Joint Session with ACEP Geriatric Emergency Medicine Section

- All right, everybody. It's two minutes after the hour. Happy Tuesday before Valentine's Day. Hopefully some of you are getting snow. Here in Boston, we got nothing despite school being canceled for all the snow we are supposed to get. So welcome to the monthly telehealth section meeting for ACEP. I'm really excited. This is a collaborative meeting today too. I think, Dr. Kennedy, I saw you on here too for the ACEP Geriatric Emergency Medicine section too. So really excited to have those who may not have been to our meetings before. As you see, we start two minutes after the hour and we roll right into everything. So I'm Emily Hayden. I'm the chair of the section. And really excited about helping emergency medicine better understand how we could be using the tools of telehealth. So really excited about today with using telehealth for the older adults, where for a lot of people reflexively think that, well, digital literacy is not the highest for potentially older adults and older adult patients. However, there are ways that we can still use these tools, and so we are lucky to have Dr. Colleen, I'm gonna say your name, hopefully correctly, McQuown. Correct or no?

- Yeah, that's good.

- Perfect. All right, great. So she is gonna be presenting on her SCOUTS program here and she also has her colleague Maria here also. So I'm actually going to hand the microphone over to you, Dr. McQuown, for you to do a more formal introduction of yourself and what you want this group, or these groups to know about you as well as for Maria.

