VA State of the Art Conference in Rural Health - September 12-13, 2016 - Ralph H. Johnson VA Health Care System
Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

Ralph H. Johnson VA Health Care System

Menu
Menu
Veterans Crisis Line Badge
My HealtheVet badge
 

VA State of the Art Conference in Rural Health - September 12-13, 2016

Health Equity and Rural Outreach Innovation Center (HEROIC) logo

Conference Abstracts

 

1. Improving Transitions of Care to VHA Primary Care Following a Non-VHA Hospitalization through an Innovative Community Transitions Consortium

Authors: Ayele AR, Nardini K, Hull A

Affiliation:
COIN: Center of Innovation for Veteran-Centered and Value-Driven Care; Seattle, WA and Denver, CO
Additional Affiliation(s): Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, CO; University of Colorado, Anschutz Medical Campus, Aurora, CO; Parkview Medical Center, Pueblo, CO

Objectives:
In 2015, Eastern Colorado Healthcare System (ECHCS) paid for approximately 2,500 Veterans to receive care in non-Veterans Health Administration (VHA) hospitals. The process of transitioning Veterans to VHA primary care following a non-VHA hospitalization can be challenging because of a lack of standardized communication methods, information transfer, and re-establishing care in VHA primary care. Poor transitions can result in medical complications, hospital readmissions and care fragmentation. Veterans who live further away from a VHA facility are less likely to rely on the VHA for inpatient care. This is especially important to ECHCS since approximately 20% of Veterans live in rural communities. Our care transition quality improvement project examined current processes, facilitators and barriers.

Methods:
We conducted 52 semi-structured interviews with providers and staff at VHA and non-VHA facilities. Of these, 10 interviews were from a VHA Community Based Outpatient Clinic (CBOC) and a community medical center serving many rural Veterans. Participants were recruited using convenience and snowball sampling. Qualitative data analysis was guided by conventional content analysis and managed in Atlas.ti software.

Results:
Both VHA and non-VHA staff described the current care transition process for Veterans hospitalized in non-VHA hospitals as inefficient due to a non-standardized notification process, untimely post-discharge information transfer and follow up care. However, when VHA providers received an alert about their patient's non-VHA hospitalization, they were able to initiate timely care coordination. One CBOC serving rural Veterans participates in an innovative community Transitions Consortium. The goal of this Consortium is to identify patients with high utilization and improve communication among healthcare providers. The Consortium meets monthly to discuss 30-day post-discharge care coordination. Members include local hospitals (discharge planners/emergency providers), community healthcare centers, and the Fire Department. The CBOC's participation has improved Veterans' transition outcomes by promoting a better understanding of VHA policies/procedures including how Veterans access post-discharge medications within the community. The CBOC also created a dedicated nurse line for non-VHA providers to inform them of Veteran care needs. Although their participation is helpful, the CBOC is limited in their ability to fully engage with Consortium members about patients who are Veterans. 

Implications:
  This innovative model helps rural Veterans transition from non-VHA hospitals back to VHA primary care for follow up. It addresses the barriers and eliminates inefficiencies while promoting facilitators that will lead to an ideal process.

Impacts:
Fostering new relationships with non-VHA providers through a community Transitions Consortium contributes to Veterans receiving timely follow-up healthcare services.


2. Partnered Evaluation of the Social Determinants of Health and Healthcare

Authors: Littman AJ, Bollinger M, Wong ES, Finley EP, Fortney JC, Pyne JM, Drummond KL, Abraham TH, Townsend J, Mader M, Lee JS, Batten A, Bosworth HB, Boyko EJ, Hudson TJ

Affiliation: COIN: Center of Innovation for Veteran-Centered and Value-Driven Care; Seattle, WA and Denver, CO

Objectives: To: 1) characterize geographic variation in access, utilization, quality, satisfaction, and outcomes for rural Veterans, 2) identify the socioeconomic, cultural and environmental factors associated with geographic variation in outcomes assessed in Aim 1; 3) describe perceived access and need and identify preferences for and barriers and facilitators to healthcare and achieving optimal health and well-being among rural Veterans in areas with high and low utilization and enrollment; and 4) identify strategies and opportunities to support innovative partnerships with community, state and federal organizations to optimize the health and well-being of rural Veterans.

Methods:
Our work is guided by the SOTA model of access and the Healthy People 2020 framework to operationalize social determinants of health. We are using both quantitative (Aims 1 and 2) and qualitative (Aims 3 and 4) methods to conduct analyses. Aims 1 and 2 are being conducted using VA administrative data (e.g., CDW), VA surveys (e.g., SHEP, VA Survey of Veteran Enrollees' Health), Centers for Medicare/Medicaid data, and individual and aggregated national publically-available data (e.g., American Communities Survey, County Health Rankings).

Results:
Analyses and interviews are underway. Areas with high and low enrollment and utilization have been identified and ten counties (five with low and five with high utilization and enrollment -- two total in each VHA district) have been selected for sampling for Veteran and stakeholder interviews. Key deliverables include: an interactive atlas (Aim 1), an electronic chart book that includes both tabular data and a narrative of individual-, community/regional-, and system-level social determinants that contribute to the observed geographic variation (Aim 2), a nationally-representative depiction of Veterans' perceptions of the contributors to high/low access/utilization/outcomes and region-specific approaches to facilitate improved healthcare, health, and well-being for Veterans living in rural areas (Aim 3), an annotated directory of resources and potential partners to improve the well-being of rural Veterans (Aim 4). 

Implications:
This project represents a unique and collaborative effort to obtain timely and actionable assessments to improve access, Veteran satisfaction, quality, and outcomes.

Impacts:
This project will gauge where gaps in care for rural Veterans exist, gain a better understanding of the reasons for those gaps, and identify opportunities for innovative partnerships between VA and other governmental and non-governmental entities.


3. Veteran Community Engagement in the Pacific through the Veterans Choice Program

Authors: Driskill, Jr. TM, Engstrom K, Joselow, K

Affiliation: VA Pacific Islands Health Care System, Honolulu, HI

Additional Affiliation(s):
Office of Rural Health, Washington, DC; Ward Circle Strategies, Washington, DC

Objectives: To better understand of the Veterans Choice program, the impact and opportunities for both Veterans and for community providers in both current and future state, a graphical description of the program was developed.

Methods:
Poster is broken down into multiple sections with information about the Veterans Administration, today's Veterans Choice Program, future state vision of community care for Veterans and a case study.

Results:
The poster conveys key information on how the Veterans Choice program works, advantages for both Veterans and community providers, future direction for Veterans Administration supported community care in sync with Veterans Administration care, then sets an example through a case study.

Implications:
This poster will be provide more comprehensive information on why the Veterans Choice Program was established, how the program works and where the program is going in the future.

Impacts:
The Veterans Choice Program has had an impact upon Veterans and community care, transforming seven legislated separate community care programs currently sponsored by the Veterans Administration into one future state consolidated program that will be called the "New" Veterans Choice Program.


4. Identifying Patterns of Geographic Clustering in VA Enrollment and Active Utilization. National Rural Evaluation Center (NREC)

Authors: Bollinger M, Mader M, Hudson TJ, Wong ES, Finley EP, Fortney JC, Pyne JM, Drummond KL, Abraham TH, Townsend J, Lee J, Batten A, Bosworth HB, Boyko EJ, Littman A

Affiliation: South Texas Veterans Health Care System, San Antonio, TX

Objectives: VA rates of enrollment and healthcare utilization vary spatially and demographically, influenced not only by individual patient characteristics but also by the characteristics of communities and the placement of VA facilities. Understanding the spatial patterning of enrollment and healthcare utilization is important information for planners and policymakers and helps identify areas where targeted interventions may be needed to either increase or reduce capacity. The objectives of this presentation are to (1) discuss the methodology used to develop our estimates of enrollment and utilization, and (2) to share the results of the spatial analyses we conducted.

Methods:
VA administrative data and the American Community Survey (ACS) (2010-2014) were used to estimate enrollment and utilization. County-specific enrollment was calculated as VHA enrollees divided by the number of Veterans in each county from the ACS. County-specific utilization rates were calculated as active users (i.e., VA use in the last 2 years) divided by the number of enrollees. To account for variation due to differences in age and sex, we calculated age- and sex-standardized rates, referred to as Standardized Enrollment Ratio (SER) and a Standardized Utilization Ratio (SUR). Finally, we assessed geographic clustering of the SER and SUR using the global and local Moran's I statistic. All results were mapped in a geographic information system (GIS) with ARCGIS 10.2.

Results:
Both enrollment and utilization had strongly positive (Moran's I > 0.6) autocorrelation indicating substantial geographic clustering. High enrollment and utilization clustering were observed in the upper mid-West and Mid-Atlantic States. Low enrollment clustering was observed in the along the coastal areas of the U.S while clustering of low healthcare utilization was seen in various parts of the country but especially in the North Atlantic states - primarily in rural areas.

Implications:
Enrollment and utilization varies geographically by rurality. Moran's I statistics, combined with GIS, provided important context for visualizing enrollment and utilization. Next steps include determining which community-level factors are associated with the observed patterns using Bayesian multilevel spatial modeling.

Impacts:
Spatial data analyses represent an important tool for ensuring VA provides needed services to Veterans. This study suggests that spatial analyses have the potential to provide greater understanding and more accurate investigations of enrollment and utilization rates particularly as they relate to social determinants of health.


5. Educational Intervention to Engage Rural Veterans in Improving their PTSD Care

Authors: Montano MA, Sherrieb K

Affiliation: VA National Center for PTSD

Additional Affiliation(s):
White River Junction VA Medical Center, Bernardy, NC; VA National Center for PTSD and Department of Psychiatry at Geisel School of Medicine at Dartmouth, Hanover, NH

Objectives: Interventions to increase access to evidence-based care traditionally focus on healthcare providers. Multiple Department of Veteran Affairs (VA) improvement strategies, including pay-for-performance, mandated trainings, and academic detailing, all place the onus of learning and change on providers already burdened with administrative and clinical duties. Direct-to-consumer (DTC) strategies are an evidence-based strategy to influence care. Specifically, minimal and DTC interventions have been effective in driving taper and discontinuation of benzodiazepines. Benzodiazepines are not recommended to treat posttraumatic stress disorder (PTSD), yet prescribing continues, with rates of use higher in both rural veterans and women veterans. Polysedative prescribing, a practice associated with high risk of adverse effects and prescription drug overdose death, are also higher in rural veterans with PTSD. Infographics and brochures aimed directly at veterans are a method to present complex information in a way that is visually interesting and understandable.

Methods:
With funding support of VA Office of Rural Health, our team engaged veterans directly in development of educational brochures. We also developed modern-appearing infographic posters that visually provide information about evidence-based PTSD treatments and the risk associated with benzodiazepine and polysedative use. When displayed or shared in clinical offices and waiting rooms, the products are intended to stimulate self-assessment and encourage veterans to engage in shared decision making with their provider.

Results:
Three shared decision making brochures for patients were developed with direct participation of rural veterans. To date, four infographic posters have been created. Posters have been disseminated nationally to at least 156 distinct sites. Organizational email and newsletter offerings have stimulated 112 requests from providers. Over 500 posters have been distributed, with requests for 624 additional pending distributions.

Implications:
Rural veteran input during development resulted in more acceptable and accessible PTSD educational products. Key clinical messages about evidence based treatments and risk of harmful agents in PTSD can be successfully simplified in infographic posters. The response by providers to materials has been overwhelmingly positive and suggests that prescribing clinicians are eager for educational products that are aimed at directly educating patients.

Impacts:
Our project supports engaging veterans directly in the creation of educational materials. Visually stimulating and easy to understand infographics aimed at improving PTSD care have been disseminated nationally. It is hoped that these products will support shared decision making and patient self-assessment, leading to improved access to quality PTSD care.


6. Intensive Referral to Mutual-Help Groups: A Field Trial of Adaptations for Rural Veterans

Authors: Grant KM, Young LB, Beaumont C, Tyler KA, Simpson JL, Pulido RD

Affiliation: Nebraska-Western Iowa Health Care System, Omaha, NE

Additional Affiliation(s):
VA Nebraska-Western Iowa Health Care System; Western Illinois University; VA Nebraska-Western Iowa Health Care System; University of Nebraska; Midland University

Objectives: This trial tested an adapted intensive referral (AIR) to mutual-help groups (MHGs) modified to address the needs of rural veterans (e.g. overcoming distance) and enlisting family support to determine if AIR increases MHG affiliation, abstinence from alcohol and other drugs and reduces PTSD symptomology.

Methods:
Veterans (N = 196) were randomized to receive standard referral (SR) or AIR at three Department of Veterans Affairs (VA) intensive substance use disorder (SUD) treatment sites in Nebraska. Utilizing a flowchart, trifold handouts, and a self-help journal, an Addiction Therapist or Peer Support Specialist explained the importance of meeting attendance, scheduled a MHG meeting with a "buddy" and enlisted support for MHG attendance from a family member (with permission). Two subsequent sessions followed-up on MHG attendance and participation. Participants completed baseline and six-month follow-up questionnaires which assessed addiction severity (Addiction Severity Index-Lite, Timeline Follow-Back calendar), social support, traumatic symptoms (PTSD checklist) and mutual-help group participation (Alcoholics Anonymous Affiliation Scale). Rural-urban commuting area codes were used to determine rural/urban status.

Results:
Completing AIR sessions was problematic with declining proportions of those receiving session 1 (58.5% of the AIR group), session 2 (35.8%) and session 3 (25.5%). Analysis was completed by identifying the number of AIR sessions participants attended: 0, 1, 2, or all 3. AIR did not improve MHG affiliation or PTSD symptoms significantly more than SR, but those who received all three AIR sessions were significantly more likely than SR clients to be abstinent from alcohol at follow-up (96.2% vs. 77.9% abstinent, X2 = 4.58, p < .05). Having a sponsor was associated with improved alcohol and drug abstinence rates.

Implications:
AIR increases rates of 30-day abstinence from alcohol and the relationship is linear, with more sessions associated with greater abstinence. The intervention, however, did not significantly increase MHG participation; improve addiction severity, drug abstinence or PTSD symptoms over SR. Insufficient power and strong 12-step emphasis among standard referral patients may have contributed to the lack of significant differences between experimental conditions.

Impacts:
Intensive referral to MHGs enhances abstinence from alcohol, but the means by which it does so merit further study and the referral process needs refinement to accommodate the resources available at a variety of programs.


7. Telemedicine approaches to extend geriatric care to rural areas (GRECC-Connect)

Authors: Hung WW, Barczi S, Thielke S, Colon-Emeric C, Rossi M, Garner K, Espinoza S, Caprio T, Moo L, Boockvar KS

Affiliation: James J. Peters VA Medical Center, Bronx, NY

Additional Affiliation(s): Howe JL Geriatric Research, Education and Clinical Center (GRECC)

Objectives: Older adults living in rural areas have limited access to geriatric teams for their healthcare needs. Providers with training in geriatric medicine often practice in urban areas rather than rural areas, thus limiting rural older adults' access to quality geriatric care. Recognizing the lack of access to geriatric care in rural settings, our objective is to implement remote geriatric consultation and rural provider support to serve rural older Veterans.

Methods:
A multi-site geriatric program (GRECC-Connect) was established to provide geriatric consultation through telehealth modalities. Geriatric Research, Education and Clinical Centers (GRECC) act as the resource sites for geriatric consultation. A total of a nine hubsites with geriatric teams established consultative relationship with rural clinics to provide consultation to Veterans through regularly scheduled case-based conference, team huddles, clinical video telehealth (CVT) and chart-based consultation (e-consult). We surveyed providers, staff and Veterans regarding their satisfaction using likert scale items (1 (strongly disagree) to 5 (strongly agree)). We also assessed mileage saved for Veterans traveling to televisits compared to face-to-face geriatric consults.

Results:
In FY15, we served through provider education or consultation a total of 1099 unique Veterans, among which 976 were Veterans from rural areas. Veterans were served by a number of modalities including clinical video telehealth (45% of Veterans), telehuddles (5%), E-consults (35 %), and telegroup visits (13%). Providers who referred Veterans to CVT service agreed that Veterans are seen within a reasonable timeframe (mean score 4.3), and that they are satisfied with the CVT service (mean score 4.4). We estimated from a sampling of surveyed Veterans utilizing CVT that Veterans satisfaction was high (mean score 4.4), and most agreed that they would continue video telehealth rather than travel long distances. Total mileage saved among Veterans served was 94,470 miles, with an average of 86 miles per Veteran.

Implications:
Implementing geriatric support at a distance utilizing geriatric teams established in urban VA medical centers is feasible and may confer benefits to rural older Veteran care.

Impacts:
For Veterans who otherwise need to travel to receive geriatric care, there was significant mileage avoided - thereby improving access to care.


8. Video to Home Inhaler Training for Rural Patients with COPD or Asthma

Authors: Thomas RT, Locke ER, Woo DM, Nguyen EHK, Tamanaha BK, Gylys-Colwell IM, Press VG, Layouni TA, Ruiber GE, Fan VS

Affiliation: COIN: Center of Innovation for Veteran-Centered and Value-Driven Care; Seattle, WA and Denver, CO

Objectives: Obstructive lung disease (COPD or asthma) is more common among rural Veterans than urban Veterans and is typically treated with inhaled medications to improve symptoms and reduce exacerbations. One-third of COPD patients never receive inhaler training, and up to 86% misuse their inhalers. We tested if the VA Clinical Video Telehealth-to-Home (CVT-H) could improve access to inhaler training for rural Veterans with COPD by determining the feasibility and effect of a CVT-H inhaler education program to improve inhaler technique.

