Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities.

Abstract

Background

Virtual care is critical to Veterans Health Administration (VHA) efforts to expand veterans' access to care. Health care policies such as the Veterans Access, Choice, and Accountability (CHOICE) Act and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act impact how the VHA provides care. Research on ways to refine virtual care delivery models to meet the needs of veterans, clinicians, and VHA stakeholders is needed.

Objective

Given the importance of virtual approaches for increasing access to high-quality VHA care, in December 2019, we convened a Think Tank, Accelerating Implementation of Virtual Care in VHA Practice, to consider challenges to virtual care research and practice across the VHA, discuss novel approaches to using and evaluating virtual care, assess perspectives on virtual care, and develop priorities to enhance virtual care in the VHA.

Methods

We used a participatory approach to develop potential priorities for virtual care research and activities at the VHA. We refined these priorities through force-ranked prioritization and group discussion, and developed solutions for selected priorities.

Results

Think Tank attendees (n = 18) consisted of VHA stakeholders, including operations partners (e.g., Office of Rural Health, Office of Nursing Services, Health Services Research and Development), clinicians (e.g., physicians, nurses, psychologists, physician assistants), and health services researchers. We identified an initial list of fifteen potential priorities and narrowed these down to four. The four priorities were (1) scaling evidence-based practices, (2) centralizing virtual care, (3) creating high-value care within the VHA with virtual care, and (4) identifying appropriate patients for virtual care.

Conclusion

Our Think Tank took an important step in setting a partnered research agenda to optimize the use of virtual care within the VHA. We brought together research and operations stakeholders and identified possibilities, partnerships, and potential solutions for virtual care.

Department

Description

Provenance

Citation

Published Version (Please cite this version)

10.1007/s11606-020-06517-3

Publication Info

Lewinski, Allison A, Caitlin Sullivan, Kelli D Allen, Matthew J Crowley, Jennifer M Gierisch, Karen M Goldstein, Kaileigh Gray, Susan N Hastings, et al. (2021). Accelerating Implementation of Virtual Care in an Integrated Health Care System: Future Research and Operations Priorities. Journal of general internal medicine, 36(8). pp. 2434–2442. 10.1007/s11606-020-06517-3 Retrieved from https://hdl.handle.net/10161/29635.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.

Scholars@Duke

Lewinski

Allison A. Lewinski

Assistant Research Professor in the School of Nursing

As a nurse scientist and health services researcher, with a joint appointment between the Duke University School of Nursing (DUSON) and the Durham Veterans Affairs Health Care System (VHA), I have acquired expertise in the areas of diabetes distress, qualitative research methods, and virtual care (e.g., telehealth, digital health) as a method of care delivery. My research focuses on the current and potential ability of virtual care interventions to reduce distress, improve self-management, increase access to evidence-based care delivery, and improve patient and population health outcomes. My collaborative and interdisciplinary research focuses on how patient-, provider-, and system-level factors influence virtual care use and outcomes. As evidence of its growing significance and impact at DUSON and the VHA, my work has been well funded, published in high-impact journals, presented at select conferences, and used to guide health system decision-making. I am a sought-after teacher and mentor because I connect my research interests to teaching students and mentees rigorous and systematic research approaches. I am frequently asked by local and national colleagues to provide guidance on distress, qualitative research methods, and virtual care approaches used in grants, projects, and manuscripts.  

My research contributions have focused on alleviating psychosocial distress, developing and implementing multi-level virtual care interventions, and enhancing qualitative methods. As a staff nurse, I witnessed the psychosocial distress of patients who experience challenges in obtaining care which led to my interest in diabetes distress. I aspire and work to improve health outcomes for individuals with chronic illness by developing equitable and sustainable multi-level virtual care interventions and assessing their implementation and adaptation. Virtual care describes any remote interaction between a patient and/or members of their care team. To achieve these goals, I use qualitative methods and implementation science approaches to enhance alignment between patient, modality, disease state, and social and environmental context; my collective assessments address for whom and what purposes, in what situations and contexts, when in a disease course or clinical activity, and in what specific ways such interventions are effective. My focus on the uptake and adoption of virtual care to address psychosocial distress considers interactions with patients, between patients and clinicians, and within health care systems and the larger population.

Allen

Kelli Dominick Allen

Adjunct Professor in the Department of Medicine
  • Improving care and outcomes for individuals with osteoarthritis and other musculoskeletal conditions with an emphasis on non-pharmacological therapies including physical activity, weight management, rehabilitation services, and pain coping
    * Understanding rand reducing disparities in musculoskeletal conditions
    * Musculoskeletal conditions in U.S. military Veterans
    * Pragmatic clinical trials
    * Adaptive interventions
Gierisch

Jennifer M. Gierisch

Associate Professor in Population Health Sciences

Jennifer Gierisch, PhD,  is behavioral scientist and health services researcher. She is an Associate Professor in the Department of Population Heath Sciences and the Department of Medicine at Duke University. She is a core investigator with the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)  where she serves as the leader of the Partnered Research Methods Core (PRESTO)  and Director of the VA OAA Health Services Research Postdoctoral Fellowship. Dr. Gierisch also is the Co-Director of the Evidence Synthesis Program (VA ESP) at the Durham Veteran Affairs Health Care System. She also served as a faculty director of the Duke Clinical Translational Science Institute's  Community Engaged Research Initiative (CeRi) for five years

Dr. Gierisch’s research focuses on three overarching areas: 1) behavioral research on the psychosocial factors that influence appropriate uptake and maintenance of complex health behaviors (eg., weight management, smoking cessation, cancer screening); 2) evidence synthesis on key health and healthcare topics to enhance uptake of evidence-based interventions to improve patient and health system outcomes; and 3) participatory and  community engaged research approaches.

