Study provides blueprint for hybrid-virtual home visit model to support patients who do not live close to a hospital

INDIANAPOLIS -- In a new study, U.S. Department of Veteran Affairs (VA), Regenstrief Institute, and Indiana University School of Medicine research scientists Dawn Bravata, M.D., and Teresa Damush, PhD, helped lead a team that developed and successfully tested a hybrid-virtual home visit model that provides care to veterans who do not live close to a VA healthcare facility.

The results from the study demonstrate the feasibility of implementing a hybrid-virtual home visit model to care for high-risk, community-dwelling older persons. Two clinical cases illustrated how this model cared for patients who might not otherwise have received timely healthcare.

The researchers suggest a widespread deployment of hybrid-virtual home visit model programs will be required to support the veteran population as they age in place.

“We were able to successfully convert an in-person home visit, conducted by nurse practitioners and social workers, to a hybrid-virtual model where we had a telehealth technician in the patient’s home working virtually with the nurse practitioner and social worker to provide care,” said Dr. Bravata, a co-principal investigator and senior author of the study. “Having the telehealth technician drive to patients’ homes allowed the nurse practitioners and social workers to telework, which gave them more time to provide patient care."

The hybrid-virtual model, known as TeleGRACE, is an extension of the established Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program. VA-GRACE is a multidisciplinary care model which provides comprehensive home-based geriatric evaluation and management for older veterans residing within a 20-mile drive radius from the Indianapolis VA facility. TeleGRACE expands access to VA-GRACE services by enrolling patients living within a 60-mile radius. TeleGRACE provides all of the same services as VA-GRACE, except it’s a hybrid-virtual home visit instead of the in-person home visit. The VA has been seeking to expand access to evidence-based practices supporting community-dwelling older persons like the VA-GRACE program.

Case Examples

The first case examination followed a patient scheduled for a TeleGRACE enrollment visit after being discharged from a VA in-patient admission. Before the visit, the patient sought care for a leg wound in a non-VA emergency department closer to home. Working remotely, the nurse practitioner identified that the patient needed additional follow-up care for the wound. The nurse practitioner used pictures of the wound taken by the telehealth technician and sent them to the VA wound care service. The wound care team reviewed the pictures, determined the appropriate care, collaborated with the VA-GRACE social worker to order home-health wound care, and sent wound care supplies to the patient’s home, all during the single TeleGRACE visit.

“The patient would typically have had to go through a couple of clinic visits to receive the right care if it weren’t for the TeleGRACE visit. The telehealth technician provided the patient with the wound care they needed in one visit,” said Dr. Bravata.

In the second case, during a TeleGRACE enrollment visit, a patient who had been discharged from a VA inpatient stay 13 days prior became unwell. The telehealth technician obtained vital signs with the nurse practitioner participating remotely. The patient was then taken to the emergency department and admitted to the hospital for a 5-day stay. The patient told the emergency department staff and inpatient teams that the TeleGRACE program saved his life.

The researchers described the challenges encountered during the pre-implementation phase and the solutions they developed during program development.  

“Previous studies have identified that geriatric patients have difficulty connecting with virtual healthcare. The TeleGRACE program overcomes many of these issues,” said Dr. Bravata. “For example, consider patients with visual or hearing impairment or perhaps mild cognitive impairment -- it’s helpful to have the telehealth technician physically in the homes troubleshooting equipment and providing assistance.”

To implement the hybrid-virtual care model, five program domains required attention and problem-solving:

• Telehealth connectivity and equipment
• Virtual physical examination
• Protocols and procedures
• Staff training
• Team integration

This work was supported by the Department of Veterans Affairs (VA), Health Services Research & Development Service (HSRD), Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI) (QUE-20-010 and VA HSRD Research Career Scientist Award to Dr. Damush RCS19-002).

“Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits” is published in the Journal of General Internal Medicine.

Dr. Bravata is the co-principal investigator for this research study.

Authors and affiliations

Cathy C Schubert^1,2, Lauren S Penney^3,4,5, Ashley L Schwartzkopf^3,6,7, Teresa M Damush^2,3,6,7,8, Alaina Preddie^3,6,7, Soyna Flemming^3,6,7, Jennifer Myers^3,6,7, Laura J Myers^2,3,6,7, Anthony J Perkins^3,9, Ying Zhang^3,10, Dawn M Bravata^{11,12,13,14,15,16}

Affiliations

¹Geriatrics and Community Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.

²Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

³Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.

⁴VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA.

⁵Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.

⁶VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.

⁷Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.

⁸Regenstrief Institute, Indianapolis, IN, USA.

⁹Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.

¹⁰Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.

¹¹Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

¹²Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.

¹³VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.

¹⁴Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.

¹⁵Regenstrief Institute, Indianapolis, IN, USA.

¹⁶Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.

Dawn M. Bravata, M.D. 

In addition to her role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Dawn M. Bravata, M.D., is a professor of medicine and adjunct professor of neurology at Indiana University School of Medicine – Indianapolis. She also serves as a core investigator for the U.S. Department of Veteran Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center. Dr. Bravata is also a co-principal investigator for the VA HSR&D Expanding Expertise Through E-Health Network Development (EXTEND QUERI). 

Teresa M. Damush, PhD 

In addition to her role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief, Teresa M. Damush, PhD, is a senior research professor of medicine at Indiana University School of Medicine – Indianapolis. She also serves as a senior investigator for the U.S. Department of Veteran Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center. Dr. Damush is also a co-principal investigator for the VA HSR&D Expanding Expertise Through E-Health Network Development (EXTEND QUERI).