Methods:
We analyzed data from a VA Office of Rural Health funded pilot CVT-H inhaler training program at VA Puget Sound from January 2014 to March 2016. Veterans had 3 inhaler training sessions. Using teach-to-goal (TTG) methodology, inhaler use is broken into 12-17 steps for 6 inhalers. Patient pre-training skills are assessed and reassessed following pharmacist instruction through patient "teach back" until mastery is demonstrated or up to 3 rounds. Participants completed evaluation surveys. Paired t-tests were performed to compare TTG scores for each inhaler.

Results:
Seven-hundred sixty rural Veterans were invited by telephone to participate. Of those contacted 32% did not have access to a computer or internet. Ultimately 114 participants were enrolled, and 81 completed > 1 visit. During the baseline visit, TTG scores improved significantly (p < 0.003) for all 6 inhalers. Effective technique was sustained or continue to improve over the 2 months of follow-up for all inhalers (p < 0.01). For example, rescue metered-dose inhaler scores increased from 10.5 to 11.9 (p < 0.0001) over 2 months. Almost all (94%) participants were satisfied with the training, and 76% would not have gotten any inhaler training if it were not provided at home. One-quarter (25%) of participants reported technical problems with the CVT-H visits.

Implications:
Rural Veterans receiving home CVT-H inhaler training demonstrated improved inhaler technique within each visit, which was maintained over 2 months. Satisfaction was high despite one-quarter of participants reporting technical problems.

Impacts:
Home internet-based video inhaler training is a promising approach to improving inhaler technique for rural Veterans with obstructive lung disease and may address barriers to receiving training via a face-to-face appointment.


9. The Rural Veterans TeleRehabilitation Initiative Creative Arts Therapy program (RVTRI CAT)

Authors: Levy CE, Myers KJ, Sonke J, Baxley-Lee J, Spooner H, Snow E

Affiliation: COIN: Center of Innovation on Disability and Rehabilitation Research (CINDRR); North Florida/South Georgia and Tampa

Objectives: The Rural Veterans TeleRehabilitation Initiative Creative Arts Therapy program (RVTRI CAT) is a telehealth based creative arts therapy program. The program aims to: 1) enhance Veterans' overall health and wellbeing 2) improve Veterans' perceived quality of life 3) allow Veterans opportunities to communicate, externalize and process life events 4) expand access to creative arts therapies for rural Veterans by facilitating sessions via telehealth.

Methods:
Following an initial in-person evaluation, Veterans participate in weekly sessions with a creative arts therapist via telehealth. Veterans complete a series of pre and post self-report assessments including the WHOQOL-BREF, MOCA, PANAS-X, URICA and FEATS. They also complete a qualitative interview with their provider after two months to evaluate program impact and progress towards their treatment goals.

Results:
Veterans who participate in the program have reported positive changes in their overall emotional state and perceived quality of life. Evaluation of pre and post assessments is currently underway and demonstrates positive change, although it is not yet clear if results will be statistically significant due to the current small sample size. 30 unique Veterans have been followed via telehealth for over 200 encounters during this fiscal year.

Implications:
Providing creative arts therapy via telehealth has successfully increased access to treatment for rural Veterans. The RVTRI CAT program appears to be an effective treatment option for improving Veterans' overall emotional outlook and perceived quality of life. The positive feedback obtained from participants suggests that expanding this program to additional participants is warranted. This will allow continued refinement of treatment methods and improved service delivery.

Impacts:
The VA Office of Patient Centered Care (OPCC) recognizes arts programs as a component of integrated, whole person health care. Creative arts therapy programs are increasingly being recognized and implemented as a cost effective and evidence supported treatment for a variety of conditions commonly faced by active military service members and Veterans. Additionally, congress appropriated an additional $2.4 million this year to the National Endowment for the Arts specifically to expand arts and creative arts therapy programs for active military service members and Veterans. This Office of Rural Health funded clinical demonstration project demonstrates that creative arts therapy can be successfully implemented via telehealth to expand service delivery to Veterans who live in rural areas. Consideration is warranted for ongoing federal support and funding for the development and expansion of similar arts-based treatment and programming for Veterans in other geographical regions.


10. Rural Veterans with Dementia and the Role of Telehealth in Home Safety Evaluations

Authors: Gately MG, Trudeau SA, Moo LR

Affiliation: Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA

Objectives: The majority of geriatric Veterans are rural. Geriatric Veterans are at increased risk of developing dementia, which is one of the most costly age-related conditions for Veterans Health Administration (VHA). Veterans with dementia have distinct clinical concerns because of the disease's progressively negative effects on cognition, social, emotional, and physical functioning. Occupational therapists (OT) provide non-pharmacological strategies for dementia management, including strategies to address home safety. However, dementia-specific OT is not always accessible to Veterans, particularly rural Veterans. Video telehealth is a way to increase access to OT strategies, including home safety evaluations. This mixed methods study investigated using clinical video telehealth (CVT) to deliver a dementia-specific home safety evaluation. Outcomes related to Veteran and caregivers were collected.

Methods:
Participating caregivers each received two types of home safety evaluations - in-person and virtual, utilizing clinical video telehealth (CVT) - by two different OT study staff. For the in-person home safety evaluation, OT study staff went into Veterans' homes. For the virtual home safety evaluation, caregivers navigated their home environment while holding a portable computing device (e.g., laptop) under the virtual direction of a different OT study staff. The OT study staff member conducting the virtual home safety evaluation was blind to results of the in-person home safety evaluation. Quantitative and qualitative measures were collected after each visit type.

Results:
Outcomes related to each type of home safety evaluation indicate that dementia-specific virtual home safety evaluations are a feasible and acceptable alternative to in-person home safety evaluations for Veterans and caregivers.

Implications:
Telehealth may increase access to dementia-specific home safety evaluations for Veterans facing access barriers to dementia care. Further research is needed to determine the efficacy and feasibility of implementing this promising model of care.

Impacts:
Telehealth has the potential to increase Veteran access to a dementia-specific home safety evaluation. More research is needed about utilizing clinical video telehealth to deliver this much needed intervention for rural Veterans with dementia and their caregivers.


11. VA PACT team perspectives on managing psychiatric and cognitive problems in aging rural Veterans

Authors: Greenberg L, Grant M, Hicken BL

Affiliation: George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT

Additional Affiliation(s): ORH: Veterans Rural Health Resource Center- Salt Lake City, UT

Objectives: Fifty-six percent of rural Veterans are older than 65. When these elderly Veterans develop psychiatric and cognitive problems, along with chronic medical issues, caring for these individuals can be difficult and time-consuming, especially in the context of scarce resources common in rural areas. Previous research suggests that healthcare professionals feel ill-equipped to care for patients with complex, comorbid disorders. We sought VA PACT providers' perspectives on caring for this population to inform development of an intervention to improve access to specialty mental health care for rural Veterans with multimorbidities.

Methods:
We conducted focus groups with PACT teams in CBOCs in the Salt Lake City VA Health Care System, which spans Utah and portions of Idaho and Nevada. Two moderators led each in-person focus group. Questions covered common concerns in caring for geriatric Veterans with psychiatric and cognitive problems, including family and caregiver issues, workflows for referring to VA and community services, and services that may be helpful. Focus groups were audio-recorded and transcribed. Transcripts were reviewed and coded by the three authors to identify thematic elements related to challenges, needs, and interventions to improve access to specialty mental health care for this population.

Results:
62 individuals from eight CBOCs participated. Three primary thematic categories were explored in the qualitatively analyzed focus groups: 1) Challenges in working with this population; 2) Caregiver issues; 3) Suggested interventions to improve care. Five themes emerged related to concerns impacting the care of these Veterans: 1) Provider burden due to time needed to address multimorbidity and lack of expertise in geriatric and mental health issues; 2) Isolation from the urban medical center; 3) Difficulties coordinating specialty services for rural Veterans; 4) Limitations in providing family and caregiver support; and 5) Difficulty navigating VA and community resource networks.

Implications:
Rural providers described challenges and unmet needs that complicate the care for Veterans with co-morbid psychiatric and cognitive issues. These Veterans stretch provider capacity and consume limited clinic resources.

Impacts:
Providers offered multiple suggestions that can be translated into practical interventions for improved care. Findings will inform development of a remote, technology-assisted geriatric mental health intervention for rural Veterans.


12. An internet and telephone support intervention for stroke caregivers living in rural and urban areas

Authors: Uphold CR, LeLaurin  JH, Schmitzberger MK, Eliazar-Macke  ND, Schember  TO, Fehlberg EA, Hugon RP, Rogers J, Jordan M, Freytes  IM

Affiliation: COIN: Center of Innovation on Disability and Rehabilitation Research (CINDRR); North Florida/South Georgia and Tampa

Additional Affiliation(s): North Florida/South Georgia Veterans Health System

Objectives: Caregiver depression and burden are common following a family member's stroke and are major contributors of stroke survivors' functional recovery, resource use, and institutionalization. Rural caregivers may be particularly vulnerable to negative outcomes due to lack of access to care and support resources. Previous studies reveal that problem-solving interventions are effective in improving caregiver and Veteran outcomes post-stroke. However, most of these interventions were burdensome, particularly for caregivers living in rural areas because they were labor intensive involved multiple, face-to-face sessions. This mixed methods study explores the feasibility, acceptability and efficacy of a nurse-led internet and telephone support intervention for rural and urban caregivers.

Methods:
A four-arm randomized controlled clinical trial was conducted with 51 stroke caregivers. Caregivers completed a baseline assessment and were randomized to one of four arms: 1) 4-session intervention, 2) 8-session intervention, 3) attention control, or 4) standard care. The intervention was based on the relational/problem-solving model of stress originally developed by D-Zurilla and Nezu. We modified the traditional problem-solving intervention by adding web-based training using interactive modules, factsheets, and tools on our national RESCUE Stroke Caregiver website (http://www.cidrr8.research.va.gov/rescue/index.cfm). Post-tests were administered two months after baseline. Qualitative interviews were conducted with 17 caregivers in the intervention and attention control groups. We used repeated measures analysis of variance (RMANOVA) to check for differences between groups and locality (urban vs. rural) in the amount of pre-post change. Qualitative interviews were analyzed using content analysis techniques.

Results:
There were no statistically significant differences between rural and urban caregiver demographics. RMANOVA results showed no evidence that the different treatment groups, nor different localities, differed in pre-post change. Moreover, the effect of treatment groups did not differ according to locality. Qualitative analysis revealed overwhelmingly positive responses to the intervention and registered nurses. Caregivers reported the intervention helped them gain problem-solving skills and make positive behavior changes. All caregivers stated they would recommend the program to others.

Implications:
The intervention and method of delivery were deemed feasible and acceptable.

Impacts:
This is the first known study to evaluate a combined Internet and telephone support intervention for stroke caregivers. The RESCUE intervention is ideal for use in rural populations as there are no geographical constraints to intervention delivery. Based on this pilot study, a larger trial, which could be translated for the rural population, is warranted.


13. Conceptualizing the role of Primary Care during TCC Outreach Events

Authors: Stewart KR, Ohl M, Lutz P, Moeckli J

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Objectives: Telehealth Collaborative Care (TCC) for Veterans with HIV seeks to improve access to specialty care via clinical video telehealth (CVT) at outlying Community Based Outpatient Clinics (CBOCs), while providing integrated care through focused collaboration with CBOC-based primary care providers (PCPs). Past research shows that care collaboration around patients with HIV is complicated, and that garnering provider acceptance is important. A core element of TCC is outreach to CBOCs to initiate collaborative relationships between primary care (PC) and HIV clinics. We examined how HIV specialty teams conceptualized the role of PC during outreach events in order to understand the role of outreach in engaging PC in collaborative care for Veterans with HIV.

Methods:
Using a rapid ethnographic assessment approach, two qualitative researchers observed outreach events at CBOCs and conducted unstructured interviews with TCC program, HIV clinic and CBOC staff. We summarized fieldnotes into tabular summaries and conducted a matrix analysis to compare how each site communicated PC's role in TCC.

Results:
During outreach events to CBOCs, we found that each site provided its own interpretation of PC's involvement in TCC. Site A approached outreach as an opportunity to educate PC staff about the current state of the HIV epidemic, HIV rapid testing, and ways PC could contribute, but did not seek to engage PC in collaborative care of patients. Site B operationalized TCC as a way to individualize care for their patients with HIV. Site C emphasized the importance of PCP buy-in to the success of TCC by personally arranging meetings with CBOCs and PC leadership. Finally, Site D stayed closest to the collaborative element of the model, referring to PCPs as "primary care specialists" whose expertise is needed as patients with HIV age and comorbidities become primary.

Implications:
The framing of PC's collaborative role spans minimal involvement to "primary care specialists" providing necessary expertise as Veterans with HIV age. In the context of goals for TCC at each site, the framing of PC aligns with clinical and cultural expectations of HIV clinics, with some specialists resisting shared care and others seeking opportunities to improve their clinic process and patient outcomes through partnerships with PCPs.

Impacts:
Understanding the ways in which sites conceptualized primary care during their outreach events provides insight into the feasibility of collaborative care relationships between primary care and HIV specialists as envisioned within the Telehealth Collaborative Care model.


14. Intensive Care Unit Staff Perceptions and Attitudes about Readiness to Implement and Impact of ICU Telemedicine

Authors: Moeckli J, Mengeling MA, Goedken CC, Reisinger HS

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s): RHRC-IC, CADRE, University of Iowa Carver College of Medicine

Objectives: Tele-ICU has the potential to improve rural Veterans' access to quality VA critical care, yet research suggests that low utilization may be impeding effectiveness. In partnership with the National Tele-ICU Workgroup and the Office of Rural Health, we developed an instrument to measure Tele-ICU implementation to support program refinement and quality improvement.

Methods:
Seven ICUs were identified to participate in repeated cross-sectional surveys administered prior to, 4 months and 12 months post-Tele-ICU implementation. ICU nurse managers at each unit identified ICU nurses and respiratory therapists (RTs); physicians (including trainees, where available) were identified through the VISN. The instrument includes validated scales (Teamwork Climate Scale, Safety Climate Scale, Organizational Readiness to Change) and questions about training and utilization informed by the literature and our past ethnographic research. Descriptive statistics are used to describe survey data distributions.

Results:
248 surveys were completed: roughly one-third each at pre-implementation (n = 79), 4 months (n = 91), and 12 months post-implementation (n = 78), including nurses (n = 184), physicians (n = 34), and RTs (n = 24). Assessments of implementation activities, measured through organizational readiness and training domains, show that that prior to activation, the majority of participants were committed to implementing Tele-ICU (73%), favorably endorsing timing being good and having knowledge and resources to implement Tele-ICU. Approximately 80% received Tele-ICU training. Despite positive measures of readiness, only 41% of participants endorsed having time to implement Tele-ICU before implementation. At 4 months, commitment decreased to 35%, and opinions about precision and usefulness of training dropped 15% and 8%, respectively. Commitment and training perceptions were slightly higher at 12 months. With Tele-ICU implementation, mean teamwork and safety climate scores were similar over time. Perceived impact on staff - a composite of workload, workflow, stress, and monitoring items - was lower (more negative) at 4 months, but pre- and 12 months post-implementation were similar (3.2, 2.9, 3.3; p = 0.02). Although contact with Tele-ICU decreased over time, participants reported changes in patient care increasing, as well as improvements in care quality (4 months: 38%; 12 months: 49%).

Implications:
Perceptions and attitudes about Tele-ICU implementation fluctuate in the first year of operation, as teams learn to work together and expectations for Tele-ICU adjust. Implementation activities, such as training and workflow integration, may need focused support to address attitudinal declines during transition.

Impacts:
To maximize utilization, facilities should consider extending readiness activities through at least the first 6 months of Tele-ICU operation.


15. Expansion of Telehealth Collaborative Care for Rural Veterans with HIV: A Rapid Ethnographic Assessment of Year One

Authors: Moeckli J, Stewart KR, Lutz P, Ohl M

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s): RHRC-IC, CADRE, University of Iowa Carver College of Medicine

Objectives: Rural Veterans seeking care for HIV in VA typically travel long distances to HIV clinics, often bypassing nearer primary care clinics. Telehealth Collaborative Care (TCC) provides improved access and integrated care for Veterans with HIV by: 1) relocating specialty care to outlying Community Based Outpatient Clinics (CBOCs) via clinical video telehealth (CVT) with HIV specialists, and 2) creating infrastructure for focused collaboration on common comorbidities, such as hypertension, between HIV and primary care teams. In 2014, the Office of Rural Health supported a multi-year expansion of TCC to four higher-volume HIV clinics within larger networks. In this rapid ethnographic assessment, we sought to understand factors influencing uptake and use after the first year of TCC expansion.

Methods:
We conducted a multi-site case study of three VA HIV clinics that implemented TCC. Data include semi-structured (n = 7) and unstructured (n = 18) interviews with TCC program, HIV clinic and CBOC staff, fieldnotes from direct observation of outreach at each CBOC, and monthly administrative teleconference fieldnotes with each site. We developed tabular summaries from evaluation objectives and emergent themes, and conducted a matrix analysis to compare and contrast sites.

Results:
At one year, two of three sites established CVT at all first wave CBOCs; the third site experienced contracting and staff acceptance barriers, but established CVT at a subset of clinics. Limited primary care and HIV clinic collaboration had occurred, although early signs of involvement in Veterans' care and care team communication were present, and often initiated by primary care. We identified three factors that impact implementation: 1) TCC program leads adapted the model to satisfy site-specific aims; 2) HIV and primary care teams were conflicted about shifting even limited aspects of primary care out of HIV clinics, leading to apprehension about TCC; and 3) uptake by PCPs was slow and in some cases allied professionals (e.g, Telehealth Clinical Technicians) became the central link to CBOCs. The full extent of their roles in negotiating care between HIV and primary care teams requires further investigation.