- All right, thanks. So yeah, Colleen. I am a physician at the Louis Stokes Cleveland VA Medical Center. And then I also work with Central VA as well on many different projects, several which surround the use of former military medics. And then I'm also joined by my colleague, Maria Wesloh. So she's an intermediate care technician with the US Department of Veterans Affairs, also helping me with it as an implementation specialist as we spread the SCOUTS program around. And then Maria is also still in the reserves as an aeromedical evacuation technician with the 315th aeromedical evacuation squadron. So she's still putting in her weekends and flying all around the world, picking up patients and driving them around. So I'm gonna go back right in. So the great thing about working at the VA is that we have a lot of older patients that we are able to take care of. More than 50% of the patients coming to our emergency departments are over 65. And the VA has a goal of being the best at geriatrics. We are never gonna be the best at trauma or peds, but we can be the best at geriatrics. So throughout the VA's 110 emergency departments, we are actively implementing geriatric ED programs, getting geriatric ED accreditation. I think we're up to around 70 or so right now of our 111 eds are geriatric accredited. And so we thought, okay, if we're doing all this stuff in the emergency department, what else can we do? We're identifying these high risk older adults. We're, we're doing things in the emergency department to help them transition home. We're trying to get more of them home, but what else can we do? And the idea with SCOUTS is supporting them once they've been discharged. So what can we do to make sure that when they go home, there's a smooth transitions of care and that we're sending the right people home and that we're sending them into a safe environment. And so the idea came up with, with SCOUTS and the idea with SCOUTS is that we can use this unique group called Intermediate Care Technicians, which are former military medics, corpsman or like Maria, medical technicians, same essentially all military medics that different branches call them different things that work in within the VA as unlicensed assistant personnel. So even though they have tons of training and take lots of classes and year, and years of experience in the military, there's no license that they have when they leave the military. So we have a unique role at the VA to use them at their highest level of their knowledge and skills in a little bit different way since in the military they're really not kicking it with Vietnam veterans, but we are here at the, at the VA, so a little bit different. So they get some extra training on geriatrics, doing geriatric screens. And then for these, for the SCOUTS program, additional training on doing home visits. And that is a QR code right there that lets you know a little bit more about the ICT program within the VA. And so the idea with SCOUT is that we identify these older adults that live in the community while they're in the emergency department. So the focus isn't on nursing home patients, it isn't on patients necessarily being admitted to the hospital. It's about people going home. And with SCOUTS, we identify them as high risk. And then after they leave the emergency department, an emergency department based ICT does a home visit. And the ICT, we try to get out there within a few days. Sometimes we specifically schedule them a little bit farther out. For instance, if someone needs packing removed or sutures taken out, the home visit may be a little bit farther out, but the ICT goes to the home, does geriatric screens, anything that we normally would've done in the, in the emergency department but may not have done. Or they may be at an emergency department that does incident level one, geriatric ed, maybe they're level three. So they do fewer screens. We ask questions about social determinants of health. We try to identify what matters, we're in their home, we can look around and see a little bit about what matters, but also we can see their, their pets and their living situations. So trying to figure out how do we fit their healthcare into their life rather than fitting their life into their healthcare. And then while they're in the home, the ICT acts as a telepresenter and video visits back with either an an ED doctor, an ED physician's assistant and says, hey, these are the screens. This is what they were in the emergency department for. And that allows the video visit then can use, can see what the patient's wound looks like, see what their cellulitis looks like, and also see what their house looks like as well because we're also looking for fall risks in the home and other home safety risks. And then we come up with a plan to address those unmet needs, those geriatric screens and then hand all of it over to their primary care team because we don't want to continue owning the patient. We just wanna own their acute ED visit and make sure that they're transitioning back. And one of the reasons that we're doing this out of the emergency department is we know even within the VA, which is a great integrated healthcare system, we just can't get people in to see their primary care that fast after they've been in the emergency department. So it allows the ED to own that whole thing. And then we also can say, yes, I sent the right patients home as well and I can send more patients home because I know I'm, one of my ED ICTs is gonna be seeing this person in two days. And then these are the types of equipment that we actually might carry in the car when we go out and visit the patients and actually give them some of these things. So we can say, okay, you can be safely in your home. We can help you organ, Help you by giving you this to organize your meds. Your daughter's here right now. We can say, Hey daughter, can you please fill this 31 day pill box or the patient has a, is a fall risk. We can see how their gait is and see if we can do anything to support them from falling. So this is just some of the examples of the equipment. We've done some program analysis looking at our original six pilot, six sites when we started as a pilot in 2021 with this program. So we started at six different sites across the country and we did propensity matching. So we made sure that our SCOUTS patients that were studying were very, very similar to patients that were, were eligible for SCOUTS but for whatever reason they didn't have a SCOUTS, there was no SCOUTS available on that day or whatever. But we try to match them as closely as we can to see hey, are we making a difference in their outcomes? And when we looked at our, our SCOUTS patients versus our general 65 and older patients we're like, okay SCOUTS patients, we're identifying the right patients. They're older than the general 65 and older patient population, they're more frail. So at the VA we have something called a CAN score, which is a computer generated score of of frailty. Our SCOUTS patients were higher users of ED resources. They're more likely to have been in the emergency department in the last 30 days and also more likely to be hospitalized. So this is a group of patients that are using resources and are frail. And what happens when we have a SCOUTS visit? Well they're a lot less likely to be admitted to the hospital. They're a lot less likely to come back and get admitted to the hospital in the next 30 days or the next 90 days. And they're also a lot less likely to come back to the emergency department. We did not decrease our 30 day ED revisit rate. However, we also think that's a win because if we sent a lot more patients home and we didn't have an increased rate of them coming back, then that's a pretty good, then we then we are also winning if they're not coming back and getting admitted and we sent a lot more patients home. And then when we looked at patients, just of the ones that were, that were discharged, so not including patients that you know from the emergency department could have been admitted or could have gone home. So only the patients that went home. We found that many more of our SCOUTS patients had durable medical equipment ordered for them, many more of them, so saw referrals to social work and within the VA social work is acts a lot more like a patient navigator to help people and veterans and their families get access to all of the different benefits that veterans get such as respite care, home health aides and then also referrals to community services as well, especially like the area agency on aging. So they're doing a little bit different job than a social worker might in a community emergency department. And then also we had decreased 72 hour ED revisits of just the patients that went home as well. And our patients were very happy. And this is one of our, this is one of our couples that was seen out of the San Diego VA. And our veterans love it. Two reasons, one, they like the extra care that they get. They also really like having, because our ICTs are veterans themselves or they're active such as Maria who is still serving, our veteran population really likes having those kind of medics come out. They're like, "When I was in the military I trusted the medic, they got me through Vietnam. I'm gonna trust the medic to tell me what else I need." And sometimes they're a little bit more open to VA and community resources than they otherwise would've been if it was a different type of person doing the, the video visit or doing their home visit. And then we looked at the cost savings for the first few years, just in really in hospital avoidance admission costs. And we thought okay, we saved a lot of money, we saved a lot of bed days, which in the VA is also important because that's more patients that we can transfer out of a community hospital and into our hospital. So we really would like our veterans to be admitted to VA hospitals and we know sometimes we just can't get them or they go to community hospitals 'cause of their closest. But this allows us to open up some beds that we can get those patients to us. And then we had very high patient satisfaction rates. So either very satisfied or satisfied. And then we've also had a lot of great wins. So this is a quote from one of our patients that the ICT got to their home and found that they were having a mental health crisis and credited the ICT with saving their life. And then some of our programs have done a little bit different takes on the SCOUTS just to make it work for them. So in San Diego actually instead of having the ICT these, so these are emergency department based ICTs, but when they actually do the SCOUTS visit, instead of staffing it with an emergency department provider, they actually staff it with an acute care geriatrician. So this is a geriatrician that has a special clinic that's set up for just doing acute care and staff these patients, and they also then can get connected with other geriatric services. And then Durham VA also is doing something special where they identify patients that have mobility issues or fall issues or functional issues. And they actually will have a physical therapist who does consults in the emergency department. But the physical therapist will actually do a video visit with the patient and then see how the patient's doing in their home and then recommend different equipment and different next steps, some of which may be following up with one of the VA outpatient physical therapist. But these are physical therapists that are doing ED consults that also do our SCOUTS visits. And this is one of the quotes from the physical therapists. All right, and then Palo Alto is one of our other sites and they have incorporated a program called VIONE into their SCOUTS visits. And VIONE is basically a de-prescribing based on not using medications or having inappropriate medications or they're not that, the patient no longer needs them. Like everyone should be on a proton pump inhibitor for the rest of their life. And so they do additional deep dive into their medications and actually do de-prescribing during their SCOUTS visit as well. And this is one of my favorite pictures of of why SCOUTS is so important, especially to our rural veterans. This picture over here on the left is actually one of the ICTs took the picture while driving to a patient's home. You don't necessarily think of Palo Alto and California as being in a rural site, but we serve, our VAs serve large catchment area. So this patient's house was about two hours from the medical center and the last 10 miles was on a dirt road. And so this older vulnerable adult was able to stay at home rather than having to make the like five hour round trip to come to the medical center for a follow-up visit. And the ICTs were able to do a lot of connections in the home and connect them to other services while there. And then Dallas, one of our other sites, had a great find, they were in the patient's home and the, the patients had been falling and he said something like, "I don't know if my life alert button worked". So the ICT checked it and it was not working and it turned out that the area had been upgraded from a 3G network to a 5G network and all of the Guardian Life Alerts no longer worked that were on 3Gs. And so 1500 veterans then got their, their Guardian Life Alert recalled and replaced to be compliant with the current networks around there. And I'm gonna turn it over to Maria to talk a little bit about how we implement SCOUTS and how we use SCOUTS with our telehealth.

