How the VA’s Teleneurology Program Mitigates Care Access Challenges

August 24, 2023 - United States veterans seeking neurologic care face numerous barriers to access. These include transportation challenges, psychological hurdles, and the healthcare provider shortage. As a result, many cannot get the care they need.

Telehealth has proved itself effective at breaking down barriers to healthcare access. The COVID-19 pandemic, in particular, showcased how virtual care can expand access across a wide range of conditions.

While many in the healthcare world found themselves setting up telehealth services for the first time during the pandemic, the Department of Veterans Affairs (VA) was no stranger to the care modality. This year, the VA Telehealth Services program office celebrated its 20th anniversary.

Thus, it should be no surprise that the VA's years-long effort to break down neurologic care access barriers involves telehealth. The department launched its outpatient National Tele-Neurology Program in 2020. Recently published study results highlighted the success of the program, which could support teleneurology efforts in health systems nationwide.

SETTING UP THE TELENEUROLOGY PROGRAM

Like other aging populations, veterans are at high risk of developing various neurological disorders, said Linda S. Williams, MD, a Regenstrief Institute clinician-researcher and co-principal investigator of the VA EXpanding expertise Through E-health Network Development Quality Enhancement Research Initiative (EXTEND QUERI), in an interview.

Additionally, due to their work and experiences on the front lines of war, certain conditions, such as stroke, post-traumatic stress disorder (PTSD), and amyotrophic lateral sclerosis or Lou Gehrig's disease, are especially prevalent among the US veteran population.

Williams, who is also a professor of neurology at Indiana University School of Medicine, noted that various longstanding access issues prevent veterans from receiving timely neurologic care, including that veterans are more likely than the average population to live in rural areas.

Rural populations often lack access to specialists, specifically neurologists. A study published in 2021 showed that while the supply of neurologists varies widely by region in the US, the prevalence of neurologic conditions does not.

"There's a real access issue for patients with neurologic disease," Williams said. "And the VA wanted to try to address that by creating a teleneurology outpatient clinic, which has been done before, but typically in a specific disease. So, you might create a headache clinic or a Parkinson's disease clinic. But they really wanted it to be a general neurology clinic open to all patients who might have a neurologic need."

The VA Office of Rural Health (ORH) funded the National Tele-Neurology Program, with start-up activities in early 2020 and the first clinical implementation in October 2020. In 2021, 12 VA care sites implemented the program.

Here is how it works: When a veteran's primary care provider requests a neurology consult, the veteran receives a call asking them if they're eligible to receive care in the community, which means the VA would pay for them to see a neurologist in the community, or whether they would prefer to connect with a neurologist via telehealth, Williams explained.

There are two ways veterans can access the outpatient teleneurology services: directly in their home on a phone or computer or by going to a nearby rural outpatient clinic.

The latest data from the VA shows that 14 VA medical centers have adopted the program, of which nine have no VA Neurology services, one has no VA neurologist and no community neurologist within three hours of driving, and five have limited VA neurology presence and are unable to keep up with demand.

HAS THE PROGRAM BEEN EFFECTIVE?

As the number of VA care sites adopting the National Tele-Neurology Program grows, Williams and her team set out to examine the effectiveness of the services.

"Neurologists in general are also in a shortage, so we don't have enough neurologists," Williams said. "The national program leaders were very aware from the beginning that there was no way that they would somehow identify and recruit enough neurologists to meet everyone's needs. So, the question is, how can you effectively implement a program so that you meet enough needs?"

The research team assessed the timeliness of access to neurological care and the volume of community care neurology consultations following the program's launch.

Community care consultations for veterans result from the Congressional Mission Act of 2018, which aimed to increase veteran access to healthcare by offering community care for those eligible. Eligibility criteria for specialty care included a drive time of more than 60 minutes or a wait time of more than 28 days from the appointment request date.

Veterans eligible for community care for neurologic services can choose whether they prefer to go to a physician in their community or receive neurologic care via the National Tele-Neurology Program, Williams explained.

For the study, researchers compared wait times and community care neurology consultation data from the 12 VA sites that implemented the program with VA control sites that had not yet adopted the program.

They found shorter wait times associated with telehealth appointments than in-person visits at the facilities participating in the teleneurology program. Wait times for teleneurology program appointments were also shorter than for community care appointments.

Further, the sites that implemented the telehealth program had a lower volume of community care neurology consultations compared with the control sites.

"So, in other words, the VA is paying for more and more community care over time, and that is rising gradually over time," Williams said. "But after sites implement teleneurology, they drop down to a much lower level of community care monthly consultation volume, and that difference is maintained over time. So, it seems to make a real impact."

The study also revealed high veteran satisfaction levels with the teleneurology program.

IMPLICATIONS OF THE STUDY

The primary benefit of the study is that it can help VA leaders determine the next sites that are ripe for teleneurology services implementation.

"Finding the sweet spot in terms of the size of the program and how many veterans they have typically in a given year that would need neurologic care, this kind of helps them hone in on where the program can be the most effective," Williams said.

But the study results also have broader implications for the healthcare industry. For instance, the study shows high satisfaction with teleneurology services.

"And this sometimes surprises other healthcare providers and even other neurologists, that patients tend to be very happy with the care and they feel like it's a very thorough evaluation and it's similar to a face-to-face visit," she added.

Further, the study shows there is real value in bringing telehealth services to rural areas. As health systems grapple with how best to distribute their already constrained resources, especially their clinicians, studies like this can help leaders make decisions that can positively impact healthcare access, Williams noted.

As healthcare organizations assess and adjust their pandemic-era virtual care strategies, research plays a critical role in determining how telehealth will be deployed in the future.

"I think this issue of comparing telehealth care to other forms of care is going to be an increasingly commonly discussed item, and not just for VA," Williams said.

Thus, the VA plans to continue assessing its telehealth programs, including the teleneurology program. Williams and her team will work on another project this fall to compare veteran satisfaction with teleneurology to community care neurology consultations.