Implications:
CVT is a viable care model in higher volume HIV clinics, but collaboration remains difficult. TCC programs laid the groundwork for collaboration; our data suggests that it may evolve organically through primary care and allied staff initiation.

Impacts:
Phased implementation may ease transitions experienced by staff, focusing first on establishing CVT and building relationships between HIV, PACT, and allied professionals, then layering in collaboration after HIV and CBOC staff develop trust.


16. The 40+ Mile Choice Cohort: Sociodemographics, VA Health Care Use and Safety Net Provider Access

Authors: Mengeling MA, Franciscus C, Sadler AG

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s):  University of Iowa, Carver College of Medicine

Objectives: The Veterans Choice Program (Choice) expanded VA-provided health care by allowing Veterans, who face barriers to VA care, access to non-VA health care providers. Choice eligibility addresses: 1) timeliness of appointment scheduling ('wait time') and 2) travel burdens ('mileage'). We sought to characterize the largely rural mileage-eligible cohort by examining their sociodemographic characteristics, prior VA health care use, and availability of local safety net providers.

Methods:
The VA's Chief Business Office, Systems Management Office identified the Choice population (April 2015). Veteran-level VA data sources were merged by social security numbers. Safety net provider information was obtained from the Health Resources and Services Administration Data Warehouse. ARCGIS software was used to compute distances from Veterans' residence to nearest safety net providers (i.e., Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes, Critical Access Hospitals, Community Mental Health Centers, and Rural Health Clinics).

Results:
Over one million VA-enrolled Veterans are eligible for Choice; the majority (58%) are mileage-eligible. Women make-up 5% of the mileage-eligible cohort but 10% of VA health care users. The median age of mileage-eligible males is 67 years; 51 years for females. Approximately half live in rural and isolated rural areas. Half have a service connection (46% men; 55% women). Ten percent served during OEF/OIF. MyVA Region 3 (Midwest) has the most mileage-eligible male Veterans, whereas MyVA Region 5 (West) has the most female Veterans. In 2014, less than 4% had at least 1 VHA inpatient stay and approximately 1% received inpatient purchased care. Two-thirds had at least one outpatient visit days (median = 3) and a fifth received outpatient purchased care. The majority of mileage-eligible Veterans (85%) have access to a FQHC/FQHC Look-Alike healthcare facility within 40 miles of their residence, but this varies by state. Region 3 (Minnesota, Nebraska, Iowa, Kansas) and Region 4 (Texas) states have the greatest number of mileage-eligible Veterans without access to a FQHC within 40 miles. Access to Community Mental Health Centers ranges from 3% to 34% among MyVA Regions.

Implications:
The characteristics, health care use, and the extent of the safety net represent baseline information for this cohort. Next steps require examining how Veterans choose to participate and evaluating Choice implementation.

Impacts:
Choice leverages the national health care system in order to provide Veterans increased access through VA/non-VA partnering; however this data identifies a subpopulation of rural Veterans who may have limited access to both VA and non-VA providers.


17. Impact of the Clinical Pharmacy Specialist in Telehealth Primary Care

Authors: Litke JR, Schultz LA, Erickson KR, Perdew CJ

Affiliation: Boise VA Medical Center, Boise, ID

Objectives: Recruitment and retention of primary care providers in the rural northwest has been a long standing challenge. Recently, VA expanded an innovative project entitled the Telehealth Hub based at the Boise VAMC. The Hub's purpose is to increase access to primary care for rural veterans in VISN 20 by providing telehealth access to pharmacists, primary care providers, psychologists, psychiatrists, and social workers. Studies identify a potential disparity between rural and urban patients' access to clinical pharmacy specialist (CPS) services.

Methods:
CPSs are assigned to provider panels with the ideal ratio being one CPS assigned to provider panels totaling approximately 3600 patients. Team members may refer patients with chronic disease states such as diabetes, hypertension, hyperlipidemia, and interest in tobacco cessation to the CPS via warm handoff or consult. Patients may also be referred via patient population management review. The CPS will determine appropriateness of the consult, work with medical support assistants to schedule patients, and meet with patients via Clinical Video Telehealth (CVT) or telephone depending on patient preference. Scheduling a CVT appointment entails ensuring space, clinic staff to room patients, and technology are available.

Results:
Since this program started in 2014, CPS services have provided remote care to over 800 unique patients. Six Telehealth CPSs provide clinical pharmacy services to 16 different VA clinics. Average A1c reduction on a sample of patients has been 2.5 percent and diabetic lipid measures have improved by 15 percent. Improvements have also been seen in opioid monitoring including state board of pharmacy reviews and urine drug screen rates.

Implications:
This program allows rural Veterans and clinic staff access to primary care CPS. Increased quality of care has also been observed based upon improved laboratory measures. Telehealth CPS services have been demonstrated to be an effective means to expand and improve care to rural patients.

Impacts:
Improved access to care and improved laboratory measures have resulted through incorporation of telehealth clinical pharmacy specialists.


18. Trauma Informed Yoga Intervention for Pain Management in Veterans with PTSD and Alcohol Use Disorder

Authors: Reyes-Rabanillo ML, Olmo-Terrasa AM

Affiliation: VACHS: VA Caribbean Healthcare System, San Juan, PR

Objectives: To evaluate the feasibility of implementing a standardized and culturally adapted trauma-informed yoga intervention (TI Yoga) to improve pain outcomes in combat Veterans with mental health co-morbidities, specifically PTSD and alcohol use.

Methods:
A Business Plan to conduct two pilot groups to provide the TI Yoga was submitted and approved by the Clinical Executive Council. The inclusion criteria included: Combat Veteran, chronic low back pain (CLBP), PTSD, history of AUD and a medical clearance by the Veteran's primary care physician. The exclusion criteria included: Not having CLBP, PTSD, history of AUD, or medical clearance, unable to participate on weekly basis, and unable to complete the scales every six weeks. The TI Yoga consisted of 12 classes, provided on weekly basis for 60 minutes. The instructor covered six main areas: Introspection, Breathing and Regulation, Affirmation, Postures, and Guided Visualization. For each class, the DOD-VHA Pain scale and the Subjective Discomfort scale were administered before and after the class. A Difficulty Level scale was administered only after each class. Every six weeks the following scales were administered: DOD-VHA Pain Scale, Brief Addiction Monitor (BAM), Patient Health Questionnaire (PHQ-9), World Health Organization Quality of Life (WHOQOL-BREF), and the PTSD Check List (PCL-5). After the completion of the TI Yoga, patients participated in focal groups developed to obtain their feedback.

Results:
A total of 18 patients were recruited for the Yoga classes. Of those, 14 (78%) continued until the end. Seventeen patients (96%) completed the scales. Twelve patients (68%) reported pain improvement at the end of the class, in more than a half of the classes they attended. None of them reported adverse side effects. After completing the TI Yoga, 14 patients (78%) attended one of the Focal Groups we conducted.

Implications:
It is feasible to implement a Yoga intervention for pain management for patients with PTSD and AUD in VACHS. Patients with PTSD and AUD could tolerate the yoga classes with no adverse side effects, and completed the questionnaires throughout the program. A record review will be conducted to evaluate the impact of the Yoga intervention in pain, PTSD/Alcohol Use Disorder symptoms and services utilization.

Impacts:
This effort is well aligned with the mission of the VACHS and, if implemented, could provide access to an innovative and cost effective approach for pain management in our mental health clinical settings.


19. Serving Veterans Where They Live: Implementing VA Video to Home to Increase Access to Evidence-Based Psychotherapy for Rural Veterans

Authors: Lindsay JA, Martin LA, Graves L, Gabriel J, Walder A

Affiliation: COIN: Center for Innovations in Quality, Effectiveness and Safety (IQuESt); Houston, TX

Objectives: Mental health (MH) treatment is one of the most prevalent, costly conditions for the VHA. Logistical and sociocultural barriers limit access to MH care for rural patients needing treatment. VA Video, which enables the connection between a VA provider and a Veteran over videoconferencing technology in their home or other remote, secure location, effectively increases Veterans' access to care. Disseminating telehealth in a complex healthcare system such as the VA is challenging, and development of specific implementation strategies is necessary to overcome the difficulty of bringing evidence-based psychotherapies(EBPs) and new technologies that support patient care into standard practice. The overall goal of this project was to implement a VA Video to Home program to increase access to mental health care for underserved rural Veterans.

Methods:
Guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, we employed Implementation Facilitation (IF) strategies to establish a sustainable and effective VA Video to the Home service that delivered EBPs specifically to rural Veterans. To evaluate the effectiveness of our implementation intervention, we collected patient encounter and demographics data from the national telehealth database. We calculated slopes to capture the growth over time for the site receiving the implementation intervention and compared it to the national average.

Results:
Over an 18-month period, a robust video telehealth into the home service was established to provide greater access to Cognitive Processing Therapy, Prolonged Exposure Therapy, Interpersonal Therapy, and Cognitive-Behavioral Therapy for depression, anxiety, and insomnia. Eighty-seven Veterans (85% rural), including women (29%), ethnic minorities (50%), and a broad age range (21-72) received MH treatment via VA Video for nearly 500 visits. Compared to national average, the growth in VA Video to the Home visits was 5-times greater (p < .0001)at our intervention site.

Implications:
To our knowledge, this is the first prospective study of facilitation as an implementation strategy for VA Video into the home. Our findings suggest that implementation facilitation is an effective and acceptable strategy to support providers as they establish clinics and make complex practice changes, such as implementing video telehealth to deliver psychotherapy to rural Veteran populations.

Impacts:
To fulfill the VA's mission to increase access to and provide more patient-centered care, implementing additional VA Video to Home programs for rural Veterans in need of mental health treatment is critical. Implementation facilitation is key to this effort by working with providers on the ground to tailor these efforts to meet the needs of specific contexts.


20. Lessons Learned from the Evaluation of Strategic Communications to Influence Maine Veterans Participation in Health Information Exchange

Authors: Wing KL, Farris GL, Lee PW, Lee RE, Markle P

Affiliation: ORH: Veteran Rural Health Resource Center, Togus, Maine

Objectives: To measure the impact of the VA Maine Healthcare System-wide strategic communications on Veterans attitude towards Health Information Exchange (HIE) and to identify HIE participation messages important to Veterans.

Methods:
Quantitative and qualitative data was collected from calls and emails to the Health Information Sharing Helpline (n = 880) and telephone interviews with Veterans (n = 33) receiving care from VA Maine. Helpline data analysis was conducted to identify frequency of calls by topic and interview transcripts were analyzed to establish Veteran knowledge about HIE, and barriers and facilitators to HIE participation; as well as Veteran perception of HIE participation risks and benefits, HIE campaign message importance, and preferred communication methods.

Results:
From May-September 2015, the Health Information Sharing Helpline received 843 telephone calls and 37 emails from Veterans (92%), Veteran family members (7%), and VA employees (1%). Seven hundred sixty-four callers referenced receiving campaign direct mail. The most frequently cited reason calling the Helpline (210) was to confirm participation in the state HIE; only 64 Veterans expressed a desire to opt-out, and only called with questions or concerns regarding the privacy or security of their health information. There were 123 referrals to the VLER Rural Health Community Coordinator, 46 referrals to the VA Maine Choice Program Champion, and 22 referrals to the Veterans Benefits Administration. Analysis of telephone interview transcripts indicate an overwhelming acceptance of HIE by Veterans (97%). Several stated, "It's about time!" and "What took the VA so long?" There were multiple references to the value of HIE in an emergency situation; and consensus that the benefits of HIE participation outweighed the risks. The most important HIE campaign messages concerned more informed care decisions and elimination of duplicate tests and treatments. More than 90% of Veterans were accepting of both an opt-out (automatic participation) and opt-in (requires signed consent) HIE. Veterans preferred contact by direct mail and telephone equally (64%), and email (43%). Less than 40% of the sample reported using the Internet.

Implications:
Veterans are positive and knowledgeable about HIE and the benefits it provides. They want their VA and community providers to "be on the same page" and are willing to accept the risk of privacy and/or security breaches to obtain better and more coordinated care.

Impacts:
Findings from this work can increase consents for Veteran HIE (formerly Virtual Lifetime Electronic Record) program participation by informing changes to the messaging of existing Veteran-facing VLER materials which are focused on privacy and security and eliminating the need to carry paper records.


21. TeleDementia Clinic- Caring for Rural Veterans with Cognitive decline via Clinical Video Teleheath

Authors: Rossi MI, Homer M

Affiliation: GRECC: Geriatric Research Education & Clinical Center, VA Pittsburgh Healthcare System

Objectives: Access to specialty care for dementia is usually limited to urban centers. Unfortunately, traveling long distances to these urban centers can be difficult for rural Veterans with dementia and adds additional stress to already burdened caregivers. The Teledementia clinic began in May 2013 at the Pittsburgh VA as a part of the GRECC Connect consortium funded by VA T21 and Office of Rural Health, to address these issues and determine feasibility of this type of care using clinical video telehealth (CVT).

Methods:
An interdisciplinary team of a geriatric medicine physician, geriatric psychiatrist, social worker and gero-psychologist used CVT as a means to diagnose cognitive disorders and provide on-going follow-up and support to Veterans and their caregivers in rural Community Based Outpatient Clinics (CBOCs).

Results:
In its first year of operation, 95 unique patients were served over the course of 156 clinic visits and 251 interprofessional provider encounters. Of the Veterans served, 61 lived in rural zip codes, 72 were diagnosed with dementia, 19 were diagnosed with mild cognitive impairment, and 4 were found to have primarily psychiatric diagnoses rather than cognitive impairment. Dementia severity was assessed with the FAST score (average FAST score 4.23+/-1.28 which indicates mild dementia). Medication issues contributed to cognitive problems in 75 of the 156 patient visits and 127 medications were changed in these patients. During that year a total of 10,463.2 miles of driving and 193.8 hours of driving were saved. Veteran/caregiver satisfaction with the service was high on satisfaction survey. In the last 3 years, the service has expanded from 5 CBOCs and 1 rural VA medical center to 15 CBOCs and 2 rural VA medical centers. The total number of unique Veterans served over 3 years has almost tripled. More than 2/3 of these patients were from rural areas. They were seen over 1367 encounters with a savings to Veterans of 61,506 miles overall. The TeleDementia team made 2487 recommendations regarding ways to improve cognition, health and safety for these patients over three years.

Implications:
The TeleDementia clinic has shown that CVT technology is a feasible means to provide interprofessional dementia care to rural patients and their caregivers. This service has been well accepted by patients and caregivers.

Impacts:
Rural Veterans with dementia are able to gain access to specialty dementia care and save travel time using telehealth technology.


22. Examination of Rural-Urban Mental Health of the Veteran Population Receiving VA Health Care: A Focus on PTSD and Depression

Authors: Davidson TM, Wojciechowski B, Davis BS, Dismuke CE, Gebregziabher M, Hunt KJ, Bunnell BE, Ruggiero KJ

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: We partnered with the VHA Office of Rural Health (ORH) to examine rural-urban disparities in PTSD and depression among U.S. Veterans receiving care at the VHA from 2007 through 2012.

Methods:
Patient and administrative files from the Veterans Health Administration National Patient Care databases were linked to create a comprehensive national database of veterans who received care at a VA facility 2007 through 2012 from which a weighted sample was selected. PTSD (ICD-9-CM 309.81) was defined by a single and depression (ICD-9-CM 311, 296.2, 293.2, 296.5, 300.4, 309.0 and 309.1) by at least two primary or secondary diagnoses within a 12 month period across inpatient/outpatient visits. Data were analyzed using complex survey-specific procedures that accounted for the stratified weighted sampling design.

Results:
Of Veterans using VAMC, the prevalence of PTSD increased from 8% in 2007 to 11.6% in 2012, while the prevalence of depression increased from 9.4% to 11.4%. Slight differences in diagnosed PTSD and depression prevalence were observed among Urban, Rural, and Highly Rural areas. However, the Insular Islands had about 5%-6% lower prevalence of PTSD (2.8% in 2007; 6.4% in 2012), but had the highest prevalence of depression (11.3% in 2007; 17.5% in 2012) when compared to the continental U.S. Differences based on gender, OEF/OIF status, and service connected disability were observed. After adjusting for age, gender, race-ethnicity, geographic region, OEF/OIF status and service related disability comparing veterans on the insular islands to urban veterans the odds of having a diagnosis of PTSD only was 66% lower [OR = 0.34 (95% CI: 0.32, 0.36)] and the odds of having a diagnosis of both PTSD and depression was 37% lower [OR = 0.63 (95% CI: 0.60, 0.67)], while the odds of having a diagnosis of depression only was over two time higher [OR = 2.18 (95% CI: 2.09, 2.27)].

Implications:
Prevalence of PTSD and depression varies based on urban-rural status with striking differences found in the insular islands.

Impacts:
The intent of the information gathered in this project is to be used by the ORH to help develop policies, best practices and lessons learned to improve care and services for enrolled rural and highly rural Veterans.


23. 30-Day All-Cause Readmissions after Acute Myocardial Infarction in the VA Caribbean HealthCare System; Descriptive Study

Authors: Escabi JE

Affiliation: VACHS: VA Caribbean Healthcare System, San Juan, PR

Objectives: 1. To assess the frequency and potential causes of thirty-day all-cause readmission after primary acute myocardial infarction (AMI) hospitalizations in the VA Caribbean Healthcare System (VACHS). 2. Assess the utility of the Centers for Medicare and Medicaid Services (CMS) readmission prediction score for risk stratification of our veterans admitted with AMI.