- Good afternoon. So for our SCOUTS that go through the training process, we follow a block training guide where the SCOUTS are completing these computer-based trainings and then they move on to doing their competencies and go do some ridealongs with home-based primary care to learn hand eye technique. And then if there the need is allowed, they can go to a neighboring site such as Durham or somewhere close to them if they wanna do ridealongs with the SCOUTS programs that are already implementing and see how the op, the visit's done. And so once they complete all that training, they can move on to starting their actual SCOUTS program and seeing patients. And the first thing is identifying which patients they want as a SCOUTS visit. So for a lot of them, like Dr. McQuown said, you know, it's those falls risks, they're having that functional decline. And so we go out there and just see what one of our programs has where we go on with the video connect and we are on with physical therapy walking through their house from the very front of the threshold and seeing that they have those falls risks. Do they have rugs that are in the way? Do they need a chair in the bathroom, a elevated toilet seat? And so we can get that through and you know, just see what exactly that they need. Do their tub need to be transformed into a walk-in shower? So and then also that follow-up care. If a patient got sutures placed in the emergency department and like you, like we showed in that picture, that patient was far away, could they go out to that patient's home now and remove those sutures instead of having them come out? Those are a few of the things that we can do for those patients. And we also follow that SCOUTS playbook that gives us a step-by-step instruction. Also it does like that pre-interview questions also. So do you have any dogs? Those are important things that we need to know. Do you have any guns because we're all veterans and we have guns. So just make sure that those are put away, these don't deem a, a patient not eligible for a SCOUTS visit. It's just some safety questions that we ask on our part and just know like if, do they have a signal out there because if they don't have a signal we're gonna have to figure out a plan B, right? Because we can't use that iPad or that cell phone. So these are certain things that we use our playbooks for and those prescreening questions and that's about it. Like that's what we do and then tie it together and come back to the facility and do that SCOUTS note and chart in there everything that happened and that way it can flow over into our data system.

