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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000422245.57588.ed
AJN Reports

Improving Access to Specialty Care for Veterans

Pfeifer, Gail M. MA, RN, News Director

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Abstract

Providers collaborate with specialists weekly to deliver best practices.

According to the Veterans Health Administration, about 41% of the 3.4 million veterans enrolled in the U.S Department of Veterans Affairs (VA) health care system live in “rural or highly rural” areas of the country, with limited access to specialty care for complex pain management and diseases such as rheumatoid arthritis, diabetes, and hepatitis C virus (HCV) infection. Challenges to access include long travel distances to specialists, long waits, and poor coordination of care between primary care providers and specialists. But the care system should move around the veteran, not the other way around, according to the VA Office of Specialty Care Transformation, which was established in 2010. Building on the Extension for Community Healthcare Outcomes (ECHO) project, which employs videoconferencing to reach providers in remote areas, the VA has launched the ECHO-based Specialty Care Access Network, or SCAN-ECHO, to address the challenges to providing specialty care for veterans.

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THE GENESIS OF PROJECT ECHO

Project ECHO was developed by Sanjeev Arora, MD, a hepatologist, professor of medicine, and director of Project ECHO at the University of New Mexico Health Sciences Center. He generated the idea as a means of raising the standard of care for patients in the underserved areas of that state. The videoconferencing is used to link specialists at university medical centers with community-based providers to provide any training, advice, and support they need to deliver evidence-based best practices to patients locally. And early research is showing promising results: in a 2011 New England Journal of Medicine report of a community-based study of patients with HCV infection, Arora and his colleagues found that patient response rates to treatment in the ECHO cohort were equivalent to those in patients treated at the university. The project is being replicated elsewhere as well; for example, the University of Washington is conducting teleclinics that reach providers in Washington State, Alaska, Idaho, Montana, and Wyoming. Harvard University, the University of Utah, the University of Nevada, and the University of South Florida are also in the process of implementing the model.

Jeannie Boyle, MSN, RN, is the executive nurse manager at the University of New Mexico Health Sciences Center. Her job is to oversee all of the Project ECHO teleclinics. “We have more than 400 partners in the state and dozens outside New Mexico,” Boyle told AJN, adding that as a result, opportunities for nurses are “just exploding.” This extends to collaborations with the U.S. Department of Defense to create a global chronic pain–management program for the armed forces and with the VA to bring complex specialty care to the millions of veterans who live in rural areas.

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TAILORING PROJECT ECHO TO THE VA SYSTEM

The VA took an interest in Project ECHO in 2010, viewing it as a means to “transform the delivery of specialty care” throughout the VA system. SCAN-ECHO is a modification of the basic ECHO concept designed to provide specialty consultation in nine medical areas—cardiology, diabetes, endocrinology, HCV infection, liver disease, nephrology, pain management, and vascular medicine—at 11 VA pilot sites (see VA SCAN-ECHO Pilot Centers). July marked the launch of the nationwide implementation of the SCAN-ECHO program. A collaborative agreement between the VA and the University of New Mexico allows Project ECHO staff to be available for consultation as VA implementation expands and new centers are added.

Jacqueline Suppan, MSN, RN, CNS, a primary care provider at the VA Community-Based Outpatient Clinic in Canton, Ohio, has been involved with SCAN-ECHO since the initial pilot programs started in the summer of 2011. Although Suppan is the designated pain management champion, all members of her VA patient-aligned care team, or PACT, are welcome to attend the weekly videoconferences, which last about 90 minutes and comprise a didactic session on a specific topic followed by case discussions. The specialists she works with, she says, are “open with their time, attention, and accessibility,” regardless of which primary care provider calls on them. And now she feels more comfortable contacting those specialists directly—for example, when she needs to determine whether a patient with unresolved acute back pain might benefit from an epidural injection.

The SCAN-ECHO program aims not only to improve access to specialists, improve care quality and safety, and reduce variations in care, but it also offers the opportunity for primary care providers like Suppan to gain the skills and knowledge to be able to manage more complex cases without imposing travel burdens and costs on the veterans she cares for.

Boyle also points out that “research is an integral part of the [ECHO] program.” She says the sites using videoconferencing plus the continued evaluation of patient outcomes are the most robust, and that includes the Cleveland, Ohio, VA site where Suppan works.

“That specialists and primary care providers are working together benefits veterans a great deal,” says Suppan, citing immediate treatment versus long waits to see specialists and the convenience of being treated locally by a known provider the patient is comfortable with instead of going to a large and unfamiliar facility.

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MAKING A BIG IDEA BIGGER

Project ECHO staff consider the program to be a game changer, stating in a June 2011 report in Health Affairs that it has “the potential to radically transform how health care is provided in the United States and to bring best-practice care to patients with chronic health conditions, wherever they are.” The program is partly funded by a Robert Wood Johnson Foundation grant that aims to help expand the model across the United States. But in the launch of the VA SCAN-ECHO program on July 11, Rajiv Jain, MD, the VA chief patient care services officer, stressed that they're working on sustainability beyond grant funding.

In the meantime, the Centers for Medicare and Medicaid Services recently awarded a three-year Innovation grant to the University of New Mexico to identify high-cost, high-use, complex patients in New Mexico and in Washington State. Under that grant, a team of primary care “intensivists” will be trained by ECHO staff and faculty—including nurses—to care for patients with multiple chronic diseases. The teams will work with area managed care organizations and care providers. And many of these intensivist teams, Boyle points out, will be headed by NPs.

The VA, with one of the largest integrated health care systems in the country, is evaluating the current SCAN-ECHO programs to ensure that veterans’ access to care is indeed improving. Once that outcome has been clearly established, a system-wide expansion will be considered.—Gail M. Pfeifer, MA, RN, news director

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VA SCAN-ECHO Pilot Centers

* VA Connecticut Healthcare System, West Haven, Connecticut

* VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania

* Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

* Salem VA Medical Center, Salem, Virginia

* Louis Stokes VA Medical Center, Cleveland, Ohio

* VA Ann Arbor Healthcare System, Ann Arbor, Michigan

* New Mexico VA Healthcare System, Albuquerque, New Mexico

* VA Eastern Colorado Healthcare System, Denver

* Portland VA Medical Center, Portland, Oregon

* San Francisco VA Medical Center

* Veterans Integrated Service Network 22 (services are split between VA Greater Los Angeles Healthcare System and VA San Diego Healthcare System)

Robert Wood Johnson Foundation Pioneer Web site. www.rwjf.org/pioneer/product.jsp?id=74591.

© 2012 Lippincott Williams & Wilkins, Inc.

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