Methods:
This is a retrospective descriptive study for a cohort of primary AMI admissions between 10/01/2010 and 09/30/2012 at the VACHS. Patients included had a principal discharge diagnosis of AMI as coded by the ICD-9 coding system (410.0 to 410.9). Patients excluded were those with in-hospital death, transferred to another hospital, discharged against medical advice and those with incomplete follow-up data to assess transition of care and readmissions. Readmissions to nursing homes, psychiatry, rehabilitation, hospice wards or elective admissions for revascularization interventions were not considered as a study readmission.

Results:
A total of 414 patients met inclusion criteria. Of these the majority were Non ST-segment elevation myocardial infarcts (86%) and primary type-1 AMI events (80%). The frequency of AMI readmissions was of 24%, with a median time to readmission of 10-days. The principal cause for readmission was non-related to a cardiovascular condition (54%), compared to recurrent acute coronary syndrome or cardiovascular complications seen in 26% and 21% respectively. Variables associated with increased readmission rate were: acute CHF (OR = 1.6), CKD (OR = 2.0), anemia (OR = 2.5), COPD (OR = 2.2), dementia (OR = 1.6), physical dependence (OR = 1.8), major bleeding (OR = 3.9) and an elevated CMS readmission score of > 19 (OR = 2.6). Variable associated with a decreased readmission rate were: invasive management strategy (OR = 0.6), inpatient revascularization (OR = 0.4) and referring a patient to hospice care (OR = 0.2).

Implications:
Non-elective 30-day readmissions after AMI in our veterans seem multifactorial. The principal cause for readmission was mostly not related to a cardiovascular condition. The CMS readmission prediction score is a simple and effective tool to stratify patients at higher risk for readmission to better target more advanced in-hospital and post-discharge care coordination.

Impacts:
The average 30-day readmission rate for acute myocardial infarction (AMI) upon Medicare beneficiaries between 2007 and 2009 was 20%. Readmissions are expensive and may be a marker for a lower quality of care and increase mortality. Despite national and Veteran Health Administration attention on reducing AMI readmission rates, contemporary data related to major contributing causes or implemented strategies aimed at reducing readmissions are lacking.


24. Care Coordination and Non-VA Gynecologic Care for VA Patients: The Role of Primary Care

Authors: Cordasco KM, Zuchowski JL, Chrystal JG, Zephyrin LC, Hamilton AB

Affiliation: COIN: Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP); Los Angeles, CA

Objectives: The Veterans Access, Choice and Accountably Act ('Choice Act') is likely to result in VA patients more frequently using non-VA care. We investigated roles of primary care providers (PCPs) and their teams related to care coordination with non-VA providers for gynecologic oncology care.

Methods:
Between February-April, 2015, we conducted 21 semi-structured interviews with VA Women's Health Medical Directors (many of whom were PCPs), gynecologists, and nurse care coordinators, at 15 VA facilities of varying size, availability of VA gynecology services, and geographic characteristics (e.g., rurality). Participants described resources and processes used at their facilities for coordinating gynecologic cancer care. Interviews were recorded, professionally transcribed, and summarized. We generated results using a team-based hybrid deductive/inductive thematic analytic process.

Results:
PCPs' roles in coordinating care of patients with gynecologic malignancies vary substantially across VA facilities. If a VA gynecologist is available, the PCP usually refers the patient to this gynecologist, who assumes responsibility for care coordination. In facilities without an available VA gynecologist, which is more common in rural areas, PCPs refer the patient directly to non-VA specialists and assume most of the care coordination responsibilities. Interviewees reported that coordinating care with non-VA providers is more difficult, compared to coordinating with VA providers, due to lacking a shared electronic medical record with non-VA providers. Care coordination tasks include submitting authorization requests; communicating directly with non-VA care providers; facilitating exchange of medical records with non-VA providers; placing orders for diagnostic tests requested by non-VA providers; prescribing medications recommended by non-VA providers; tracking patient progress through all phases of cancer care; communicating with patients about appointments and questions; communicating with VA specialty providers who may be delivering portions of the cancer care or caring for comorbidities; and facilitating transitioning to hospice care, if needed.

Implications:
Multiple tasks are associated with coordinating care with non-VA providers for gynecologic oncology care.

Impacts:
As Veterans more frequently use non-VA specialty care providers in tandem with VA-based care, care coordination tasks may result in a significant workload increase for VA PCPs, not only for gynecologic malignancies, but potentially for other complex conditions as well. PCP teams in facilities with less specialty care services, such as those in rural areas, may be particularly affected.


25. Physical, Mental and Obstetric Needs of Rural and Urban Pregnant Veterans

Authors: Cordasco KM, Katzburg JR, Katon JK, Zephyrin LC, Yano EM

Affiliation: COIN: Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP); Los Angeles, CA

Objectives: Providing high-quality, coordinated maternity care for Veterans is integral to VA ensuring comprehensive care for women Veterans. We explored physical and mental health needs, and obstetric complications, of pregnant Veterans using VA maternity benefits. Given that recent work revealed that rural Veterans are, in general, less healthy than urban Veterans, we compared needs of rural and urban pregnant Veterans.

Methods:
We conducted a medical record review of pregnant Veterans receiving phone calls from 13 VA Maternity Care Coordinators (MCCs). We distinguished rural and urban women based on their zip codes of residence and, within these strata, assessed prevalence of pre-pregnancy and newly-occurring physical and mental health problems, as well as obstetric complications.

Results:
Among 244 medical records reviewed (one-third rural; two-thirds urban), 41% of pregnant Veterans had one or more pre-pregnancy physical problems; 34% one or more pre-pregnancy mental health problems; and eighteen percent actively or recently smoked. During pregnancy, 36% Veterans developed a new non-obstetric physical issue; 11% a new mental health issue; and 38% an obstetric complication. Rural and urban women were similar on these measures, with the exception of trends toward rural women Veterans being less likely to have a pre-pregnancy endocrine problem, PTSD/anxiety diagnosis, or prior obstetric complications. Rural women were less-commonly reported as having been diagnosed with gestational diabetes, compared to their urban counterparts, but more likely to be active smokers during pregnancy.

Implications:
Pregnant women Veterans using VA maternity care have a substantial burden of physical health, mental health, and obstetric complications. Our work did not show evidence of that among pregnant Veterans, rural women are less healthy than urban women. However, rural pregnant women Veterans may have greater need for smoking cessation support.

Impacts:
Our findings suggest that Veterans using VA maternity benefits may have a significant need for co-management of their physical and mental health concerns. Our findings underscore the important need that VA's MCCs are currently addressing as well as the importance of efforts to bolster this initiative, especially supporting MCC's coordination between obstetricians and VA providers managing Veterans' physical and mental health issues. More information is needed about the health needs of rural women Veterans, in general, and pregnant women Veterans in particular, and how these needs may be similar or different from their urban counterparts. Innovative care models are needed to deliver smoking cessation support to rural Veterans.


26. Health and Health Care Access of Rural Women Veterans: Findings from the National Survey of Women Veterans

Authors: Cordasco KM, Mengeling MA, Yano EM, Washington DL

Affiliation: COIN: Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP); Los Angeles, CA

Objectives: Disparities in health and healthcare access between rural and urban Americans are well-documented. There is evidence that these disparities are mirrored within the U.S. Veteran population. However, few studies assess this issue among women Veterans (WVs).

Methods:
Using the 2008-2009 National Survey of Women Veterans, a population-based cross-sectional national telephone survey, we examined rural Women Veterans' health and healthcare access compared to urban WVs. We measured health using the Medical Outcomes Study Short-Form (SF-12); access using measures of regular source of care (RSOC), healthcare utilization, and unmet needs; and barriers to getting needed care.

Results:
Rural WVs have significantly worse physical health functioning (SF12-PCS) compared to urban WVs (mean SF12-PCS 43.6 versus 47.2; p = 0.007). We did not observe significant differences by rurality in mental health functioning (mean SF12-MCS 47.9 rural versus 49.1 urban; p = 0.321). Rural and urban WVs had similar overall number of healthcare visits (mean 5.8 versus 7.1; p = 0.11). However, rural WVs had fewer healthcare visits to non-VA providers compared with urban WVs (mean 4.2 versus 5.9; p = 0.021). Rural WVs were more likely to name VA as their RSOC (16.4% versus 10.6%; p = 0.009) and use VA healthcare (21.7% versus 12.9%; p < 0.001). Over half of rural WVs who used VA care in the prior 12 months used both VA and non-VA sources of care. Rural WVs reported transportation as a major factor affecting healthcare decisions. Affordability was named as a barriers associated with having unmet healthcare needs for rural WVs.

Implications:
Similar to rural-urban disparities observed in other populations, rural WVs had significantly poorer physical health than urban WVs. However, we did not detect a rural-urban difference in overall utilization, whereas such differences have been observed in other populations.

Impacts:
Our findings demonstrate VA's crucial role in addressing disparities in health and healthcare access for rural WVs in that the similarity in care utilization between rural and urban WVs may be explained by rural WVs having access to VA healthcare services. However, our findings that rural WVs have poorer physical health than urban WVs, and have unique access challenges, suggest that further research in, and implementation of, innovative care models, such as mobile and virtual care, are needed to meet these needs and overcome these barriers. Furthermore, given high concurrent use of both VA and non-VA care among rural WVs, it is imperative that VA prioritize developing and evaluating mechanisms for seamless care coordination and communication with non-VA providers in rural communities.


27. Feasibility of Using a Tele-Presence Robot to Conduct Home Safety Evaluations

Authors: Romero S, Lee MJ, Poulin ER

Affiliation: COIN: Center of Innovation on Disability and Rehabilitation Research (CINDRR); North Florida/South Georgia and Tampa

Objectives: The purpose of this study was to test the feasibility of using a telepresence robot to assist therapists in conducting a remote home-safety evaluation.

Methods:
In this study, five occupational therapists and five remote assistants participated. Therapists received training on the use of the robot and practiced driving it. Next, they conducted a telepresence home safety evaluation with the help of the remote assistants. The Westmead Home Safety Assessment (WeHSA)was used to evaluate the home environment. Data was collected on the use of the robot from a technical perspective and the feasibility of using this technology to conduct remote home-safety evaluations.

Results:
On average, therapists needed 40 minutes to complete our training (instructional and driving course). The home safety evaluation using the robot took an average of 48 minutes. A total of 26 issues were identified and categorized into: connection (6), equipment limitations (11), usability (6), and video quality (3).Connection issues included: audio, video, computer-to-robot connection, and iPad-to-robot connection. Equipment limitations included: viewing a narrow angle, balancing on uneven surfaces, experiencing a blind spot, assessing dual camera view, judging distance, maneuvering, locating power button, simultaneously viewing both party's camera perceptions on iPad, orienting the robot in space, and driving over thresholds. Usability issues included: difficult URL, echoes and beeping, iPad unfamiliarity, joysticks, unclear directions in training, and Westmead unfamiliarity. Lastly, video quality issues included: pixilation and unable to determine textures.

Implications:
Operating the telepresence robot is not intuitive at this point and requires training above what was provided in our study. While a number of limitations of the technology were identified, overall, therapists indicated this was a feasible approach for conducting home safety evaluations.

Impacts:
This study provides preliminary results of the use of telepresence technology in conducting remote home safety evaluations. Our study shows that this approach can be a promising method in the future as technology advances. While this technology is not entirely independent yet, with adequate assistance and a stable internet connection it is a feasible method for reaching patients remotely.


28. "Getting the ball rolling" -- Rural Veterans' experiences initiating mental health care

Authors: Miller CJ, Bovin MJ, Burgess JF

Affiliation: COIN: Center for Healthcare Organization and Implementation Research (CHOIR) Bedford, MA and Boston, MA

Additional Affiliation(s):  National Center for PTSD at the VA Boston Healthcare System

Objectives: Many Veterans face substantial barriers when attempting to access VA mental health services. These barriers may be especially daunting for Veterans who have never been enrolled in VA care before, as they are unlikely to be familiar with the VA system. Such Veterans may lack knowledge of what services are available, whether they are eligible for those services, and how to actually access them. Furthermore, many mental health symptoms (e.g. concentration problems) further complicate Veterans' efforts to navigate entry into VA care. A better understanding of the ways that Veterans first get connected to VA mental health care is therefore crucial to streamlining access and improving Veterans' receipt of timely and appropriate services. In this study, we sought to explore the barriers faced by Veterans when they first considered accessing VA-based mental health services. Methods: This study was conducted as part of an HSRandD-funded project (CREATE 12-300) in which we conducted semi-structured qualitative interviews with 72 Veterans from rural and suburban areas within three VISNs (in the Northeast, South, and West). Interviews were digitally recorded, professionally transcribed verbatim, and analyzed using qualitative content analysis (focused on barriers and facilitators for initial use of mental health services).

Results:
Interview results revealed several Veteran- and system-level barriers to initiating mental health services after separation from the military. Veteran-level barriers included stigma surrounding mental health and help-seeking; system-level barriers included widespread difficulties obtaining information about available services. At the same time, Veterans noted a variety of facilitators that allowed them to overcome these barriers and seek care. Results also suggested that entry into the VA mental health system was often achieved in roundabout fashion (e.g. through the service-connected disability system, the legal system, or non-VA Veterans groups).

Implications:
Findings from this study build on previous reports of the difficulties Veterans may face when attempting to first access VA-based mental health services. Of note, our findings suggest that the service-connected disability system served as the de facto entry point into mental health services for many Veterans.

Impacts:
Results from this study suggest that improving access to mental health services for rural Veterans may require a broader view of the information provided to military service members about available care, as well as non-traditional pathways that Veterans may take to accessing services for the first time.


29. Travel time to nearest VA Medical Center, Continuity of Care, and Electronic Health Information Exchange

Authors: Turvey C, Klein D

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Objectives:  This nationwide survey of My HealtheVet Users explored the relation between travel time to the nearest facility, continuity of care, and awareness of and participation in VA's electronic health information exchange programs.

Methods:
  27,808 Veterans were surveyed nationwide while using My HealtheVet, VA's Patient Portal. Of these 27,808, 12,504 (45%) indicated receiving care from a non-VA provider. Dual use respondents were asked three questions adapted from the Commonwealth Fund's Care Coordination measure. They were also asked about their awareness of VA's electronic health information access and exchange programs, the My HealtheVet Blue Button and Veterans Health Information Exchange (VHIE).

Results:
Veterans with greater travel time to the closest VA reported significantly worse continuity of care as evidenced by higher endorsement of unavailability of medical test results from outside organizations (p = 0.001); duplicate laboratory testing (p = 0.001); and receipt of conflicting information from VA and community providers (p = 0.001). For each item, there was a clear graded decrease in continuity corresponding to increased travel time to the nearest VA Care Continuity Metric: Percent endorsing by travel time to VA. Unavailable Test Results: Less than 30 minutes- 17%, 30 to 60 minutes- 20%, 61 - 90 minutes- 25%, 91 minutes to two hours- 28%, Over two hours- 30%; Laboratory Duplication: Less than 30 minutes- 7%, 30 to 60 minutes- 8%, 61 - 90 minutes- 10%, 91 minutes to two hours- 11%, Over two hours- 12%; VA and Community Provider Information Conflicts: Less than 30 minutes- 13%, 30 to 60 minutes- 15%, 61 - 90 minutes- 18%, 91 minutes to two hours- 23%, Over two hours- 25%; There was little to no association between travel time and awareness of My HealtheVet Blue Button (range 53-56%) or VLER (range 20-21%) and small differences in actual use of VA health information programs (My HealtheVet Blue Button range 65-73%; VHIE Range 26-31%) with slightly lower use in Veterans with greater travel time to VA.

Implications:
My HealtheVet users with greater travel distance to the nearest VA report lower continuity of care. However, awareness of VA's Blue Button and VLER health information programs was similar across travel distance groups.

Impacts:
In this nationwide sample of My HealtheVet users, greater travel time to nearest VA is associated with greater gaps in care continuity. There is still great opportunity for VA to promote Veteran adoption of electronic health information exchange to reduce these gaps.


30. "Hopeful Yet Unsure": Participant Perspectives on the Impact of the Renal SCAN-ECHO Program

Authors: Young JP, Simons C., Germani M., Helfrich CD, Young BA

Affiliation: COIN: Center of Innovation for Veteran-Centered and Value-Driven Care; Seattle, WA and Denver, CO

Objectives: Renal Specialty Care Access Network-Extension for Community Health Outcomes (SCAN-ECHO) is a Veterans Affairs (VA) program to improve rural Veterans' access to nephrology specialty care through specialty care-primary care telemedicine consultation and education. We conducted qualitative interviews with participants of the four active Renal SCAN-ECHO programs to evaluate current scope, structure, impact, and challenges in order to inform a possible program expansion. Methods: As part of an ongoing program evaluation, 24 Renal SCAN-ECHO participants (7 Nephrologists, 12 Primary Care Providers, and 5 Program Administrators) completed semi-structured phone-based interviews. Interim data analysis was conducted using inductive content analysis; themes related to perceived program impact are reported.

Results:
Participants generally described Renal SCAN-ECHO as valuable, their participation as positive, and rural veterans' access to nephrology specialty care as important. Participants also described a range of primary care provider (PCP) level program impacts including increased knowledge, confidence in managing renal/kidney disease, and sophistication of PCP/specialist collaboration. However, some participants described uncertainty regarding wider systemic impact on providers and patient access to specialty care due to a lack of metrics and outcomes data. Specialists and program administrators expressed a need for evaluation to guide program improvement, growth and sustainability and described a range of efforts to measure impact. Barriers to evaluation included lack of resources such as knowledge, necessary support, and clear appropriate, realistic measures of impact.