- So, so some of the ways that our SCOUTS can see our patients, we're following up on patients that were either seen in a VA emergency department or potentially seen in a community ED. And then also as we expand our VA's emergency telehealth services patients that call into our nurse triage line and end up talking to and doing a video visit or a telephone visit with one of our ED VA providers, they're also eligible for a SCOUTS visit. And so this, the idea with some of those is that we can keep patients from even having to come into the emergency department at all potentially by getting a SCOUTS visit and getting that TelePresenter role. So it's kind of preventing in-person emergency department visits and then following up after emergency department visits as well. And then we're also tackling patients that were seen in community emergency departments to try to get them back into VA services as well. So we have some sites that are, have gone live already. We're implementing in a few, in a few more sites right now. And really just trying to see, this is kind of the first proof of concept of using a TelePresenter in the home within the VA. We have several other programs where TelePresenters are used and they're more of a facilitator of kind of just like this is the equipment. So I'm at a primary care building or a contract building, we don't have oncologist where we are, I'm gonna do a video visit with an oncologist that it's at a VA that's in another state. And so those kind of TelePresenters are more just helping to hook up to like the digital otoscope or the wound camera, those kind of things. Whereas our ICTs as TelePresenters being medical people also they in addition to assisting with physical exam or doing technology to do exams, they can also are doing those home safety checks and doing those additional geriatric screens and then helping us come up with a plan to take care of the patient's kind of whole health. And then also doing some of that care coordination to get them back to see their primary care team. So in the VA we have primary care teams that have a provider, a nurse manager or a nurse kind of case manager, pharmacists and social workers all in the same location, also most of them have mental health integrated in. So we've had ICTs actually staff visits with mental health providers instead of with an emergency provider as well. And just kind of really the idea with the SCOUTS is we just kind of figure out what they need because we know that you can just deal with one kind of, one aspect of of geriatric emergency medicine to keep people from coming back. You've gotta think of their meds and their fall risks and their social support and their caregivers being stressed out and all of these different things that really need to be addressed to keep them out of the hospital and out of the emergency department. But we also know we're not gonna be solving all of these things. So figuring out what we can fix now. We can order you a tub transfer chair, but I'm not gonna be following you for the next six months to help you figure out how to manage your blood pressure better. That's going back to your primary care team, or being referred to one of the VA's home monitoring programs for blood pressure or COPD, or something like that. So it's really just figuring out what other services they need to be able to connect them to. And then also taking a bit of the weight off of what needs to be done in the emergency department as part of the geriatric ED and allowing us to get some of those things done in the home instead of having to do necessarily all of the screens in the emergency department that may, we may want. And it is, we're all happy and we're expanding we're, we've had another site go live this past week and we have three more sites we expect to go live in the next few weeks and then bring on at least seven sites in the next year, is seven more sites is in the next year as well. And lots of other people in the VA and are interested in this ICT as a tele presenter for other programs as well. And that is the end of our presentation and I'm gonna open it up to questions.

- Thank you so much for coming to present on this. I think as I'd mentioned at least to the telehealth section in this one it's just the couple things. One, to be able to highlight how telehealth can be used successfully, right with what you've shown for older adults as well as the creativity of having the ICTs. I know that they do other things in the VA system too, but to have them as the telepresenter piece too. The one that helps facilitate the telehealth calls. So it's really great to hear about this and I'm sure there's gonna be questions out here so I'm gonna open it up the floor now to, if anybody wants to, you can just unmute, you can put your hand up but we're, we're a very informal crowd right now, so please ask questions now your chance.

- The other thing I forgot to mention was that we are introducing our patients to using telehealth as well and in the VA you can actually some of our veterans, many of our veterans, especially our older veterans, will qualify for a VA issued tablet to be able to do video visits in the future. And our patients that have had SCOUTS visits are seven times more likely to do a video visit in the next year after a SCOUTS visit than those match controls that did not. So it also helps them to adopt telehealth themselves.

- Hi. My name's Kathy Li, thanks for such a great presentation. This is awesome work. I'm curious just from a, like a logistical standpoint, you know how many, 'cause it sounds like some of these veterans are, are quite far away or quite remote, you know is one ICT doing one visit each day or like what's the like kind of referral volume for a given site and, and your capacity to handle that?

- Sure. So our smallest VA that's participating sees about 9,000 patients a year. That's Grand Junction, and our largest one is Dallas and I think they are in the 40 to 50,000 range. And so Dallas has like 10, 15 at different ICTs that take turns being okay, this week I'm an ED ICT versus I'm an a, a SCOUTS ICT this week. And some sites just have ICTs that are dedicated to mostly doing SCOUTS and identifying those high risk older adults in the emergency department. And so some of our, we have an obligation to serve our rural veterans as well as our urban veterans. And so we try not to put too much restrictions on how many patients that you could see because if you prevent one hospitalization, you might have just prevented, you know, I think our, our average hospitalization for over 65 to a general medical floor is like $18,000. So even if your ICT saw one patient in a whole day, if they prevented one hospitalization that, that has paid for itself. So about 25% of our patients that we've seen so far are in rural zip codes by the, I can't remember whatever the US Census defines as a rural zip code, and then the other 75% are in more urban areas. So, so typically I would say max of three patients in a day is seen by an ICT. Most of the time it's more like two or one and the other times they're doing things like doing, we also do callbacks afterwards. So we do callbacks a little while after the SCOUTS visit just to make sure people are connected back to their primary care team if they're having any issues getting scheduling or if to making sure that they have that equipment as well. And so some of our sites that are primarily serving rural patients may see just one patient a day.

