Improving Wound Care

Access

and Coordination Between

Home, VA Primary and

Tertiary Care Medical

Centers

VISN 11 Wound Care Teleconsultation Program

Julie Lowery, PhD and

Leah Gillon, MSW

DM QUERI, Ann Arbor VAMC

Diabetic Foot Ulcer Treatment and Amputation Prevention in Non-Tertiary VA Care Facilities

Greg J. Raugi, MD, PhD;

Gayle E. Reiber, MPH, PhD

Seattle VAMC

Developing a Home Telehealth Program to Manage Pressure Ulcers in Spinal Cord Injury/Disorder

Marylou Guihan, PhD,

Chester Ho, MD and

Christine Woo, MSSCI QUERI/Cleveland VAMC

Overview of Telehealth

VA has been increasing access to care by building CBOCs.

Via the Office of Care Coordination (OCC), VHA has taken the lead in developing telehealth programs to serve veterans who would otherwise lack access to care.

Telehealth enables patients to receive specialty care at remote sites.

Defining Telehealth

Telehealth is the use of electronic and telecommunications technologies to provide and support health care when distance separates the participants.

Level Store-and-Forward

Real Time

Type of data transmitted

MinimumBandwidthKbit/s per

Connection

Advanced

IV

Convergence of traditional telehealth, integration with EMR,

makes distinctions between traditional

medicine and telehealth meaningless

Convergence: Images, high

resolution video, EMR

High, (512kbits/s or greater)

Modern Telehealth

III Hybrid with high resolution video and

image

Images, high resolution video,

Medium (364 kbit/s)

IIa. High

resolution still images

b. Low resolution

video

Images, low resolution video

Low (128 kbit/s)

Pre-Telehealth

IEmail of

text information

Faxing of text

information

Electronic transmission of text information

Modem (<10 kbit/s)

0Postal mail Verbal

report by phone

Traditional, non-electronic

methods of communication

Telephone network

Telehealth Levels

Home Telehealth Equipment

Video telephones Data messaging devices Video tele-monitor devices Optional medical peripheral

devices

Care Coordination Home Telehealth

In CCHT, patients are assessed and monitored in their homes using telehealth technologies for preventive care, intervention and/or treatment management purposes.

Videophones

Advantages: Low cost Easy to use

Disadvantages: Performance varies Sporadic connection

& transmission of images

Limited use (mostly mental health)

Plain Old Telephone (POTS) with camera for video display

Some programs have used videophones for wound care

Home Telehealth Data Messaging Devices

Advantages Easy to use Low-cost Portable

Disadvantages Time gap between

patient data entry and clinician review

Provider must depend on accuracy of patient response to questions

Video Tele-monitor – Patient Station

Glucose Meter Pulse Oximeter

Desktop devices with video display screens, as well as camera and various biometric peripherals (some wireless)

Allows for real-time two-way interactive monitoring and management of disease between patient and provider

Wound care management limited by camera specifications and connectivity options

Video Telemonitor – Clinician Station

During scheduled appointment, provider reviews video, audio or text data from patient

Data can be reported directly by patient or automatically via peripheral device connected to patient station

Data transfer from home to clinic via telephone line

Data (e.g., wound photos) received at clinician station can be placed in patient’s electronic medical record

Video Telemonitor and Peripherals

Advantages Visual interaction Real-time data review Provider supervision of

information collection /transmission

Disadvantages High equipment

cost Video images

marginal over POTS telephone line

More complex to operate

Combination Video Telemonitor, Messaging and Peripheral Devices

Telemonitor and Peripherals:

Real-time videoconferencing Multiple medical peripherals

Data Messaging:

Assignment of customized health management programs

Advice messages for patients Schedules and reminders for

medications, measurements, and questions

Graphical display of results/trends Server access to educational

materials

VHA Clinic-to-Clinic Telehealth

Care coordination: general telehealth

Real time 2-way interaction between patient and health care provider at two different locations