Implications:
Renal SCAN-ECHO participants reported a range of program impacts at the individual provider level, but were uncertain about wider provider, patient and system impacts and described a need for rigorous evaluation to guide program development and demonstrate value. However some participants described a lack of resources necessary to conduct impact evaluations including knowledge, staffing and clear measures of impact.

Impacts:
Evaluation of impact is important to program development and sustainability, however some Renal SCAN-ECHO programs lack necessary resources to conduct evaluation.


31. Increasing access to cost effective home-based rehabilitation for rural veteran stroke survivors

Authors: Housley SN, Garlow AR, Ducote K, Howard A, Thomas T, Wu D, Richards K, Butler AJ

Affiliation: ORH: Eastern Resource Center, Atlanta, GA

Objectives: As the leading cause of long-term disability, an estimated 15,000 Veterans experience a stroke annually, accounting for an estimated $1 billion in total VA costs. With more than half of the survivors experiencing moderate to severe physical impairment and loss of quality of life, most require rehabilitation. For survivors in rural areas, limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robot-assisted therapy is a promising option for survivors with finite access to conventional therapy. Studies indicate that home-based, robotic devices deliver reproducible therapy and measurement of patient performance while providing equivalent outcomes without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor) to improve functional ability and quality of life, while improving access and cost savings.

Methods:
Twenty, mostly rural and highly rural Veteran stroke survivors with upper or lower extremity motor impairments performed three months of home-based rehabilitation using an upper or lower extremity robotic device, while a physical therapist remotely monitored progress. Baseline and end of treatment function and quality of life were assessed using validated outcome measures to determine change. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy.

Results:
Compared to baseline, statistically significant improvement in upper extremity function (26.16%, p = 0.046), clinically significant benefits in gait speed (25.4%), moderate improvement in depressive symptoms (33.2%) and modest improvement in distance walked (25.4%) were observed. Overall, participants indicated satisfaction with the device and their overall improvement. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the Veterans no longer receiving formal services and increased daily access for the remaining 65%. Cost analysis revealed a $2,352 (64.97%) savings per person compared to clinic-based therapy.

Implications:
Veteran stroke survivors made clinically and statistically significant improvements in the use of their impaired extremities using a robotic device in the home. Participants indicated satisfaction with the device and with their outcomes at the end of the 3-month treatment period.

Impacts:
Home-based, robotic-assisted therapy reduced costs, while expanding access to a rehabilitation modality for Veterans who would not otherwise have received care.


32. Improving transitions of care for rural Veterans : The Rural Transitions Program

Authors: Kelley LR, Ho M, Burke, RE

Affiliation: COIN: Center of Innovation for Veteran-Centered and Value-Driven Care; Seattle, WA and Denver, CO

Objectives: Rural Veterans are often transferred to tertiary VA hospitals for specialized care, but experience unique barriers when transitioning from hospital to home. These include; inadequate discharge instructions, conflicting medication lists, a lack of primary care provider (PCP) notification and follow-up and adequate post-discharge monitoring. The Rural Transitions Program (RTP), a personalized, nurse-directed intervention informed by interviews with rural Veterans and their PCPs, was created to address these unique barriers.

Methods:
Eligible Veterans are transferred to a tertiary VA for acute medical illness, and discharged back to their rural place of residence. The Transitions Nurse (TN) enrolls these patients, assesses their discharge readiness, and addresses gaps through teach-back methodology. The TN obtains a follow-up appointment at the rural primary care site within 14 days of discharge and notifies the rural care team of the hospitalization, delivering comprehensive discharge information through a novel use of the electronic medical record. The TN then calls the patient within 3 days of discharge to assess symptoms, reinforce medication reconciliation, verify follow-up plans, and educate the patient on self-management. We evaluated the program using both quantitative and qualitative methods.

Results:
Our analysis compared 235 enrolled Veterans to a group of 237 non-rural Veterans hospitalized during the same 16 month period, matched on age, sex, inpatient status and Charlson comorbidity index. Enrolled Veterans had significantly higher rates of completed follow-up within 14 days of discharge (67.6% vs. 44.2%, P < 0.001) and significantly lower rates of ED visits and hospital readmissions within 30 days of discharge (19.2% vs. 29.8%, P < 0.01). Qualitative interviews with Veterans and providers suggested significant perceived value of the program.

Implications:
The TNP improves transitional care and reduces post-discharge adverse events for rural Veterans hospitalized at tertiary VA hospitals, aligning with The VA's Blueprint for Excellence Strategies, ORH FY 2015-19 Mission and Goals, as well as UnderSecretary Priorities.

Impacts:
We seek to leverage our experience and are pursuing opportunities for dissemination and implementation at other sites. We plan to initially target the 28 VA tertiary hospitals that discharge more than 1000 Veterans annually; these 28 sites are responsible for more than 60% of all rural Veteran admissions in the VA nationally.


33. Racial-Geographic Disparities in Veteran Traumatic Brain Injury (TBI) Mortality Rates

Authors: Dismuke CE, Wojciechowski B, Gebregziabher M, Egede LE

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: Prior studies have shown short term evidence of higher mortality among Hispanic Veterans diagnosed with Traumatic Brain Injury (TBI) .The objective of this study is to examine the long term association of Veteran mortality with Veteran residence and race/ethnicity among Veterans diagnosed with TBI.

Methods:
A national rolling cohort of 145,535 Veterans diagnosed with TBI between January 1, 2000 and December 31, 2010 were followed until January 21, 2015 or until death from VA Informatics and Computing Infrastructure (VINCI) databases. Survival was calculated as the difference between the date of entry into the cohort and the date of death or the date of the last reported death in the cohort. Rural Urban Commuting Area (RUCA) codes based on resident zipcodes were used to classify Veterans as residing in urban, rural, highly rural and insular island areas. Race was classified as Non-Hispanic White, Non-Hispanic Black, Hispanic and Other Race. Fully adjusted Cox proportional hazard models were estimated for the different RUCAs to examine the association of mortality with race/ethnicity, while adjusting for TBI severity, demographics and comorbidities

Results:
There were statistically different mortality rates among Veterans with TBI by residence with 21.96% of urban, 21.63% of rural, 21.10% of highly rural and 38.52% of insular island Veterans with a confirmed date of death. Mean survival months were 86.62 for urban, 85.80 for rural, 87.77 for highly rural, and 75.31 for insular island Veterans. Fully adjusted models showed that Hispanic race/ethnicity was only associated with higher mortality (HR 1.30 95% CI 1.09-1.55) in the insular island Veterans.

Implications:
Prior evidence of higher short-term mortality among Hispanic Veterans with TBI appears to be concentrated in insular island Veterans. These results are however consistent with a recent study of Medicare Advantage Enrollees which found that Hispanic enrollees in Puerto Rico had substantially worse care compared to their US continent counterparts.

Impacts:
By isolating the racial/ethnic disparities in Veteran TBI mortality by geographic area, targeted interventions and resources can be identified and deployed in order to close the equity gap between Veterans with TBI on the US continent and the insular islands.


34. Diabetes Prevalence in Rural and Urban Patients seeking care from the Veterans Health Administration (VHA) 2007 through 2012

Authors: Hunt KJ, Davis M, Wojciechowski B, Lynch CP, Dismuke CE, Gebregziabher M, Egede L, Axon, RN

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: Prior studies of veterans have not focused on rural-urban residence or obesity levels in relationship to prevalent diabetes. Therefore, in our ORH funded project our objective was to examine rural-urban disparities in prevalence of diagnosed diabetes in the VA and to determine the extent to which demographic factors and obesity levels contribute to disparities.

Methods:
A stratified weighted random sample of veterans who received care at a VA facility was selected for 2007-2012. Rural Urban Commuting Area (RUCA) codes based on resident zip code classified Veterans as urban, rural, highly rural or insular island. Diabetes was defined by two or more primary or secondary ICD-9 codes for diabetes (250.xx) within a 12 month period. Data were analyzed using complex survey-specific procedures.

Results:
Diabetes prevalence 2007-2012 was lowest in urban (20.5%-21.0%), followed by highly rural (21.1%-22.1%) and rural (22.3%-23.0%) areas with the prevalence being significantly higher on the insular islands (31.0%-32.4%). In 2012, 41% of urban, 43% of rural and highly rural and 30% of insular island veterans were obese. After adjusting for age, gender, race-ethnicity, geographic region, OEF/OIF status and service related disability, relative to urban areas, veterans living in rural areas had 10.1% increased odds [OR = 1.10 (95% CI: 1.08, 1.12)] and veterans living on the insular islands had a 19% increased odds of having diabetes [OR = 1.19 (95% CI: 1.16, 1.23)], while veterans living in highly rural areas were at similar odds [OR = 1.00 (95% CI: 0.98, 1.02)] of having diabetes. Further adjusting for obesity categories attenuated differences in rural [OR = 1.04 (95% CI: 1.03, 1.06)] areas, but accentuated differences reducing relative odds in highly rural areas [OR = 0.92 (95% CI: 0.90, 0.95)] while increasing relative odds on the insular islands [OR = 1.34 (95% CI: 1.30, 1.38)]. Moreover, the magnitude of association for factors predicting prevalent diabetes differed depending upon rural-urban residence.

Implications:
Prevalence of diagnosed diabetes is high in Veterans residing in rural, highly rural and urban areas, but markedly higher on the insular islands.

Impacts:
Understanding the burden of disease and factors driving disparities with respect to rural-urban residence facilitates effective allocation of resources as well as development of targeted interventions.


35. Using Video Telerehabilitation to Deliver Vocational Services to Rural Veterans with Disabilities

Authors: Ottomanelli L, Cotner BA, Njoh E, O'Connor DR, Jones VA, Levy C

Affiliation: COIN: Center of Innovation on Disability and Rehabilitation Research (CINDRR); North Florida/South Georgia and Tampa

Objectives: Video-teleconferencing represents a potential vehicle for delivering cost effective and accessible vocational services to persons with disabilities in rural communities but is underutilized. Only small minorities (1-10%) of vocational rehabilitation counselors and clients have access to videoconferencing, and even less use it. Providing access and training for videoconferencing for vocational rehabilitation (VR) service delivery should allow easier access to timelier, less expensive VR services. To explore this potential, the Rural Veterans Supported Employment Telerehabilitation Initiative (RVSETI) was funded by Veterans' Affairs (VA) Office of Rural Health to deliver VR through internet enabled televideo to rural Veterans with disabilities. The goal was to use telehealth to deliver vocational assistance and supported employment by 1) facilitating the use of existing technology and 2) providing mobile internet equipped tablets for videoconferencing. The purpose of this program evaluation was to examine the feasibility and use of telehealth to provide supported employment and vocational assistance services to rural Veterans with mental and/or physical disabilities and describe Veteran and providers' experiences these services. Methods: Program evaluation data were collected during the first year of the RVSETI project. Data included information from the Veterans electronic medical record, patient satisfaction surveys, and qualitative interviews. Quantitative data were obtained and analyzed from 22 Veterans and qualitative interviews and observations were conducted with nine Veterans and eight vocational staff members.

Results:
There were 113 telerehabilitation sessions conducted (i.e. encounters), with each Veteran participating in 5 sessions on average. The majority of Veterans used VA issued technology (iPads) (86.4%), as only some (9.1%) were able to use their previously existing technology. The program saved over 10,000 miles of travel time and costs that would have been incurred by services delivered at the VA Medical Center. Results of patient satisfaction surveys indicate Veteran participants were highly satisfied with services delivered via telehealth. Qualitative analysis suggested that strong leadership support facilitated implementation. Participants and providers reported that telerehabilitation increased the number of encounters and reduced travel and wait time for services.

Implications:
This project found that telerehabilitation can extend vocational services for Veterans with disabilities living in rural areas and/or who have transportation barriers to care. Both Veterans and their providers were satisfied with the use and quality of telerehabilitation for vocational services.

Impacts:
This program evaluation demonstrated that telerehabilitation is a feasible and satisfactory method of service delivery for vocational services for rural Veterans with disabilities.


36. Tailored Telephone-based Treatment for Smoking Cessation in Rural Veterans

Authors: Vander Weg MW, Cozad AJ, Howren MB, Cretzmeyer M, Scherubel M, Turvey Ca

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s): ORH: Rural Health Resource Center, Central Region

Objectives: Although evidence-based counseling and pharmacotherapy are available to assist with quitting smoking, access to treatment is often limited for those who reside in rural locations. In addition, smokers often experience tobacco-related issues including risky alcohol use, depressive symptoms, and concerns about post-cessation weight gain that can interfere with smoking cessation. Telephone-based treatment strategies that concomitantly address tobacco use and these associated issues may help to facilitate access and improve outcomes for rural Veterans.

Methods:
The study was a randomized controlled pilot trial. Sixty three rural Veteran cigarette smokers (mean age = 57 years; 87% male; mean number of cigarettes/day = 25) from a single Midwestern VA Medical Center were randomly assigned to an individually-tailored telephone-based intervention that combined treatment for tobacco use with supplemental counseling to address issues related to depressive symptoms, risky alcohol use, and weight concerns (Tailored) or to standard treatment provided through their state tobacco quitline (Quitline Referral). Choice of guideline-recommended pharmacotherapy in both treatment groups was made based on medical history and a structured interview. The primary outcome was self-reported 7-day point prevalence abstinence at 12 weeks and six months.

Results:
Using an intention-to-treat analysis, quit rates did not differ significantly by group at 12-weeks (Tailored = 39%; Quitline Referral = 25%; odds ratio [OR]; 95% confidence interval [CI] = 1.90; 0.56, 5.57) or six months (Tailored = 29%; Quitline Referral = 28%; OR; 95% CI = 1.05; 0.35, 3.12). Satisfaction with treatment was high for both treatment conditions.

Implications:
Telephone-based treatment that concomitantly addresses other health-related factors that may adversely affect quitting appears to be a promising strategy over the short term. Whether this results in improved outcomes relative to standard tobacco quitline counseling requires further study in a larger sample of smokers.

Impacts:
Access to treatment for tobacco use and dependence for the large number of rural Veteran smokers can likely be enhanced through telephone-based treatment strategies. These preliminary findings further suggest that cessation outcomes are comparable to those typically observed with face-to-face intervention approaches, with high levels of treatment satisfaction. Large-scale efforts to facilitate the use of telephone-based treatment for tobacco use and dependence have the potential to positively impact the health of rural Veterans.


37. Coordinated Care Approach to Improve Diabetes Care for Veterans

Authors: Hermayer K., Fernandes J., Walker RJ, Egede LE

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Additional Affiliation(s): Department of Medicine, Medical University of South Carolina, Charleston, SC

Objectives: Nearly 1 in 4 Veterans are diagnosed with diabetes, and over 20% of them live in rural areas. Therefore the demand for an effective and efficient process for providing high quality, personalized care is imperative. This project was designed to improve diabetes care in veterans through a coordinated care approach.

Methods:
Veterans with poorly controlled diabetes (HbA1c > 9%) at the Ralph H. Johnson VAMC and surrounding CBOCs were identified through a coordinated approach by Endocrinology, Primary care, Pharmacy and the Charleston Center of Innovation (COIN). Diabetes educators initiated an educational information mailing and increased the number of classes offered by telemedicine to CBOCs. A nurse navigator contacted Veterans to discuss support available at the VA. This included medication support through PACT team pharmacy services, scheduled primary care visits, A1c orders, and referrals to the diabetes APRN. In addition, a process for using point-of-care A1c testing was implemented.

Results:
Over 1,000 Veterans with diabetes were contacted and connected with VA services. 14% were rural Veterans, mean age was 60, and 45% were African American. The percentage of Veterans with poorly controlled, diabetes decreased from 81% to 64%. Performance measures for diabetes care also improved from 26% poorly controlled to 15% poorly controlled, bringing our facility scores below both VISN7 and National performance measure standards for uncontrolled diabetes.

Implications:
A proactive and coordinated care approach to improving access to VA services for Veterans with diabetes was effective at improving A1c for those with poorly controlled diabetes. Expansion of the project to include telehealth delivered intervention will further improve the VA's ability to improve access for rural Veterans.

Impacts:
The structural, economic, and cultural differences between rural and urban health care delivery require a more coordinated and proactive approach to providing care. In addition, providing more support and a process of navigating the options for care is important for minority and rural populations. The use of care coordination and medication support was an efficient and effective method for improving access and outcomes for Veterans with diabetes.


38. Creation of a Dashboard Reporting System that Identifies the Near Real-Time Risk of a Psychiatric Hospitalization

Authors: Burningham Z., Sauer BC, Rupper R., Parry K., Leng J., Hicken B.

Affiliation: COIN: Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0); Salt Lake City, UT

Additional Affiliation(s): Salt Lake City Veterans Affairs Medical Center; University of Utah Division of Epidemiology, Salt Lake City, UT

Objectives: The medical and cognitive problems common with aging often complicate the management of psychiatric problems in older veterans. Patient Aligned Care Team (PACT) care managers are often interested in intervening or altering a patient's care plan in order to prevent psychiatric crisis. PACT care managers can utilize prepared reports or perform electronic chart review in order to assist in their decision making process for care plan alterations. However, prepared reports can take weeks to produce and electronic chart review is highly inefficient. In order to address these resource shortcomings, we validated a prediction model for geriatric psychiatric hospitalization and integrated the prediction model into a dashboard reporting system and informatics infrastructure that provides a near real-time risk of psychiatric hospitalization for older veterans currently assigned to PACT teams in VISN 19.