- There's a couple of questions from Brock Daniels in the chat right now. One to say it's an amazing presentation, and then so how many visits do patients typically get? So you identify them and then they're gonna be seen by the ICT, are they seen just that one time 48 to 72 hours later? Are you seeing them a couple of times for the next few weeks? What's sort of the average and what's sort of the range?

- Yeah, so most of our patients are one visit, about 10% of our patients get two visits. And the idea is that for as much as we can, we're trying not to take the place of other programs that would the patients would benefit for. So you know, if you really would benefit from having a home-based primary care team. So where you have a physician and staff that all visits you at home and you never go to the medical center, so say you're bed bound, like you really should have that team and not, we're not trying to replace that and we're also not trying to replace if someone needs skilled nursing where they have wound dressings that are changed every day or hospital and home programs where someone's getting IV medications every single day for two weeks or something like that. And so we're really trying to just be like, okay, and especially since it's an ED owned program for the most part we have one site that works out of primary care but for the most part we want to just kind of get in there and make sure that we've safely sent this person home, identify some stuff and then and then hand it off. And the interventions that our ICTs are performing in the home, so suture removal, packing removal, they can also do things like get ear wax or foreign bodies out of ears. They can do a bladder scanner, take out a Foley catheter, they can, Maria help me out. What are the, some of the other other kind of minor procedures that we have on our, on our list? Splinting, taking splints off.

- Right Foley catheter insertion, that I&D packing removal or EPISTOPS, and if they needed a rhino rocket, if it was time to be taken out, there are several other things, suture removal, staple removal, wound, wound dressing, those types of things.

- And then formalized process to identify which older adults are high risk. So all of our emergency departments that are doing SCOUTS are geriatric emergency departments and many of 'em are either using some sort of fall screen, like a steady screen, you know, steady three question, are you falling or were was their visit for fall or using the identification of seniors at risk screen. So we don't say what sites have to do, we just say you have to have a process to identify your high risk older adults and some of them are a little bit different depending on their resources. You know Durham is awesome because they have a physical therapist that can do ED consults but some of our other sites don't have that so they're maybe less likely to focus on falls and more likely to focus on medication because they have a great pharmacy supported program. And so it just has to be a something and it helps because SCOUTS and geriatric ED are so, are so connected that SCOUTS help support the geriatric ED accreditation and the geriatric ED accreditation, how we're, how they're identifying their patients help support SCOUTS.

- Can I ask on that last thing you just said with the SCOUTS, the ICTs helping with the accreditation, I'm also curious too, is there a formal process for that, that follow up piece, right? Like that follow up piece in terms of back to the emergency department to say, wow, you know, you sent that patient home, we had the ICT go out there. Did you know that there was like, that like maybe next time we should have done in this way or we should be setting this up in our geriatric ED for a certain program. Has there been that formal knowledge transfer back to the EDs or, that's probably something on the wishlist and it's just, there's only so much time of the day.

- I mean those, these are ICTs that work in the emergency department so, it may not be as formal so much as hey that patient that you sent home the other day, I saw them, this is, this is what happened. Within the VA as well, we have the system where we can kind of communicate with each other by adding people's additional signers to a note. We kind of tag 'em on a note and so it's like okay you ordered this, you saw this patient, you thought they could be SCOUTS. Some of our sites actually use like a consult where they put in an order for SCOUTS and then when that SCOUTS visit is completed they'll get a message back so then they can see what, they can read the SCOUTS note and see exactly what happened.

- One thing I forgot to mention also is our tele emergent care, we have those doing sort of like the, the nurses are doing the triage and then the providers are following up and speaking to these patients who call in for an emergency visit, but doing it from home and those can also trigger a SCOUTS visit, keeping that patient at home from coming into the ED. So that's another perk of this whole SCOUTS program is that if they weren't sick enough to come into the ED, but we can go out there and put eyes on 'em and maybe do some follow up vitals or check out a wound that they have that they have concerns about and have that video there. So those are some of the perks that we have for that.

- I see some people that came on video so maybe there's some people that wanna unmute to ask their questions too. I could fill the whole time, so I can keep asking questions so don't worry everybody, but if you do, please do speak up. I just a question for you guys, what was the most surprising thing for both, for both of you?