Provider at remote site can collect real-time data from peripheral devices, (e.g., digital camera, camcorder, pressure mapping)

View and guide procedures or activities performed real-time from a remote clinical setting, (e.g., wound measurement)

Store-and-Forward Telehealth

Data collected at primary care site

Data transmitted to remote storage device

The encounter typically involves digital images, diagnostic testing or other clinical data captured during a clinical visit at remote site

Data retrieved and reviewed at the convenience of reviewing medical practitioner(s)

Feedback is provided to PCP at remote site

Developing a Home Telehealth Program to Manage Pressure Ulcers in Spinal Cord Injury/Disorder

Marylou Guihan, PhD1, Chester Ho, MD2, Christine Woo, MS3

1 Assistant Director, SCI QUERI, Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, IL2 Chief, SCI Center, Louis Stokes Cleveland VAMC, Cleveland, OH3 Program Manager, SCI Telehealth Program, Louis Stokes Cleveland VAMC, Cleveland, OH

Background

Spinal Cord Injury/Disorders (SCI/D) is the most costly condition in VA.

PrUs account for about 1/3 of all VHA SCI/D admissions and 87% of hospital days.

PrUs are a serious condition because: Very common Often preventable Cause increased morbidity/mortality,

and decreased quality of life.

Background

Patients with SCI and severe PrUs are admitted to regional centers for treatment.

Healing often takes months to resolve.Promoting prevention and/or early detection and reporting of PrUs in the community setting are important goals for the VHA SCI/D system of care.

One tool to promote these goals is the home telehealth data messaging device.

VISN 10Hub and Spokes

OHIO

Study Objectives

To develop the tools necessary

for implementing a new home

telehealth disease management

protocol (DMP) to manage

community-dwelling veterans

with SCI/D at high risk for

developing PrUs.

Home Telehealth Data Messaging Devices

Currently used by patients throughout VHA

Compact device displays text

Multiple chronic health management programs available

Q & A covers patient: 1) knowledge, 2) behavior, and 3) symptoms regarding key aspects of care

Built-in education reinforcement and reminders that prompt patient action

Daily sessions take about 10-15 minutes

Telehealth equipment is not designed for use by functionally impaired persons and may need to be adapted Therapist can assess physical limitations Provide adaptive devices (mouth stick, head

pointer and typing aids)

Recommend home environment adaptation Privacy issue with caregiver assistance

Adaptation of Telehealth Equipment for Veterans with Disabilities

                                             

Patient responses are sent from the patient’s home to a data center via telephone line.

Clinicians review patient responses in a spreadsheet on a secure VHA web site.

Patient responses are risk stratified-color coded as “high” “medium” or “low” risk answer.

Clinician makes decision regarding follow-up on patient response.

Home Telehealth Data Messaging Devices

In collaboration with VHA SCI/D Field Workgroup and VHA Office of Care Coordination, clinicians at Cleveland SCI/D Specialty Center developed a draft Pressure Ulcer Disease Management Program (PrU DMP).

Sources of DMP items 1) the SCI Clinical Practice Guideline (CPG) 2) the SCI PrU Consumer Guide 3) “Yes I Can” - a patient guide to self-care that is

used at all VA SCI Centers as part of the rehabilitation process after SCI.

Developing the PrU DMP

PrU DMP ItemsDMP categories

General Medical Status (including co-morbidities)

General Psychosocial Status Safety Issues Prevention (PrU specific)

General knowledge about prevention Daily skin care Risk factors Nutrition Equipment

Treatment (PrU specific) General knowledge about treatment of PrU Monitoring, complications, recurrence

Developing the PrU DMP

Consensus was obtained for following:

1. Purpose, goal and comprehension of questions/content items,

2. Determination of frequency with which each item should be administered,

3. Identification and assignment of weights to responses (high, medium, or low risk),

4. Strategy for reporting triggered alert items to local clinicians.

Final versions of the DMP and responses with follow-up education were developed in collaboration with an expert clinician panel to validate PrU DMP items.