Methods:
The VA CDW national production server serves as the source of underlying data for the dashboard reporting system. The Locally Secured Views (LSV) permissions model has been utilized to ensure that viewable data are filtered based on the current authorizations of each PACT team care manager. SQL Server Integration Services (SSIS) packages have been developed to handle the repeated data extraction process. SQL Server Reporting Services (SSRS) was used in producing report visuals and in adding important interactive functions to the dashboard system. The dashboard report(s) have been published using the SharePoint platform, managed by the VA's Business Intelligence Service Line (BISL).

Results:
The dashboard reporting system displays the number of patients at risk for psychiatric hospitalization at the VISN level and PACT team level. Drill-down functionality allows the PACT team care manager to view individual patient summaries. The probability of psychiatric admission and accompanying risk scores for each patient are displayed numerically. Dominant predictive factors found to have contributed to each patient's risk scores are also displayed.

Implications:
This reporting system will further enable PACT team care managers the ability to alter patient care plans in order to prevent unnecessary psychiatric admissions. The dashboard system also identifies demographic, clinical, and wellness indicators that are predictive of psychiatric admissions which may lead to the development of new care plan initiatives.

Impacts:
Through combining informatics, statistical modeling, and report building technology we are able to significantly enhance the decision-making abilities of PACT care managers.


39. Lessons learned from developing a clinic model to improve access to mental health care for rural American Indian Veterans

Authors: Goss CW, Richardson WJ, Bair B

Affiliation: ORH: Veteran Rural Health Resource Center, Western Region, Salt Lake City, Utah

Additional Affiliation(s): VA Rocky Mountain Healthcare Network VISN 19

Objectives: Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Native veterans, who more often live in rural areas than veterans of other races, have a disproportionate prevalence of post-traumatic stress disorder and other mental illnesses. The considerable need for mental health care services for rural Native veterans led to the establishment in 2002 of a pilot telemental health clinic in VISN 23 and the subsequent expansion to eight other sites serving tribes in VISN 19. We aim to summarize a model of telemental health clinics for American Indian and other veterans living in rural areas, and to identify key features of clinics as well as barriers and levers to their administration.

Methods:
We enumerated service data (intake and follow-up visits, group sessions and unique veterans) from all telemental health clinics held at nine rural sites between April 2002 and February 2011. We also reviewed controlled studies, case reports, and model descriptions of American Indian Veteran Telemental Health (AITMH) Clinics. A qualitative assessment of review findings was undertaken to identify key components of the AITMH Clinics model and lessons learned from clinical as well as administrative perspectives.

Results:
In 970 clinics between 4/2002 and 2/2011, 185 American Indian veterans received psychiatric services. A total of 3845 sessions (185 intake, 3220 follow-up, and 440 group sessions) were held. A clinic model that uses cultural facilitation to increase access for this population is delineated. The qualitative assessment revealed eight lessons. A key clinical lesson is that limiting the veteran to one or two key treatment relationships (e.g., clinician, local champion) facilitates the trust and long-term engagement necessary for successful treatment. A key administrative lesson is that multi-organization collaborations are essential and possible to implement telehealth care for special populations in remote environments.

Implications:
AITMH clinics successfully served veterans who have complex conditions and challenges accessing care. The lessons learned from establishing and operating clinics include suggestions for logistical success, building trust, and addressing barriers to telehealth.

Impacts:
In their first years of operation in rural communities, AITMH clinics delivered 3845 telemental health treatment sessions to 185 Native veterans who faced substantial barriers to accessing care. Our evaluation of these clinics from their start yields lessons on how clinic staff can partner with similar communities to bridge gaps and bring services to rural veterans.


40. Model of Traumatic Brain Injury Using Imaging, Physiological and Psychosocial Parameters: The VA Caribbean Healthcare System Experience -Pilot Study

Authors: Molina-Vicenty IL, Santiago M, Matos A, Velez-Miro I, Motta-Valencia K, Borras, I, Figueroa J, Jones G, Freytes M

Affiliation: VACHS: VA Caribbean Healthcare System, San Juan, PR

Objectives: The purpose of this study was to measure the size and location of TBI lesions using Tc99m-ECD-SPECT/CT and F-18-FDG-PET/CT in subjects with TBI, while assessing neurophysiologic parameters using Somatosensory-Evoked-Potentials (SSEP). The magnitude of the association between brain perfusion/metabolic impairments and electrical disturbances was correlated with quality of life measures. In addition, the study aimed to describe the psychosocial experiences of Puerto Rican veterans with TBI.

Methods:
This was a prospective, pilot study to characterize the brain injuries of OIF/OEF veterans. The study population included males and females returning soldiers who were diagnosed with TBI. The participants underwent SPECT/CT, PET/CT, neurological exam and SSEP within 2 weeks of TBI diagnosis confirmation by a Polytrauma expert. Quantitative data on functional status, activities of daily living and depression was obtained using Functional Independence Measure (FIM), Barthel Index and Beck Depression Inventory-II (BDI-II). Qualitative data on the daily activities and experiences were obtained using a semi-structured interview methodology.

Results:
Six-patients were enrolled in the pilot. The correlation between FIM and the imaging data showed a 0.87 Spearman-coefficient in both SPECT and PET. The correlation coefficient between SPECT and BDI-II and PET and BDI-II was 0.74 and 0.63, respectively. An increased severity and number of perfusion defects compared to metabolic defects were observed. The most common site of perfusion abnormalities was the frontal lobe and of metabolic abnormalities was the temporal lobe. Perfusion and metabolic findings were detected in the presence of negative CT. SSEP showed an abnormally increased Central Time from cervical to cortical response.

Implications:
The data showed that higher trauma severity is accompanied by greater rates of depression and low level of independence. Damage to the Basal-Ganglia correlated with the presence of severe depression (.89-Spearman). The mismatch between perfusion and metabolic defects suggested up-regulation of cerebral glucose-transporters/receptors to compensate for diminished perfusion. The etiology of TBI may be related to impaired vasomotor response or endothelial dysfunction.

Impacts:
SPECT/CT and PET/CT have an add-value in the diagnosis of patients with TBI. A larger clinical trial is required in order to develop new predictive TBI model-systems and proposing algorithms to target rehabilitation interventions in post-deployment population.


41. Rurality Status Does Not Affect Kidney Transplant (KTP) Rates amongst Veterans

Authors: Kalil RS, Franciscus CL, O'Shea AMJ

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s): Internal Medicine/Nephrology, University of Iowa, Iowa City, IA

Objectives: It has previously been demonstrated that rural patients had a lower rate of wait-listing and transplant rates (Axelrod). In the Veteran Affairs (VA) system however transplant eligible patients can be referred to any one of six VA kidney transplant programs regardless of geographic proximity to the facility. We assess kidney transplant (KTP) rates amongst veterans according to their rurality status.

Methods:
The study cohort included KTP in the United States from 2000 to 2013 derived from the United Network for Organ Sharing (UNOS) database. Rates of KTP amongst veterans were evaluated between residential zip code classifications as determined by the Rural-Urban Commuting Area Codes and compared to non-veterans overall using the chi-square or non-parametric Kruskall Wallis test for categorical or numerical data, respectively.

Results:
During the study period 479,834 non-VA and 3,418 VA patients were registered for KTP. Overall veterans were older (p < 0.001), male (p < 0.001), less likely to live in an urban setting (p < 0.001), and had a higher rate of diabetes (p < 0.001). Amongst veterans, residential rurality was classified as isolated (5.2%), small rural (5.3%), large rural (10.4%), and urban (79.1%). Among VA KTP candidates, we found no statistical difference in overall KTP rates between rural and non-rural residents. However rural veterans, especially those in isolated areas, had a higher rate of living donor transplant (p = 0.006), longer graft survival (p = 0.006), and a shorter time on the wait list inclusive inactive time (p = 0.030). Dialysis duration prior to registration was longer among urban residents (p = 0.016), but time from registration on the transplant wait list to KTP was similar among rural and non-rural Veterans (p = 0.155).

Implications:
Although VA beneficiaries have a higher rate of residential rurality, this does not portend longer waiting times or lower rates of kidney transplantation.

Impacts:
Previous studies have suggested that rurality status would have a negative impact on transplant rates. Our results do not confirm these findings among Veterans receiving transplant care in the Veteran Affairs Hospital System.


42. The effect of ICU telemedicine on inter-hospital transfers in VA health system

Authors: Vaughan Sarrazin M, Fortis S, Beck BF, Reisinger HS

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Additional Affiliation(s):  University of Iowa Carver College of Medicine

Objectives: Telemedicine may reduce inter-hospital transfers, particularly among lower resource and rural hospitals. The effect of ICU telemedicine on transfers has not been studied. Our objective was to examine the effect of a ICU telemedicine program on inter-hospital transfers. Methods: We retrieved data from 8 hospitals that implemented an ICU telemedicine program (Tele-ICU) and 121 hospitals that did not receive any ICU telemedicine support (Control). ICU telemedicine was implemented in 2011-2012. We compared the transfer rates in calendar year 2010 before implementation and in calendar year 2014 after implementation in all subjects, in multiple diagnosis categories, and APACHE III quartiles.

Results:
In the tele-ICU hospitals, the average age and APACHE III before ICU telemedicine was 64.6 years and 41.84 respectively. After tele-ICU, the average age and APACHE III were 65.2 years and 41.52. In controls hospitals, the average age and APACHE III was 66.2 years and 42.8 in 2010 and 66.6 years and 42.3 in 2014, respectively. In the tele-ICU hospitals, the total ICU admissions before and after implementation were 13,952 and 21,176, respectively. In the control group, the total ICU admissions before and after implementation were 64,654 and 108,278, respectively. In the tele-ICU hospitals, the transfer rate before tele-ICU (4.6%; 643 of 13,952) was higher compared to the transfer rate after tele-ICU (3.8%; 799 of 21,176, p = 0.0001). The reduction in transfers occurred in cardiovascular diseases from 6% (255 of 4,220) to 4.9% (291 of 5,909;p = 0.014) and in sepsis from 6.9% (43 of 524) to 4.1% (64 of 1,577;p = 0.005). We observed significant transfer rate reduction only in the 2nd APACHE III quartile from 4.5% (153 of 3,387) to 3.6% (187 of 5,264; p = 0.024) and 3rd APACHE III quartile from 5.1% (176 of 3,447) to 3.9% (203 of 5,148; p = 0.01). Transfers decreased in non-surgical patients from 5.1% ( 601 of 11,764) to 4.2% (740 of 17,640;p = 0.0002). In the control hospitals, the transfer rate in 2010 (2.6%; 1667 of 64,654) did not change compared to the transfer rate in 2014 (2.6%; 2,867 of 108,278, P = 0.38). We did not identify a transfer rate change in any diagnosis category and APACHE III quartile. However, the transfer rate decreased in surgical patients from 1.8% (211 of 11,586) to 1.4% (261 of 18,895; p = 0.0025).

Implications:
ICU telemedicine may reduce inter-hospital transfers.

Impacts:
By reducing inter-hospital transfers, ICU telemedicine programs allow patients and families to remain closer to home, particularly in rural areas, and may reduce cost for lower resource hospitals.


43. Magnitude and disparity of multimorbidity by location of residence and race/ethnicity in the Veterans Health Administration: evidence from 3 cohorts

Authors: Gebregziabher M, Ward RC, Wojciechowski B, Yeager DE, Walker R, Egede LE

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Additional Affiliation(s): Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC

Objectives: While medicine generally focuses on managing patients for a single disease, a common characteristic of patients seen at the Veterans Health Administration (VHA) is a high number of comorbidities (i.e. multimorbidity). As managing each disease separately has been shown to be inefficient and costly for providers, and inconvenient for patients, there is movement towards holistic management of patients with multimorbidity. To provide a more complete understanding of multimorbidity in the VHA, this study examines the magnitude of and disparities within multimorbidity by location of residence and race/ethnicity.

Methods:
Three national cohorts were created using ICD9 codes and lab values from VA administrative databases for Veterans with chronic kidney disease (CKD) (n = 2,190,564), traumatic brain injury (TBI) (n = 167,954) and diabetes (n = 1,263,906). Multimorbidity was measured using Quan versions of Charlson-Deyo, Walvern-Elixhauser and Elixhauser count of comorbidities. Multimorbidity measures were compared by race/ethnicity and location of residence using negative binomial regression to estimate the association between multimorbidity-count and covariates.

Results:
The CKD cohort had a mean age of 74.5, 80.9% non-Hispanic white (NHW), and 64.4% urban residence. TBI had a mean age of 49.7, 76.4% NHW, and 70% urban. Diabetes had a mean age of 66.9, 63.8% NHW, and 70.9% urban. For Veterans with CKD, rates of multimorbidity in non-Hispanic blacks (NHB) were 1.16 times higher in urban areas and 1.10 times higher in rural areas compared to NHW. Diabetes and TBI were similar with rates for NHB 1.05 higher in urban areas and 0.97 lower in rural areas for both diseases.

Implications:
Multimorbidity rates vary for traditionally disadvantaged groups including non-Hispanic blacks and rural Veterans, across three major chronic illnesses. Given the impact of multimorbidity on mortality and health outcomes, patient management system should take these variations into account to minimize its contribution to existing equity gaps.

Impacts:
Challenges faced by Veterans with high multimorbidity necessitate more coordinated and multi-faceted management addressing clinical and social factors. Variations in multimorbidity seen between and within three chronic diseases suggest development of policies and guidelines that provide a culturally tailored approach to chronic disease clusters and leverages health technology to better address the needs of Veterans.


44. Homelessness Predictors among Veterans Requesting Services at the Homeless Program of the VA Caribbean Healthcare System

Authors: Rivera-Rivera N, Villarreal AA

Affiliation: Research & Development Service, VA Caribbean Healthcare System

Objectives: Research in the last 40 years has found that veterans are at a greater risk of becoming homeless when compared with the general population. While VA efforts have reduced veteran homelessness by 36 percent, there has been an increase in Puerto Rico. Recent studies have identified factors that predispose veterans to homelessness as: extreme poverty, social isolation, post-military psychiatric disorders, substance use disorders, low social support, welfare policies, housing affordability and availability, the job market, bad conduct or dishonorable discharges and childhood foster care experiences. However, there is limited information regarding the validity of these predictors with Hispanic veterans.

Methods:
We evaluated 684 homeless veterans' records to assess these predictors and surveyed 27 homeless veterans to assess military and homeless experiences, mental health, drug/alcohol use and VA Services utilization. Chi-Squared, Mann-Whitney test and Fisher's exact test were performed. Outcomes included 30 Day and Lifetime usage of alcohol, drugs and psychological conditions.

Results:
The analyses indicated that low social support, high poverty levels, unemployment, substance use and post-military psychological disorders were the predominant predictors. Alcohol (64%) and cocaine (63.2%) were the substances of preference while depression (62.6%) was the commonest psychological diagnosis. Fisher exact test found that participants had the most difficulty finding housing, food, extra money and employment after military service. Analyses confirmed the incursion of OEF/OIF/OND and women homeless veterans and its profile change impact.

Implications:
Results suggest that the VACHS Homeless Program should focus their efforts in the treatment of post-military psychological disorders and substance use while providing employment assistance. Moreover, social support interventions should be developed to build and maintain social networks that provide supportive relationships for behavior change.

Impacts:
As stated in the HUD 2015 Continuum of Care Homeless Assistance Programs, there are 47,725 homeless veterans. Results of this pioneer study support the VACHS Homeless Program in their fight to end veteran homelessness. Contrary to previous studies we addressed predictors' roles as a combination rather than individually to highlight their complexity. Future research in this are needs to address the preparedness of VA Services to address the necessities of OEF/OIF/OND and women homeless veterans.


45. Research Considerations and Social, Health and Mental Health barriers identified by Homeless Veterans Providers of the VA Caribbean Healthcare System

Authors: Rivera-Rivera N, Molina-Vicenty, I

Affiliation: Research & Development, VA Caribbean Healthcare System; VA Nuclear Medicine, VA Caribbean Healthcare System

Objectives: In 2009 the Department of Veterans Affairs, in response to the high numbers of homeless veterans, supported programs within VA to end this serious problem. However, according to the Homeless Program at the VA Caribbean Healthcare System from 2013-2014, there was a 25% increase in veteran homelessness. Using a Focus Group Interview as part of an official Quality Improvement process the scope of homelessness and issues related to social services use, recovery and potential research areas were analyzed.

Methods:
A Focus Group approach was used to obtain emic data or "insiders perspectives", from homeless veterans' providers at the VA Caribbean Healthcare System. A total of 14 participants from the Homeless, Social Work and Behavioral Health Services shared their thoughts regarding the problems and barriers confronting homeless veterans seeking social services and their program's limitations. The session was examined through content analysis which involved coding, categorization and clustering of data.

Results:
Providers self-reported a high incidence of health and mental health problems, limited resources, negative public perceptions, service coordination difficulties with VA and non-VA entities and unattainable program expectations. They encountered profile differences regarding military experience and personal, situational, and bureaucratic barriers to obtaining services. Moreover, security and space are proving to be a challenge as the homeless veteran population keeps growing in the island.

Implications:
These findings suggest a need for a Program restructuration that includes Integral Services like health and mental health providers, occupational therapists and coordinators of services (VA and non-VA entities). Additionally, social skills, affordable housing, employment opportunities, family education and involvement are becoming crucial in the decisional process between social reintegration and readmission to the streets of homeless veterans.

Impacts:
Results of this Focus Group direct research into three areas: mental health, resource related services and program evaluation. Specifically, substance use, employment and time management skills, housing opportunities and coordination of services. Future research should consider these areas to align efforts with the VACHS Homeless Program and directly benefit this population.