- So I went on a actual, I was doing a ride along with Durham and the surprising thing was that it's, it can be anything that you encounter and we had the, it wasn't a worst case scenario, but our first visit, you know, unstable vital signs from patient while the patient was in the shower still when we arrived. And so we started doing his home assessment and when we came up there and that patient's vitals were completely unstable and so what we did was, you know, we let the provider know like these are the vital signs and they said, oh yeah, let's, let's call 911 and we did that warm handoff, so we're we can be there. And it was just, it was shocking to see like, oh okay, this is how this works and this is how we can help the patient. So it was kinda eye-opening. And then the other situation, the patient had, you know, an infection in his leg from where his sutures were being removed, but we utilized that as, okay, well let's get some antibiotics on that. Like not the ICT but the provider on and can prescribe and that, that veteran actually got his, his prescriptions from an outside instead of at the VA. But it was great because that way he didn't have to go all the way to the, the ER and be seen for his leg. Already, his per his prescription was waiting for him at the pharmacy. So those are the surprising things for me.

- I think one of the most surprising things for me, though it shouldn't be 'cause I love the VA, was that when we ran our numbers for the first time and we're like when we were going to the Office of Rural Health and asking 'em for funding we're, they're like, well how many rural veterans have you seen? We're like, well none of our places are really that rural like, you know, Grand Junction is but the other places. And then we ran our numbers and it was 25% of our patients were rural. And so it was like each of these sites took it on their own to be like, we're not, we're not gonna narrowly, like we're not gonna put limits on the patients that we see. We're gonna go wherever the patients are and serve them where, where they are. You know, and I think it just goes to the testament of how kind of the VA's mission to own, own our patients as well.

- Thank you. And Mike Baker, Michael Baker put into the chat, what resource, telehealth resource, telemedicine resource did like, were there gaps in the care or gaps in that you needed to develop yourself?

- So, you know, we started, we, our original funding was actually CARES Act funding. So Congressional Cares Act funding was what kind of, we got the seed money to start our first pilot program and I see Dr. Eids is on here with the VA's geriatric and extended care. So he was actually the one that kind of highlighted to us that hey, there's this funding out there where you can use it to treat, you know, to target use for telehealth and to prevent COVID and vulnerable population. So our idea was that okay, we can prevent our older adults from having to go to a facility where they might be exposed to COVID or having to go back to a primary cares office or, or be admitted to the hospital where they might be exposed to COVID and then it kind of grew from there. And then really for this patient population we, you know, as far as, so I guess I guess the point, first point is it was 2020 so everyone was growing telemedicine programs, so the VA was growing telemedicine programs. We're trying to see all of our patients at home and get them tablets and you know, who can get a tablet? Who can't get a tablet because not everyone, if you have your own cell phone that has video, you can't, can't get a tablet. And so I think we were all kind of growing at the same time. So it's hard for me to say we were having different, you know, telemedicine struggles. And the other thing about the VA is that they had already been doing telemedicine for several different programs before we started because we're not tied to that Medicare reimbursement that, you know, wasn't paying for telemedicine before. So we already had several telemedicine type of programs that were going on or in the works. One of the main things was that many of the emergency departments did not have telemedicine programs set up and so that was kind of new for them. Whereas some of the specialists or some of the nurse educators or some of these kind of monitoring programs such as blood pressure or blood sugar or weight monitoring programs, those were already set up but our ED docs that was new to them. And so teaching people, yes you can do a physical exam by video and certainly it's much easier when you have an ICT there as well. And just thinking, okay, this is the structure of how you fit in like in your workflow, getting an emergency visit, you know, getting a video visit. And we found it's worked, we've tried to implement this in primary care and we found that it's actually a lot easier to implement it in emergency medicine because we don't have a clinic fully scheduled months out of patients. And also it's hard to kind of time when the patient's ready to get seen because maybe your, you know, Google map says it's gonna take 20 minutes to drive, but it actually takes 35 minutes to drive and then the patient wants to, it's in the shower when you get there and so you don't start the visit right away or you know, they wanna tell you about their dog and show you their house first and, and you know, and you need that time to get rapport before you're like, okay, we're ready to video back in. So having it being ED docs that are doing telehealth is makes it a lot easier to, to be able to implement the program.

- Great. Dr. Mike Ross, you have your hand up.

- Sorry. I'm interested, I'm interested in the, the barriers to the use of telemedicine by elderly patients in a way you have, you, you you've set up a provider for provider telemedicine where your, the providers on the scene perhaps help the elderly adapt the use of telemedicine. I can, have you, can you summarize what, what you found are barriers to the use of telemedicine for geriatric, in your geriatric population? Is it equipment? Is it software? Does that make sense?

