Geriatric Research, Education and Clinical Centers (GRECCs), located at urban tertiary medical centers, having already established geriatric teams, can serve as clinical and educational resource for outreach to rural clinics where geriatrics expertise is lacking.
The project connects GRECC teams based in urban areas with rural CBOC sites to provide education and clinical support through telemedicine means, thereby enhancing care provided by rural providers for older rural Veterans. The modalities used in each site vary, with all 18 sites having established consultation and support for rural providers in their catchment area.
The GRECC Connect project team has developed a network infrastructure of specialists to support rural providers using the resources of Geriatric Research, Education and Clinical Centers (GRECCs) located in multiple states. GRECCs in VISN 1, 2 North, 2 South, 4, 6, 7, 8, 10, 12, 16, 17, 19, 20, 21, and 23 have established links with rural CBOCs within their VISNs to provide clinical and educational support through a number of modalities, which varies by site based on GRECC resources and rural needs and interests. Below are summaries of the implementation of several modalities that have been developed within the Virtual Geriatrics project.
1. Regularly scheduled case-based conferences -- This educational intervention enabled shared expertise in outreach to rural primary care providers who are caring for older adult veterans age 65 and over. The format of these sessions includes a clinical case presentation, a brief didactic portion to enhance knowledge of participants, and an open question/answer period. The focus of this intervention is on challenging clinical case discussions, addressing common problems (e.g. driving concerns), and the assessment/management of geriatric syndromes (e.g. cognitive decline, falls, polypharmacy, etc.). The discussions are held using web-based teleconference technology, video conferencing with VANTS line as back up to connect rural providers with VA medical center geriatricians and GRECC care teams.
2. Electronic consultation—Geriatric teams from GRECCs provide electronic consultation to rural providers to address clinical needs by clinical referral and also condition specific case finding. An example of the implementation of this modality was in VISN 6 where the GRECC team identifies Veterans with osteoporotic fractures not currently receiving fracture prevention therapies using Corporate Data Warehouse monthly reports. Under a facility-wide standing order for, the project team provides expert chart review and CPRS electronic consultation to their primary care providers recommending any additional osteoporosis testing or treatment as recommended by current practice guidelines.
3. Virtual meetings with primary care providers and staff (telehuddle)—regularly scheduled meetings with primary care providers and/or staff where rural team has the opportunity to discuss specific questions on care for older adults with geriatric teams located in GRECC sites.
4. Clinical video telehealth (CVT)-- GRECC teams provided geriatric consultation to rural Veterans via telemedicine where Veterans only need to travel to their local rural CBOCs to be seen. An example is the telehealth clinics in VISN 6, which provides geriatric consultation and VISN 4 where the focus of the clinic is dementia and provides team based care for dementia and mild cognitive impairment. Via CVT the team can diagnose a cognitive decline, determine if there are any interventions that may improve cognition, educate caregivers about the disease and services that can ameliorate caregiver burden and provide assistance with disturbing behaviors that can develop in later stages of the illness. In VISN 20, a “telegroup” program was established, in which 6-10 Veterans and their caregivers meet at a more rural site, and a geriatric psychiatrist and geriatric social worker are at the medical center. They address medications, behaviors, caregiver burnout, and any other questions.
In FY21, GRECC Connect has successfully been implemented and expanded to an additional GRECC (Gainesville); GRECC Connect teams offered consultative support from 14 GRECC hubsites (17 VA Medical Centers; one with a GeriPACT team in Central Iowa) for a total of 128 CBOCs/ VAMCs serving rural Veterans.
The modalities used in each site varied, with all sites having established consultative support through clinical video telehealth or electronic consultation for rural providers and teams in their catchment area. In FY21, we served through provider consultation a total of approximately 500-600 unique Veterans in each quarter (486, 643, 653 and 578 in Q1-4), among which 54% were Veterans from rural or highly rural areas. Veterans were served by a number of modalities with the breakdown of service as follows: video visits (74% of Veterans), Electronic consultation (25%).
Consultation with GRECC teams have also led to improved use of medication through identifying and stopping potentially inappropriate medications such as medications that increase fall risk or with significant anticholinergic properties, modification of dosing to improve safety, and starting appropriate medications by treating conditions such as dementia and depression (approximately 0.84 medication change per Veteran served). GRECC Connect consultation also identify unmet needs that results in geriatric support services referred (0.49 services per Veteran served).
Total mileage saved among Veterans served in FY21 was 455,845 miles, with an average of 194 miles per Veteran served, which corresponds to a modest saving on average of $108 travel cost per Veteran estimated using standard mileage rate published from the General Services Administration (GSA). Table 1 summarizes project impact.
GRECC Connect project provided support or education to 1,767 clinicians (including providers and staff) in FY21 (6,488 unique clinicians cumulative since 2014). Clinicians impacted not only include physicians, nurse practitioners or physician assistants, but also registered nurses, social workers, physical and occupational therapists, pharmacists and other members of the interdisciplinary team. Table 2 summarizes project impact on providers and clinicians. Feedback from providers and staff participating in the case-based education series indicate that overall high satisfaction (4.4 out of 1 to 5 likert scale), with providers and staff reporting learning new knowledge and skills (4.3 on a 1 to 5 likert scale). Most indicated that GRECC Connect offerings advanced their knowledge, attitudes and skills to contribute to their VHA interprofessional team for patient care (4.3 on a 1 to 5 likert scale).