Follow-up clinical care guideline responses for alert triggers were developed based on PrU question/content risk level and patient response risk level.

Developing the PrU DMP

Sample Behavior Question

Category Type of Question

Question with Follow-up Response

Daily Skin Care

Behavior What do you do if you see a color change, dark, or red area on your skin?

1. Nothing (medium risk).2. Stay off Area3. Continue with normal activities (medium risk)

F/U Responses

Medium risk: You must immediately stay off the area to minimize the chance of developing a pressure ulcer. Check your skin every 15 minutes. If you do not see any changes in the color of your skin after 1 hour, please contact your care coordinator.

Low risk: Good.

Sample Knowledge Question

Category Type of Question

Final Version of Question with Follow-up Response

Prevention Knowledge How much time does it take for a pressure ulcer to develop?

1. Two months2. One month3. One week4. Several days5. Half an hour

For all responses: When blood cannot circulate past areas where the blood vessels are choked by the pressure of your weight on a surface, the cells that are fed by those blood vessels die and a sore develops. This can happen in as short a time as 30 minutes.

High Priority Items (n=9)

Quality of care provided by caregiver

Able to communicate with caregiver

Daily skin inspection

Notice new skin reddened areas on skin

Problems with equipment

Able to change position in bed

Able to keep skin clean and dry

Able to do pressure relief or weight shifts

Able to take care of skin

Study Design

PrU patients who about to be discharged from Cleveland SCI Center are screened for eligibility to participate in the study.

Patients with open or closed skin may participate.

Inclusion/exclusion: Cognitively intact and has a phone.

Design: Patients randomly assigned to receive daily (5 days a week) or weekly (1 day a week) calls implementing the proposed PrU DMP.

Study Status: Currently enrolling patients.

Study Data Analysis

Study data will be used to determine the appropriate frequency with which each item

should be asked whether certain items should be dropped whether the items that the patients respond to should

be determined by patient or SCI factors, (e.g., history of previous ulcers, Braden risk, open vs. closed skin, etc)

We will make the following comparisons daily vs. weekly interviews closed vs. open skin those who do/do not develop open skin during the

study

Interim Results

Alert Trigger by Type

PrU Safety Issues

22%

Equipment Issues

22%

Daily Skin Care56%

Keeping Skin Dry 20%

20%

Dragging across

surfaces20% Regular

Pressure Relief40%

Skin Inspection

20%

Daily Skin Alert Triggers

Resolving Triggered Alert Items

When a high or medium risk response item is triggered, the study research assistant contacts the Cleveland SCI clinic nurse that day who may:

provide advice or education to patient, refer patient to Cleveland VA or local

specialty clinic and/or contact spoke site PCP to address/resolve

the issue.

Study RA will follow-up with Cleveland RN, review CPRS notes or contact spoke site PCP to determine what actions and/or care (if any) was received.

Triggered Alert Issues

We have identified problems with provider ability to communicate via CPRS about the resolution of clinical alerts between the hub-and-spoke sites.

Providers within a site are more accustomed to using interdisciplinary team notes.

We have observed differential ability among providers to use CPRS remote notes.

Future Directions

1. Use information/experience from this study to guide larger DMP.

2. Develop a larger prospective study to assess outcomes associated with patient use of PrU DMP in SCI.

Acknowledgements

Expert Panel MembersFred Cowell (PVA)Susan Garber MA, OTMichael Priebe, MDSusan Thomason, PhD, RN

DMP Development

GroupKaren Farrell, CNPCarol Gill, MDMarylou Guihan, PhDChester Ho, MDSadie Hughes-Young, CNPChristine Woo, MSKristina Young, MOT OTR/L

OCC RepresentativePatricia Ryan, MS, RN