- Yeah, we found, you know, there's been studies, you know, non VA studies as well that shows older patients may be, they're not opposed to telemedicine, they're just not telehealth ready.

- Yeah.

- They weren't born with an iPad in their, in their hand. And so if you're going to set up a visit with them for the first time, you know the provider, you know, the ED provider will be like, okay, this the first video visit this patient's ever gonna done, the VA sent them their iPad, it's all set up and then they spend 20 minutes just trying to get them to get the camera facing the right direction. And so it's, you know, and sometimes you find that older adults are less comfortable just tapping buttons and hitting things until they figure out how it works. Whereas like, you know, your five-year-old will just pick up your phone and they're not afraid of hurting it and they will just do things till like it, they can get it to work and do what they want. And so it's getting them comfortable with these things are really not breakable. You're not gonna like crash the whole system if you the wrong button and just showing them, you know, this is all you need to do is you open it up and you hit this button to connect to your appointment and you can turn it around this way. And so they're, 'cause our ICTs are using tablets as well, so they're really just modeling to the patient how they can do a video visit. And some of our patients just love it and they wanna do visits like that in the future because it really saves them a drive in as well. So I think it's, and it's really, the VA does have a service where they can send you a tablet and then they can call you on the phone and talk you through how to get it set up. But it's just not the same as having someone like physically there show you how to set it up. And then also our ICTs, if there's other, the VA does when you do, for instance, you're in the program where the, the VA's monitoring your blood pressure, they send you a blood pressure cuff and then it's blue Bluetooth and it sends information back or you have a insulin, or a, you know, glucose monitor or a digital scale or something like that. So the ICDs can also show them those kind of equipment and how it works and make sure it connects while they're in the home. So it's kind of like a white glove service.

- Just, I'm just gonna , because Emily gave me the opportunity to. My name's Maura Kennedy. I am the chair of the Geriatric Emergency Medicine Section and really thrilled to co-host this with Emily, or quote unquote co-hosted. Emily basically did all the work and I just jumped on the band wagon. I really am excited to have this opportunity for our sections to collaborate. And so if any of you have questions pertaining to older adults and telehealth, please reach out to us. 'Cause I think really there's a lot of work that we do that really can help each other. So one of the things that I think a lot about in older adults is not just that they're older but all the comorbidities that they have, so that maybe hearing impairment, vision impairment as well as cognitive impairment and those can contribute to their ability to use telehealth resources. And so that's where a program such as this that sort of facilitates the telehealth component can address some of those disabilities that they have. And though those are more common in older adults, they also occur in, in younger adults with disabilities, including I'm sure veterans with traumatic brain injuries for instance, who could provide or, or hearing impairment from, from service that could use the added support of having this facilitated telehealth event.

- Thanks Maura. And yes, thanks for collaborating on this. Carla Clements.

- Hi, yes, good afternoon. So I'm Carla Clements, I'm the service chief for the Office of Connect the Care here in Philadelphia. And I just wanted to comment on the questions regarding the use of technology with the older adults. Some of the best practices that we are presently using in Philly is in addition to the 24 hour, as Dr. Colleen said, the white glove, we actually have on site five days a week a walk-in service in the Office of Connected Care where veterans can actually come on site and we do the one-to-one. And the other best practice that we found with the technology, we, we incorporate the caregivers. So the caregivers, when we usually do the test calls is what we call them, we pretty much make sure that there's a caregiver, whether it's a grandkid or a wife or so forth. And I have to say that our outcomes have been pretty well, even with our geriatric population along with the digital divide consults that you referenced, which we ensure that all the veterans who are eligible with our social work colleagues that they do have access to the iPads. So just wanted to bring that up as well.

- Thanks so much Carla. It's, you know, one of those things, it's like if you know one VA services, you know one VA services, so that is awesome to know that Philadelphia has that. It's probably, you know, now I can go back to all our SCOUTS teams and say, hey, have you talked to your local Office of Connected Care and seen all the other services that they can do to support your veterans? So it's, we're always learning new things that we can do. And so certainly the other plug I'd like to make is if you see someone in your emergency department and you're not at the VA, and they are a veteran, please encourage them to become a patient with the VA because we can do so much for them. And sometimes especially our older adults, they may not have been VA patients in the past and some of that is due to the eligibility because they, if you weren't in combat or you weren't injured in the service, you may, you're, the types of services you can get at the VA are based on your income. And we find that we get a lot of patients that they've retired and now they're on a retirement income and now they're actually qualifying for more VA services because of that new income. So like my father became a VA patient after he retired and loves the VA. So if you see patients encourage them, we are always wanting to, to bring our veterans back into their, this integrated care system. And sorry if you're frustrated and you're trying to transfer a patient out of your emergency department to the VA, and it's not getting anywhere, everyone's struggling right, right now with beds and we're trying to get them at home as much as we can. So, but as much as we can. All right, I see a question.