Area of expertise: health behavior, community-engaged research, evidence synthesis, intervention development,  qualitative research

Goldstein

Karen M. Goldstein

Associate Professor of Medicine

Dr. Goldstein's research interests include women's health, cardiovascular risk reduction, evidence synthesis methodology and peer support.

Hastings

Susan Nicole Hastings

Professor of Medicine
Jackson

George Lee Jackson

Adjunct Professor in Population Health Sciences

Areas of expertise: Epidemiology, Health Services Research, and Implementation Science

George L. Jackson, Ph.D., MHA is a healthcare epidemiologist and implementation scientist with a background in health administration.  He joined the faculty of the UT Southwestern Medical Center in February of 2023 as a Professor and Director of the Advancing Implementation & Improvement Science Program in the Peter O'Donnell Jr. School of Public Health.  Dr. Jackson is also a Veterans Affairs (VA) Health Services Research & Development (HSR&D) Research Health Scientist who works with the VA healthcare systems in both Durham, NC and Dallas, TX.  He is the Director of the Implementation and Improvement Science Lab/Core at the Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT).  Additionally, he is a co-leader of a cooperative effort between the Dallas VA and Program on Implementation and Improvement Science designed to enhance the infrastructure for partnered health services and other research across the Dallas VA and UT Southwestern focused on enhancing the health and healthcare of Veterans in North Texas and across the Nation.

The UT Southwestern Advancing Implementation & Improvement Science Program seeks to further enhance collaborations between the UT Southwestern and affiliated health systems and community partners in the pursuit of common missions to enhance the health and healthcare of the people of North Texas.  The goal is to develop a system to identify potentially successful projects using implementation and improvement science – which uses rigorous, data-driven research to expand programs and improve a community’s health.

Dr. Jackson’s own research and evaluation efforts focus on the development, testing, and implementation of team-based approaches to address the treatment and prevention of chronic conditions such as diabetes, hypertension, and cancer.  He has also evaluated efforts to enhance the organization of mental health care.  As an implementation scientist, Dr. Jackson studies strategies focused on the adoption and spread of evidence-informed practices across large health systems.  He is currently the corresponding principal investigator for two VA program grants focused on the process of identifying, replicating, and spreading innovations across large healthcare systems.  These include the Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) partnered evaluation of the Veterans Health Administration (VHA) Diffusion of Excellence program and the Dynamic Diffusion Network (DDN) QUERI Program, both funded by the VA Quality Enhancement Research Initiative (QUERI).

Dr. Jackson received his Doctor of Philosophy (Ph.D.) in epidemiology, Master of Health Administration (MHA), and Bachelor of Science in Public Health (BSPH) in health policy and administration degrees from the School of Public Health at the University of North Carolina at Chapel Hill.  He completed an Agency for Healthcare Research and Quality (AHRQ) pre-doctoral fellowship in health services research at the Cecil G. Sheps Center for Health Services Research and AHRQ post-doctoral fellowship in health services research in the Duke Division of General Internal Medicine and HSR&D Center at the Durham VA.  He came to UT Southwestern from Duke University, where he was a Professor in the Departments of Population Health Sciences, Medicine (Division of General Internal Medicine), and Family Medicine & Community Health.  He also co-taught evidence-based practice in the Duke Physician Assistant (PA) Program.  Dr. Jackson currently maintains appointments as an Adjunct Professor of Population Health Sciences at Duke and Adjunct Professor of Health Policy and Management at the University of North Carolina at Chapel Hill.

Zullig

Leah L Zullig

Professor in Population Health Sciences

Leah L. Zullig, PhD, MPH is a health services researcher and an implementation scientist. She is a Professor in the Duke Department of Population Health Sciences and an investigator with the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham Veterans Affairs Health Care System. Dr. Zullig’s overarching research interests address three domains: improving cancer care delivery and quality; promoting cancer survivorship and chronic disease management; and improving medication adherence. Throughout these three area of foci Dr. Zullig uses an implementation science lens with the goal of providing equitable care for all by implementing evidence-based practices in a variety of health care environments. She has authored over 150 peer-reviewed publications. 

Dr. Zullig completed her BS in Health Promotion, her MPH in Public Health Administration, and her PhD in Health Policy.

Areas of expertise: Implementation Science, Health Measurement, Health Policy, Health Behavior, Telehealth, and Health Services Research

Bosworth

Hayden Barry Bosworth

Professor in Population Health Sciences

Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)  at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities. 

Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.

Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy


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