46. Comparison of All Cause Hospital Readmission and Mortality among Dual Users of Hospital Care and All-VA Users Across Multiple Conditions

Authors: Axon RN, Gebregziabher M, Everett CJ, Hunt KJ

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: Dual use is a risk factor for higher healthcare utilization and worse outcomes in selected conditions. This study aimed to determine if dual users of hospital care have higher likelihood of hospital readmission or mortality as compared to all-VA or all non-VA users.

Methods:
Using merged VA, Medicare, and state-level data, we conducted a retrospective cohort study of 27,895 Veterans with at least 2 hospitalizations between 2007-2011. To model the association between dual use and odds of 30-day all-cause hospital readmission, we constructed logistic regression models for patients hospitalized in each of 18 major diagnostic categories (MDCs). We used Cox regression to model the association between dual use and all-cause mortality.

Results:
Dual and all-VA users were similar, though a slightly higher proportion of dual users were over age 65 and they had a significantly higher comorbidity burden (proportion with ? 9 Elixhauser comorbidities 27.2% vs. 14.6% for all-VA users). Compared to all-VA users, dual users had higher odds of 30-day readmission in 15 of 18 MDCs, the exceptions being reproductive, infectious/parasitic, and drug-related disorders. Dual users had higher hazard for mortality in 8 of 18 disorders including nervous system (HR 1.32, 95% CI 1.10, 1.58), circulatory (HR 1.22, 95% CI 1.09, 1.37), musculoskeletal (HR 1.37, 95% CI 1.12, 1.68), kidney/urinary (HR 1.21, 95% CI 1.04, 1.40), infectious/parasitic (HR 1.29, 95% CI 1.01, 1.65), mental (HR, 1.43, 95% CI 1.04-1.96), alcohol-related (HR 1.76, 95% CI 1.15, 2.70), and health factors-related disorders (HR 1.37, 95% CI 1.07, 1.75). Rurality did not appear to significantly impact readmission or mortality risk.

Implications:
Veteran dual users of hospital care appear to have higher risk for hospital readmission and mortality across multiple disorders. While these patients clearly have higher comorbidity burden, there may be additional factors associated with these phenomenon. Thus, while dual use appears to be a marker of higher risk, and it may also be a factor in the causal pathway for worse outcomes for Veterans hospitalized for multiple conditions.

Impacts:
Given their higher risk, programs focused on care coordination and disease management may improve patient outcomes for both rural and urban dual users.


47. The Interaction between Rural/Urban Status and Dual Use Status among Veterans with Heart Failure

Authors: Axon RN, Gebregziabher M, Everett CJ, Hunt KJ

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: Heart failure (HF) is a common reason for hospitalization, and receipt of both VA and non-VA care (i.e. dual use) is associated with higher rates of hospitalization, readmission, and mortality. This study aimed to determine the extent to which rurality modifies the likelihood for acute healthcare use among Veterans with HF when comparing all-VA users to dual users.

Methods:
Using merged VA, Medicare, and state-level data, we conducted a retrospective cohort study of 4985 Veterans with HF between 2007-2011. In order to model differences between rural/highly rural vs. urban Veterans, all-VA vs. dual users, and to test for interactions between rurality and dual use, we constructed a series of negative binomial regression models using zero inflation methods.

Results:
Compared to urban Veterans with HF, rural/highly rural Veterans had significantly lower adjusted rate ratios (RR) for all-cause ED visits (0.93, 95% CI 0.88, 0.98), hospitalization (0.92, 95% CI 0.86, 0.99), and 30-day hospital readmission (0.93, 95% CI 0.86, 0.99), but rates were not significantly different between groups when HF was the primary diagnosis. Compared to all-VA users, dual users had significantly higher RR for all-cause ED visits (1.17, 95% CI 1.11, 1.22), hospitalizations (1.87, 95% CI 1.77, 1.98), and 30-day readmissions (1.78, 95% CI 1.68, 1.88), and dual users also had higher rates for all outcomes when HF was the primary diagnosis. Only all-cause ED visits were subject to interaction [RR for dual use in urban (1.17, 95% CI, 1.11, 1.22) and rural (1.28, 95% CI, 1.221, 1.35); interaction p = 0.011] between rurality and dual use status.

Implications:
Poorer access to care may affect both VA and non-VA facilities for rural Veterans with HF. However, except for the case of all-cause ED visits, when analyzing a cohort with information on both VA and non-VA acute healthcare utilization, we did not observe rural residence to significantly modify likelihood of acute healthcare utilization when comparing all-VA users to dual users.

Impacts:
Dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural Veterans, and interventions to address this higher risk in both groups should be developed.


48. "Where's my choice?:"Experiences of Veterans Accessing Hepatitis C Treatment in the VA and the Choice Program

Authors: Yakovchenko V, Skolnik A, Jones N, Noska A, Tsai J, McInnes K, Gifford AL

Affiliation: COIN: Center for Healthcare Organization and Implementation Research (CHOIR) Bedford, MA and Boston, MA

Objectives: In 2015, a shortage of funding for Hepatitis C (HCV) medications in the VA led to the institution of the Hepatitis C Veterans Choice Program in which some Veterans with HCV were referred to non-VA providers for their HCV treatment. The initial development of Choice was to address long waiting times and travel distances (of special importance for rural Veterans). The objective of this project was to understand the perspectives and experiences of Veterans and providers regarding Hepatitis C care through the VA and the Choice Program.

Methods:
We conducted 48 semi-structured interviews with Veterans, and VA and Choice HCV providers in VA New England (VISN1) between October 2015 and May 2016. Veteran interviews focused on experiences with past and current treatment, processes of obtaining VA and non-VA care, and barriers and facilitators to treatment access and completion. Provider interviews focused on experience with new HCV medications, the VA HCV funding shortage, and Choice program processes. Analysis involved a rapid approach drawing from grounded theory, involving inductive and deductive coding, and triangulation between respondent types.

Results:
Most Veterans interviewed had recently completed or were currently receiving HCV treatment. Veterans expressed a desire to receive the "miracle cure" (new HCV medications) while recognizing access was limited: "It's just frustrating as hell to keep going through that back and forth,...if there's no funding for me this coming year I'll wait another year. I'm not going back to Choice." Veteran accounts of treatment processes, in the VA and with community Choice providers, included coordination challenges, extended waiting, and burdensome efforts to obtain care. Veterans in Choice emphasized additional feelings of "abandonment", lack of control, medical record and billing obstacles and general, though not unanimous, disappointment. Facilitators of treatment initiation included ease of access to HCV specialists, positive history with VA care, and self-advocacy. Once on treatment, facilitators of completion included having a routine for managing medications, positive relationships with providers, and social support. Barriers to HCV treatment completion included lack of noticeable HCV symptoms, side effects, pill burden, and difficult relationships with providers.

Implications:
The results will inform VA's understanding of how Choice affected HCV care processes, satisfaction with care, and access to care. Continuation of Choice-type programs is likely to be especially relevant for rural Veterans.

Impacts:
Lessons learned can lead to modifications to HCV treatment processes to overcome barriers to Veterans' HCV treatment initiation and completion. Rural Veterans using Choice for HCV or other conditions are likely to be most affected.


49. A Qualitative Study of the Diversity of Veteran Engagement in Mental Health Care

Authors: Zamora KA, Koenig CJ, Abraham TA, Pyne JM

Affiliation: San Francisco VA Health Care System, San Francisco, CA

Additional Affiliation(s): UC San Francisco; Central Arkansas Veterans Healthcare System; University of Arkansas Medical Sciences

Objectives: "Patient engagement" has become central to patient-centered care, emphasizing patients' active participation in health-related activities. However, there is controversy as to how patient engagement is defined and measured (Barello et al., 2012). The VA Uniform Mental Health Services Handbook has defined engagement as participation in > = 8 mental health (MH) treatment sessions or receiving > = 2 months of psychiatric medication plus > 4 MH visits within 1 year, yet few Veterans achieve these thresholds due to lack of services, stigma, or other barriers. We sought to explore the concept of MH engagement among Veterans living primarily in rural communities.

Methods:
This research was conducted as part of an HSRandD-funded implementation-pragmatic effectiveness trial of telephone motivational coaching delivered by Veteran peers to improve rural Veterans' engagement in MH care. The first phase consisted of a formative evaluation to tailor the coaching intervention to regional contexts and community cultures. Three qualitative researchers conducted 37 in-depth interviews with rural and suburban Veterans across the two geographical regions (the mid-South and the West). All interviews were digitally recorded, professionally transcribed, and analyzed using thematic analysis (Braun and Clarke, 2006).

Results:
Interviews revealed that Veterans' perceptions of MH engagement do not necessarily align with VA's institutional definition of MH engagement. While some rural-dwelling Veterans engage in VA and community MH care, some Veterans reported engaging in activities ranging from attending community classes and web-based and mobile applications to self-care activities in order to support their mental health. In this poster we will present four rural Veteran case studies to illustrate Veterans' diverse experiences with engagement in VA and community activities to support their mental health.

Implications:
Findings from qualitative interviews illuminate how heterogeneous patient-centered MH engagement strategies do not necessarily align with VA institutional metrics of engagement. These findings can inform development of a more patient-centered definition of Veteran engagement in MH care.

Impacts:
Qualitative research can help reveal the diverse practices rural Veterans use to maintain their mental health. Although many of these activities are not captured by traditional VA metrics of MH engagement, in rural communities, where services are sparse and stigma toward mental health pronounced, validating and motivating Veterans to engage in health-promoting activities may be a pragmatic and cost-effective approach, and for some, a starting point for greater engagement in MH care.


50. Outreach to Improve Care Coordination with Community Providers

Authors: Clark J, Garvin L, Lee P, Lee R, West A, Markle P

Affiliation: COIN: Center for Healthcare Organization and Implementation Research (CHOIR) Bedford, MA and Boston, MA

Objectives: Health care for rural veterans served by the VHA is often shared with community providers, indicating the need to understand and improve care coordination with our diverse partners. We describe community providers' perceptions of care coordination with the VHA and explore prospects for developing new partnerships.

Methods:
We conducted individual and group qualitative interviews with directors, care coordinators, and other staff of 20 organizations (health centers, managed care organizations, home health agencies) serving rural communities in the six New England states. Field notes and interview transcripts were analyzed using inductive content coding to identify significant topics and themes.

Results:
Directors of community organizations are ready supporters of VHA, but say they do not receive timely, integrative VHA policy updates to help them to advise their clinicians and the Veterans they serve. VHA outreach efforts are received very positively as opening doors to collaboration; names and contact information of advisors and gatekeepers in VA facilities were particularly valued. 3 kinds of relationships with the VHA were defined Partner: collaboration and coordination resulting from reciprocal familiarity and trust Friendly Rival: competition for Veterans, with VA care preferably restricted to service-related conditions Stranger: professional distance and no interaction with the VHA Challenges in coordinating care: VHA services are very "fragmented" community care coordinators' lack of knowledge of VA counterparts perceived need for complicated, repetitive prior approval Veterans lack knowledge of their eligibility and the breadth of services available to them Lack of connectivity between community and VHA medical records is persistently vexing Local relationships in the community and the VA enable essential communication

Implications:
Community providers, including "strangers", express strong interest in improving care coordination in meeting the needs of Veterans. They emphasize communication and interaction to build trust and familiarity that will enable coordination. Knowing who to call in the VA for help in understanding policy or managing care for a specific patient is an important step.

Impacts:
These findings are guiding large scale studies of care coordination to develop strategies and tools for fostering effective collaboration between VHA and community providers in widely diverse rural settings.


51. Brief behavioral telehealth treamtent for Veterans with alcohol misuse and co-existing psychiatric disorder

Authors: Santa Ana E.J, Lamb K, LaRowe, SD, Nietert P

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Additional Affiliation(s): Substance Abuse Treatment Center, Mental Health Service, Ralph H. Johnson VAMC; The Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC

Objectives: Alcohol misuse disorders are prevalent among veterans and the availability of effective treatments in primary care is a significant health care need. The aim of this pilot study is to present treatment outcome data based on the self-reports of 25 VA primary care patients with alcohol misuse disorder who completed a telehealth intervention, referred to as 'Brief Intervention for Alcohol Misuse in Primary Care' (BIAM-PC), based on motivational interviewing and cognitive behavioral therapy regarding participant's average and peak amount of alcohol consumption.

Methods:
This project is a prospective within-subject repeated measures design with 1 treatment group, BIAM-PC, delivered to 25 primary care patients identified as having an alcohol misuse disorder based on the AUDIT-C and SCID. Participants were evaluated at baseline and at 2-month follow-up. Four therapy sessions were delivered in the participant's home via 1-hour one-on-one video-conferencing sessions using Cisco Jabber Video for TelePresence (Movi) over a 4-week period.

Results:
Statistical analyses were performed using SAS v9.3. To test whether there were statistically significant changes in study outcomes over time, a series of general linear mixed models were created. Random subject effects were included, and an autoregressive error structure was used to account for repeated outcomes being clustered within-subjects. BIAM-PC was associated with significantly reduced alcohol use and severity. Compared to baseline, participants drank less alcohol (measured in standard ethanol content units) (M = 148.6 [SD = 97.9] vs. M = 47.1 [44.8]; p < .01), drank alcohol on fewer days (M = 14.4 [9.5] vs. M = 7.5 [7.8]; p < .01), and exhibited significantly reduced AUDIT-C scores (M = 9.4, [2.0] vs. M = 3.0 [3.6]; p < .01) by the 2 month follow-up. Results suggest that BIAM-PC is associated with reductions in alcohol consumption and days of drinking among veterans with alcohol use disorder and other co-existing psychiatric disorders.

Implications:
Results suggest that BIAM-PC delivered through telehealth may be effective for reducing drinking behavior in veterans with alcohol misuse and co-existing psychiatric disorders.

Impacts:
Findings offer support for BIAM-PC delivered through telehealth which may enhance treatment access among veterans faced with treatment barriers for reducing harmful and hazardous drinking.


52. Availability of Community Providers for Rural Veterans Eligible for Purchased Care Under the Veterans Choice Act

Authors: Ohl ME, Carrell M, Thurman A, Vander Weg M, Hudson T, Mengeling M, Vaughan-Sarrazin M

Affiliation: COIN: Center for Comprehensive Access & Delivery Research and Evaluation (CADRE); Iowa City, IA

Objectives: Under The Veterans Access, Choice, and Accountability Act of 2014, Veterans who are enrolled in Veterans Health Administration (VHA) and live more than 40 miles from the nearest VHA facility are eligible to receive care purchased from non-VHA providers (ie "community providers"). To better understand how this act may impact access to care for rural Veterans, we characterized the availability of Community Providers for Veterans eligible for purchased care due to distance to VHA facilities.

Methods:
We combined 2013 data on VHA-users with county-level data on rurality, population, and community provider availability from the Area Health Resource File (AHRF).

Results:
Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these rural Veterans lived in federally-designated primary care shortage areas, while the majority (75.4%) lived in mental health care shortage areas. Most lived in counties that completely lacked a range of specialized health care providers (e.g. cardiologists, pulmonologists, neurologists, psychiatrists, and rehabilitation specialists). Approximately half (52.2%) lived in counties lacking Federally-Qualified Community Health Centers. Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population (Veteran and non-Veteran) in counties that were farther from VHA facilities (30.7 VHA-users / 1,000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1,000 adults in counties within 20 miles of VHA facilities, p < 0.01).

Implications:
Initiatives to purchase care for rural Veterans living more than 40 miles from VHA facilities may not significantly improve their access to some types of care, as these areas are generally underserved by Community providers. Community providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care.

Impacts:
In addition to initiatives to purchase care for rural Veterans from community providers, VHA should continue to develop telehealth models for remote delivery of care that often cannot be purchased locally, such as mental health and specialty care.


53. The Feasibility of a Psychoeducation for PTSD Program Delivered via Clinical Televideo to Ethnoracially-Diverse Rural Veterans and Family Members

Authors: Whealin JM, Yoneda A, Hilmes T, Darden D

Affiliation: VA Pacific Islands Health Care System, Honolulu, HI

Objectives: Incorporating family members in Veterans' treatment for posttraumatic stress disorder (PTSD) has shown to benefit Veterans for several reasons, including increasing support, reducing family stress, and decreasing Veterans' reluctance to participate in treatment. The goal of this pilot project was to prospectively evaluate the feasibility of a nine-session family education program for PTSD (FE-PTSD) delivered to rural Veterans via clinical televideo (CVT).

Methods:
In 2013-2015, dyads consisting of Veterans and their identified support person (e.g., spouse, adult family member) were offered FE-PTSD via CVT at rural community based outpatient clinics (CBOCs) as part of an Office of Rural Health-funded project. This poster presents pre- and post-feasibility, usability, and outcome data on forty Veterans with PTSD and their support persons who received FE-PTSD via CVT.

Results:
The average age of Veterans was 48 years and the large majority (98.7%) were male. Most participants (62.5% of Veterans and 55.0% of support persons) identified as primarily of Native Hawaiian/Pacific Islander (NHPI) ethno-racial status. Others identified equally with two or more ethno-racial categories or as Caucasian, Asian American, or Black/African American. Technological barriers to treatment delivery that were serious enough to interrupt treatment occurred in less than 7% of sessions. Veteran and support person scores on the Working Alliance Inventory (revised) indicated high comfort level when communicating with their provider during the CVT sessions. They were pleased with the usability aspects of the program that were evaluated (modal score 5 "Very Satisfied" on a scale from 1-5). When asked how likely it is that they would use this type of mental health service again in the future, participants most commonly responded with "very likely". Veteran and support person scores on the Revised Dyadic Adjustment Scale and Burns Relationship Satisfaction Scale significantly improved following the intervention. Support person scores on Zarit Burden Interview (measuring caregiving stress) significantly decreased.

