of Veterans Affairs. (2019). VHA Directive 0320.02, Veterans Health Administration Health Care Continuity Program,Government Accountability Office. Veterans Health Administration Regional Networks Need Improved Oversight and Clearly Defined Roles and Responsibilities. https://www.gao.gov/reports/GAO-19-462/.

• Department of Veterans Affairs (2020). Ethical principles for access to and use of Veteran data. (Memorandum VIEWS #01256748)https://www.oit.va.gov/about/ethical-data-use/index.cfm

• Department of Veterans Affairs. (2020). Veterans Health Administration—Office of Emergency Management, COVID-19 Response Plan Incident-specific. Annex to the VHA High Consequence Infection (HCI) Base Plan, Version 1.6. VA Releases COVID-19 Response Plan. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5405.

• Department of Veterans Affairs. (2021). COVID-19 National Summary, June 14, 2021. https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary

• Department of Veterans Affairs. (2021). COVID-19 Pandemic Response. Weekly Report. https://www.va.gov/health/docs/VA_COVID_Response.pdf

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References (continued)

• Department of Veterans Affairs. (2021). Department of Veterans Affairs National Surveillance Data, https://app.powerbigov.us/groups/me/apps/5b3696b5- ace4-44c8-9e0d-53eca3c29171/reports/93a22c14-7964-4b6f-93d2-ba853297fe4f/ReportSection3dd692a49dd2b508b812?ctid=e95f1b23-abaf-45ee-821d-b7ab251ab3bf. (The website was accessed on June 27, 2020. This is an internal website that is not accessible to the public.)

• Department of Veterans Affairs (2021). Fiscal Year 2021 Budget Submission. https://www.va.gov/budget/docs/summary/fy2021VAbudgetInBrief.pdf#page=12

• Department of Veterans Affairs (2021). Review and Use of Patient-generated Health Data under the Office of Connected Care. VHA Directive 6506, Veterans Health Administration, Washington DC. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9252

• Department of Veterans Affairs (2021). Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness. Report #20-02717-85 Review of Veterans Health Administration’s COVID-19 Response and Continued Pandemic Readiness (va.gov).

• Ferguson, J. M., Jacobs, J., Yefimova, M., Greene, L., Heyworth, L., & Zulman, D. M. (2021). Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization. J Am Med Inform Assoc, 28(3), 453-462. doi:10.1093/jamia/ocaa284.

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References (continued)

• Gromatsky, M., Sullivan, S. R., Mitchell, E. L., Spears, A. P., Edwards, E. R., & Goodman, M. (2021). Feasibility and acceptability ofVA CONNECT: Caring for our nation's needs electronically during the COVID-19 transition. Psychiatry Res. 296, 113700. doi: 10.1016/j.psychres.2020.113700

• Hanlon, C., Huang, C., Sloss, E., Price, R. A., Hussey, P., Farmer, C. & Gidengil, C. (2017). Comparing VA and non-VA quality of care: systematic review. J Gen Intern Med 32(1):105–21, doi:10.1007/s11606-016-3775-2

• Heyworth, L., Kirsh, S., Zulman, D., Ferguson, J. M., & Kizer, K. W. (2020). Expanding access through virtual care: the VA’ s early experience with Covid-19. NEJM Catal Innov Care Deliv 2020; 1 (4): 1–11. doi: 10.1056/CAT.20.0327.

• Hilty, D. M., Armstrong, C. M., Edwards-Stewart, A., Luxton, D. D., Gentry, M. T., & Krupinski, E. A. (2021). A scoping review of sensors, wearables, and remote monitoring for behavioral health: uses, outcomes, clinical competencies and research directions. [Special Issue: Clinical and Educational Interventions for Technologies]. Journal of Technology in Behavioral Science. doi:10.1007/s41347-020-00190-3

• Lin J. C., Humphries, M. D., Shutze, W. P., Aalami, O. O., Fischer, U. M., & Hodgson, K. (2021). Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care. J Vasc Surg. 73, 392-398. doi:10.1016/j.jvs.2020.06.051.

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References (continued)

• Myers, U. S., Birks, A., & Grubaugh, A. L., & Axon R. N. (2021). Flattening the curve by getting ahead of it: how the VA healthcare system is leveraging telehealth to provide continued access to care for rural Veterans. J Rural Health, 37(1),194-196. doi: 10.1111/jrh.12449.

• National Academy of Sciences, Engineering, and Medicine (2020). Developing a patient-centered approach to optimizing veterans access to health care services. Retrieved from: https://www.nationalacademies.org/event/03-12-2020/developing-a-patient-centered-approach-to-optimizing -veterans-access-to-health-care-services-a-workshop.

• Park, E. R., Chiles, C., Cinciripini, P. M., Foley, K. L., Fucito, L. M., Haas, J. S., Joseph, A. M., Ostroff, J. S., Rigotti, N. A., Shelley, D. R., Taylor, K. L., Zeliadt, S. B., & Toll, B. A. (2021). Impact of the COVID-19 pandemic on telehealth research in cancer prevention and care: A call to sustain telehealth advances. Cancer, 127(3), 334-338. doi:10.1002/cncr.33227.

• Reddy, A., Gunnink E., Deeds, S. A., et al. (2020). A rapid mobilization of ‘virtual’ primary care services in response to COVID-19 at Veterans Health Administration. Healthcare, 8(4), 100464.

• Schueller, S., Armstrong, C. M., Neary, M. & Ciulla, R. (2021). An introduction to core competencies for the use of mobile apps in cognitive and behavioral practice. Cognitive & Behavioral Practice, 27(4). doi:10.1016/j.cbpra.2020.11.002

• Shura, R. D., Brearly, T. W., & Tupler L. A. (2021). Telehealth in response to the COVID-19 pandemic in rural Veteran and military beneficiaries. J Rural Health, 37(1), 200-204. doi: 10.1111/jrh.12454.

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Thank you!

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Christina Armstrong, Ph.D.

www.linkedin.com/in/christinaarmstrong

@_Armstrong1_

christina.armstrong@va.gov