- Yeah, Kathy, you just, whether similar programs are being disseminated outside of the VA. Kathy, what do you mean by that?

- Oh, I just meant like, you know, this is great and it clearly works for, for veterans who are within this like integrated VA health system. I didn't wanna interrupt earlier and, and so I'm curious if, you know, I know you're trying to disseminate it just within the VA to start with, but I'm curious if others have heard of, you know, similar, similarly targeted programs that have been successful outside of the VA.

- Yeah, so.

- Emergency rooms,

- There was a great geriatric ED collaborative on community paramedicine that was a couple weeks ago, that if I try to find the link I will put it in the chat. But there's pockets and typically outside the US, Canada is doing it, Ireland is doing it. Other, you know, other integrated healthcare systems. Within the US, it is most of these type of programs are associated with accountable care organizations. So they're going to eat the cost if they have all of their heart failure patients come back and get readmitted. And so they're, they may be targeting specifically heart failure patients. So I think that's like the Cornell system, New York Presbyterian. So there's pockets of these programs kind of popping up throughout the US. The difficulty is payment, you know, it's--

- Yeah.

- Will Medicare continue to pay for video visits and you know, outside of Medicare, accountable organization who is gonna pay for this? So philanthropic donations or, or something like that. So, you know, we like to say at the VA we can prove the best way to do things and then, and then show other people how they can adopt it as well. But certainly if you're part of an accountable care organization, that is a way to be thinking about, you know, could we do this type of community paramedicine program that we own. And the, so the equivalent kind of role outside the VA is a, is a paramedic. So that's what most of the programs that do the similar kind of thing is the role that they're using.

- Yeah, I've heard of, I'm familiar with community paramedicine and have seen it kind of more in the role of maybe trying to avoid the ED visit in the first place and less so on the post ED side. So that's kind of, but that's good to know that that exists too.

- Yeah. Yeah, and I think the nice thing about if you go to that, Maura put the, the link in the chat, if you go to that link for the GEDC webinar, if you click on the different speakers, they have links to all of their literature and there's a great one that like the Irish government did that actually looks like did a, a review of all of the different programs that are doing this and their outcomes. And so both people that are, they're targeting don't send them to the emergency department and then also targeting after they've been in the emergency department, transitioning 'em back.

- Yeah, I would say the majority of emergency departments in their care transitions post discharge are doing more telephone follow up phone calls than mobile integrated health visits and home visits. And exactly what Colleen said, it's the payment model. The VA has this very unique opportunity to, to innovate because they, they know that initiatives like this, it doesn't matter if they can put a billing code to it and get reimbursed for this visit if they know that on the whole it is providing higher value care to their patients. And I think for organizations outside of the VA, they're either having to look at it exclusively from that risk management contract or looking at it for how it, the return it does for the hospital and other metrics such as increasing discharges so that there's fewer patients admitted and increases the capacity in their hospital. And so they have to look at the impact indirectly on the finances for the hospital. And I think that's a hard argument to make and it, it can be made but it takes, it takes knowledge, information and a receptive audience. And so that's why a lot of places do more follow-up phone calls. I think also the fact that post-care visits or post-care calls by case management, for instance, are not reimbursed for ED visits but they are for discharges. That's another area where we just are, are challenged in our healthcare environment is getting the reimbursement for the care.

- Thanks Maura. And I know, I don't think I see Judd Holland on today, but typically he will come up when we say this now too, is that even though we try to say we're trying to create more capacity that the, that the, to go to the chief financial officer of the hospital or of the healthcare system, sometimes they don't like to hear that as much as saying what's, how much are we gonna be able to, you know, cover the cost of this with what's brought in, which is very hard from the emergency medicine side for these types of programs too, so outside of the VA. So I'm looking at the time. We do need to come to a close 'cause all of us need a little break before we get to our next whatever is gonna be, Zoom or whatever. Really appreciate it, Maria and Colleen, thank you so much for coming in to present this. Thank you also for the geriatric emergency medicine section to join us on this afternoon/morning depending on where you are right now, and look forward to continued collaboration in the future. I know we have maybe some other presentations coming up in the future we're trying to schedule still. And yeah, everybody have a great rest of the day. Thanks so much.

- Thanks.