Implications:
This project demonstrated the feasibility of delivering FE-PTSD via CVT to ethno-racially diverse Veterans with PTSD and their support persons. Findings indicate that Veterans and support persons perceived FE-PTSD delivered via CVT as highly acceptable and useful. Participants reported feeling comfortable communicating during the CVT sessions and showed improvements on clinically-relevant outcome measures.

Impacts:
Previously there was no evidence that CVT technology would be feasible for the delivery of psychoeducation for PTSD to ethno-racially diverse rural Veterans and family members. Findings suggest that CVT has great potential for improving access to family interventions and quality of care.


54. Lessons in Population Health from the Indiana Telemonitoring to Optimize Use of CPAP at Home (IN-TOUCH) Program

Authors: Bravata DM, Lenet A, Guenther D, Ferguson J, Stahl SM, Lightner N, Aichinger J, Miech EJ

Affiliation: COIN: Center for Health Information and Communication (CHIC); Indianapolis, IN

Additional Affiliation(s): Precision Monitoring to Transform Care (PRIS-M)

Objectives: An estimated 100.000 Veterans with obstructive sleep apnea (OSA) receive new positive airway pressure (PAP) devices annually. We pilot-tested an innovative "TeleSleep" program that used remote PAP monitoring and leveraged existing VA Sleep Medicine and Telehealth infrastructure to provide in-home care and improve outcomes for Veterans with OSA. Our objectives involved evaluating program effectiveness, assessing patient satisfaction, and constructing a business-case analysis. Our population health goal was designing and testing a program that could be scaled to serve the entire Indianapolis VAMC population of approximately 13,000 patients with OSA.

Methods:
OSA patients received ResMed AirSense-10 PAP machines with wireless capability. The Sleep Medicine service provided PAP set up, mask fitting, and patient education. The telemedicine service followed patients using a protocol designed specifically for this TeleSleep program to adhere to existing VA Telehealth requirements and provide state-of-the-art sleep medicine care. We compared effectiveness and patient satisfaction for TeleSleep versus usual care patients three months after PAP setup. The business-case analysis was constructed from the VA facility perspective and included all costs for program implementation.

Results:
Among the 146 Veterans who received a PAP device (N = 43 TeleSleep; N = 103 usual care), TeleSleep patients had improved clinical outcomes including: higher CPAP adherence (81% versus 73% of nights with CPAP use); lower leak (9.2 versus 13.1); and lower residual AHI (2.5 versus 3.9 events/hour). Benefits reported by Veterans included not having to drive "all the way to the VA just for a data download", having someone in telehealth "to call to help them" as they adjusted to being on PAP, improved relationships with bedpartners, improved energy, decreased headaches, and satisfaction with care provided by VA staff. The business-case analysis included financial (e.g., travel pay savings: average roundtrip was 72 miles; 33% of patients had roundtrip journeys of > 100 miles) and non-financial elements (e.g., improved clinic access: TeleSleep visits required 20 minutes versus 40 minutes for in-person PAP clinic appointments).

Implications:
This pilot demonstrated that a new TeleSleep program improved outcomes for Veterans. TeleSleep required a robust clinical infrastructure and data integration system to support its use. Implementation of this program requires considering needs related both to the whole population of patients with OSA as well as individual Veterans.

Impacts:
TeleSleep could be scaled up as a Veteran-centered innovation to help address the unmet needs of Veterans with OSA.


55. Evaluating Clinical Video Telehealth Services of Anticoagulation Care for Rural Veterans

Authors: Lee RE, Lee PW, Puglisi G, Hansen D, Smith SM

Affiliation: ORH: Veteran Rural Health Resource Center, Togus, Maine

Objectives: Use of clinical pharmacy specialists (CPS) to manage Anticoagulation Clinics (ACC) is standard in Veterans Health Administration (VHA). CPS is credentialed to actively manage veterans enrolled in ACCs. The Veterans Affairs Maine Healthcare System with support of the Office of Rural Health began virtual delivery of ACC via Clinical Video Telehealth (CVT) to the most remote Community Based Outpatient Clinics (CBOC) and Outreach Clinics (OC) in an effort to provide high-quality anticoagulation care to rural patients. These distant sites often do not benefit from CPS services and add to the burden of nursing staff to manage ACCs. The primary objective of this study was to assess the efficacy of delivering anticoagulation care remotely using CVT and telephone follow-up versus in-person and telephone follow-up. It was hypothesized that Time in Therapeutic Range (TTR) would be equal to or greater for patients at ACC intervention sites (IS) than usual care (UC) sites.

Methods:
This was a retrospective analysis of clinical and administrative data for veterans receiving ACC care between 03/11/2013 and 09/13/2014. Data was abstracted from the Veterans Health Information Systems and Technology Architecture (VistA). ACCs utilizing CVT/telephone were designated as IS. IS included Rumford and Calais, ME CBOCs, and Lincoln/Houlton, ME OCs. CBOCs located in Caribou and Bangor, ME utilized in-person ACCs and were designated as UC. Records for 99 IS and 180 UC patients were compared. The primary therapeutic outcome was TTR (measured in days) of International Normalized Ratios (INRs) during the study period. We calculated TTR using the method defined by Rosendaal et al.

Results:
Chi-Square analysis indicates a significant difference between TTR for IS group (.7356) and UC group (.7133) (p < .0001). A risk difference of 0.0223 (CL:0.0161, 0.0285) is significant at 0.05, suggesting ACC with CVT is more effective than traditional ACC in VHA settings.

Implications:
Results indicate utilizing CVT with ACCs has potential to maintain patients in therapeutic range for significantly more days than patients at UC ACCs in VHA.

Impacts:
Utilizing CVT in rural ACCs not only increases the quality of care in these locations, but is being done to greater therapeutic effect than in-person ACCs.


56. Remote Eye Care Screening for Rural Veterans with Technology-based Eye Care Services (TECS): A Quality Improvement Project

Authors: Maa AY, Wojciechowski B, Hunt K, Dismuke C, Janjua, R, Lynch MG

Affiliation: Atlanta VA Medical Center, Decatur, GA

Additional Affiliation(s): Ophthalmology Division, Atlanta Veteran Affairs Medical Center, Atlanta GA, Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)

Objectives: Veterans are at high risk for eye disease because of their older age and comorbid conditions. Rural and highly rural Veterans have many barriers to accessing eye care, and therefore, Technology-based Eye Care Services (TECS) was launched in March 2015 from the Atlanta VA as a quality improvement project to provide eye screening services for rural Veterans.

Methods:
Multiple quality of care, access metrics, and cost measures were tracked, including patient satisfaction, demographic data, access to care metrics, distance and time saved, and overall cost to the VA system. Characteristics of rural, highly rural, and urban Veterans who received eye care through TECS were examined and cost of receiving care through TECS was compared to the cost of receiving care through the traditional face to face exam at the Atlanta VA.

Results:
TECS significantly improved access to care, allowing many rural and highly rural Veterans to receive same day access to eye care screening. TECS also provided care to a significant percentage of homeless Veterans. Finally, TECS reduced cost for the VA system, saving up to $148 per visit and approximately $52 per patient in round trip travel reimbursements when compared to completing a face to face exam at the Atlanta VA.

Implications:
In the current economic climate of healthcare, VA leadership faces many questions about how best to provide timely access to care for Veterans. TECS, utilizing principles of telemedicine, is a VA driven, internally developed innovation that has significantly improved access to screening eye care in the rural and highly rural Veteran population that also appears to be cost saving to the system.

Impacts:
TECS successfully reduced healthcare disparities by providing improved access to rural, highly rural, and homeless Veterans. TECS has saved Veterans time and money, and reduced cost to the VA system. TECS addresses the visual needs of Veterans through the primary medical care home, focusing on maintaining Veterans' visual health and preventing blindness.


57. The Utilization of Video-Conference Shared Medical Appointments in Rural Diabetes Care

Authors: Lisa Tokuda, Lenora Lorenzo, Andre Theriault , Tracey H. Taveira, Lynn Marquis, Helene Head, David Edelman, Susan R. Kirsh, David C. Aron, Wen-Chih Wu

Affiliation: COIN: Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans; Providence, RI

Objectives: To explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings.

Methods:
We conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ?7% were enrolled into the study during 2013-2014. Six groups of 4-6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient's perceptions.

Results:
Thirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usual-care (9.1±1.9 to 8.3±1.8 vs. 8.6±1.4 to 8.7±1.6, P = 0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P = 0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care.

Implications:
Video-SMA in diabetes, delivered remotely through video conferencing technology, was feasible, well perceived by the patients and providers, and associated with a significant decline in HbA1c compared to the usual-care comparator. Video-SMA to improve DM care might also lower rates of emergency department visits, but did not impact rates of hospitalization.

Impacts:
Video-SMA improves access, patient and staff satisfaction, and has the potential to improve diabetes outcomes in a rural setting.


58. Evaluation of the Office of Rural Health Providers Continuing Education Initiative

Authors: Hanjian JH

Affiliation: ORH: Veteran Rural Health Resource Center, Togus, Maine

Objectives: This poster will discuss the evaluation of the Office of Rural Health (ORH) "Rural Provider and Health Care Staff Training and Education Initiative" (RPSTI). The demonstration program started in the fall of 2013, and 19 sites are now 2 1/2 years into the development of their continuing education projects for rural healthcare providers and staff. The purpose of the training initiative was to establish innovative, cutting-edge training and education projects that do not require travel, utilize the latest technology and curricula, and are convenient and easily accessible to providers and staff working in rural VA clinics.

Methods:
A mixed methods approach, and a development and implementation model, were used to evaluate the first 2 1/2 years of the training initiative. Five program and implementation objectives were evaluated, at each site: 1) utilizes a needs assessment as a basis for their project, 2) meets the training needs, through the use of innovative means, of the rural staff and providers, 3) integrates the rural sites into the VA healthcare system, 4) shows its project can be sustained, and 5) demonstrates it has increased the rural staff and providers' skills and knowledge.

Results:
The evaluation showed that the 19 sites had developed the infrastructure needed for their continuing education programs. Each site's approach met the challenge in a unique manner developing infrastructure, training technologies and curricula, assessing rural facilities training needs, and utilizing a wide variety of training modalities. Data on the sites' infrastructure development, training technologies, training methods and modes, innovations developed, and challenges will be discussed.

Implications:
The majority of the RPSTI sites successfully demonstrated they created the infrastructure and curricula needed provide continuing education to rural VA clinics. The sites were able to utilize a wide variety of training modalities and technologies in their programs, and overall more than 15,000 rural VA providers and staff received training.

Impacts:
Providing convenient, high quality and easily accessible continuing education to rural healthcare providers has impacted the providers practice and by extension the access and quality of care for rural Veterans. The RPSTI has demonstrated that distance learning is a viable model for the rural VA healthcare field.


59. Creating a Rural Veterans Health Care Atlas

Authors: Ahern JK, Litt ER, Wilson LK, Cowper Ripley DC

Affiliation: COIN: Center of Innovation on Disability and Rehabilitation Research (CINDRR); North Florida/South Georgia and Tampa

Objectives: The Rural Veterans Health Care Atlas 1st Edition FY- 2014 (the Atlas) was produced to serve as a comprehensive resource guide with an expansive focus on rural Veterans, rural VHA enrollees, and rural VHA patients and their health care needs. The Atlas uses FY-2014 data and Geographic Information Systems (GIS) technology to display geographically relevant information.

Methods:
The VHA Support Service Center (VSSC) and external data sources were utilized to generate tabular data to produce 17 chapters of the Atlas. The geographic units for the national-scale maps are VISN, State, and county level. The geographic unit for the VISN-scale maps is county level. These units provide sufficient detail to assess patterns in VHA, while at the same time protect patient confidentiality and privacy. Further measures to ensure VA privacy standards by creating maps that combined data of highly rural and rural patients, as highly rural patients generally represent low numbers.

Results:
The Atlas presents information for VA healthcare facilities, non-VA healthcare facilities, and outpatient utilization in rural and highly rural areas in all VISNs, States, and counties. Additionally, it shows broadband access for patients who could potentially utilize telehealth; ten disease cohorts and their prevalence in rural areas illustrate the health care needs and access for each group (Diabetes, Stroke, PTSD, Tobacco Use, Alcohol Use, Coronary Artery Disease, COPD, Obesity, Congestive Heart Failure, Chronic Renal Failure); and county health ranking access measures.

Implications:
GIS can create, access, integrate, and display geographically relevant information. GIS can be used to examine population-level effects of services as reflected in geographic and spatial distribution of populations and allows predictive modeling. This product can enhance knowledge of VA's rural enrollees and rural patient population and their health care needs, and, ultimately, provide background information that will improve the formulation of specific research questions to address those needs.

Impacts:
This first edition represents a baseline of robust and valuable data that can be compared with future editions to show evidence of improvement of health care resources for VHA enrollees and patients within the dynamic landscape of the VHA health care system.


60. Improved Mobility in Rural Veterans Using Telehealth Technology

Authors: Nocera JR, Whitney K, McGregor KM

Affiliation: Atlanta VA Medical Center, Decatur, GA

Additional Affiliation(s): Atlanta Department of Veterans Affairs RR&D Center for Visual and Neurocognitive Rehabilitation

Objectives: As the life expectancy among US Veterans continues to rise, the maintenance of physical independence and mobility has emerged as a major clinical priority in the VA healthcare system. Veterans who lose mobility are less likely to remain in the community, have higher rates of morbidity, mortality, hospitalizations, and experience a poorer quality of life. Several studies executed in VA Medical Centers, including our own, have shown that regular physical activity improves mobility as well as other physical parameters. However, 3 million US Veterans (40% of the Veterans in Georgia), the majority of which are over the age of 55, live in rural settings and, as such, cannot feasibly take advantage of the successful exercise service projects based at VA Medical Centers. The objective of this proposal is to implement a simple, user-friendly health technology to track activity and implement individualized activity regimens that we have demonstrated to be effective at improving physical function, health, and quality of life.

Methods:
Our team is developing a customized telehealth application (app) that incorporates movement tracking features. Previous movement tracking technologies have required the use of multiple devices to accurately assess a Veteran's movement profile. These devices include triaxial accelerometers (step counters), heart rate monitors with chest straps, GPS-based movement tracking, barometers, gyroscopes and separate tablets to record survey responses. Our app integrates all of these technologies into a single, user-friendly device that can give immediate, aggregated feedback to both the Veteran and project manager at any time. This technology allows our developers to create a customized, progressive exercise programs.

Results:
Our current, in-house, intervention is demonstrated to improve cardiovascular fitness, as measured by volume of oxygen consumed, increased mobility as measured by a 400m walk and the short physical performance battery.

Implications:
We believe translating our exercise program will be successful and effective as is allows for a convenient, user friendly interface to instruct Veterans on the correct amount and intensity of exercise activity.

Impacts:
Increased exercise in older adults is strongly recommended by the American Heart Association, the CDC, and the VA. It is not a palliative intervention, but a preventative measure and serves as both a direct therapy and adjuvant to the internal healing process. Yet, despite the great benefits of programmatic exercise interventions, rural Veterans remain underserved due to logistical challenges (travel, expense, access). The current proposal seeks to remove those logistical barriers with the use of a revolutionary TeleHealth delivery device.


61.  Adapting a Web-Based Intervention Targeting Alcohol Use and Sexual Assault Risk among Female Veterans

Authors: Gilmore AK, Maples-Keller JL, Resnick HS, Ruggiero KJ, Acierno R, Kilpatrick DG

Affiliation: COIN: Charleston Health Equity and Rural Outreach Innovation Center (HEROIC); Charleston, SC

Objectives: Providing VA/DoD recommended practices via web-based delivery is a public health approach to increasing access to care by decreasing barriers to treatment utilization for female Veterans. Approximately 30% of female Veterans engage in alcohol misuse, ranging from drinking above gender-specific recommended limits to alcohol dependence, and rates of alcohol misuse are higher among women not receiving VA services than VA-users. Due to the bidirectional association between alcohol use and sexual assault among women, and the high rates of alcohol misuse and sexual assault among female Veterans, we adapted a web-based intervention targeting both alcohol use and sexual assault to female Veterans. 

Methods:
We developed the first iteration of this web-based intervention for heavy episodic drinkers that incorporated sexual assault risk reduction strategies, personalized according to respondent answers to preliminary questions. This treatment was effective for college women in reducing re-victimization rates and frequency of heavy episodic drinking among women with more severe sexual assault histories. We adapted the intervention and are currently receiving feedback on this intervention from female Veterans recruited nationally through advertisements on the Internet. To be eligible, participants must be female, Veterans, and engage in heavy episodic drinking at least once in the past month.

Results:
Results for the poster will include quantitative and qualitative findings of 20 participants regarding alcohol, sexual assault risk, and referral content. Currently, 2 participants have completed the study. The current participants rated all content as helpful, interesting, and indicated that the content made them want to engage in treatment. Further, they indicated that the content was not perceived as victim blaming. Participants indicated that the content was "extremely informational," was "straightforward and easy to understand," was "catered to me and feels very helpful to improve my issues," and "makes me want to get help if needed." Data from the remaining participants will be presented.

Implications:
The current study is a pilot adaptation of a web-based alcohol use and sexual assault risk reduction program to female Veterans. This intervention was effective among college women and the adaptation to Veterans could allow for increased access to treatment for Veterans after successful adaptation. 

Impacts:
It is essential to reduce the burden of sexual trauma and consequences of alcohol misuse on female Veterans with an easily accessible intervention that targets both alcohol and sexual assault risk. Therefore, after adaptation, it is imperative that this intervention undergo testing among female Veterans and dissemination if effective.