This document discusses increasing access to care for veterans with multiple sclerosis (MS) in rural areas through the use of telehealth. It describes how the Lake City VA Medical Center has established an MS clinic and uses telehealth to provide specialty neurology follow-up visits and physical therapy to rural veterans, avoiding thousands of miles of travel. Patient and provider satisfaction with telehealth services has been high. The aim is to demonstrate that telehealth can effectively deliver specialty neurology care to rural veterans living far from VA medical centers.

1. Increasing Access to Care for MS
Veterans in Rural Areas
Paul M. Hoffman, MD
Director
Veterans Rural Health Resource Center – Eastern Region
December 5, 2014

2. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 2
Office of Rural Health (ORH)
ORH Director
Secretary’s Veterans’
Rural Health
Advisory Committee
(VRHAC)Veterans Rural Health
Resource Centers
(VRHRCs)
VRHRC
Eastern Region
VRHRC
Central Region
Staff
Assistant
Budget
Analyst
ORH Deputy
Director
VRHRC
Western Region
VRHAC
Program
Analyst
VISN Rural Consultants
(VRCs) Program
Analysts
Health Systems
Specialists
Staff
Assistant
VHA Assistant Deputy Under Secretary for Health
for Policy and Planning

3. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 3
Lake City VAMC

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Distribution of Veteran and non-Veteran MS
patients in North Central Florida
MS Patients Self-Reported to NFNMSS

5. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 5
MS Patient Population seen at NF/SGVHS
• 283 patients with MS seen at NF/SGVHS
• 120 MS patients followed at Lake City MS Clinic
• > 45% live in rural or highly rural zip codes
• Majority are progressive (primary or secondary)
• VA MS population is older, more male and disabled than non-
VA population
• Access is a major issue due to disability and travel distance

6. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 6
• Neurology
• Medicine
• Physical Therapy
• Occupational Therapy
• Speech, Swallowing
• Social Work
• Hospital Referrals
• Psychiatry
• Neuropsychology
• Urology
• Nutrition
‘National Multiple Sclerosis Society Affiliated Center of
Comprehensive Care’ at Lake City, FL VAMC

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Care Coordination
Rural Mobility Evaluation Clinic
• Evaluation and comprehensive
care for rural veterans with
ALS, MS, SCI, PD, and
neurodegenerative disorders
• Maximize independence and
safety in the home and community
• Provide VA specialty care closest to the Veterans’ home

8. VETERANS RURAL HEALTH RESOURCE CENTER – EASTERN REGION (VRHRC-ER) - 8

9. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 9
Tele-presenter Demonstrating Reflexes

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Caregiver and Patient Satisfaction

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MS CVT NEUROLOGY FOLLOW-UP

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Care Extension for MS and SCI/D
in Rural NF/SGVHS
• 29 CVT-Neurology F/U visits in FY13-14
• Neurology and rehabilitation televideo consultation
to primary care practitioners in rural
Community-Based Outpatient Clinics (CBOCs)
and extension clinics
• Training and consultation with Home
Based Primary Care (HBPC) teams
covering rural areas
• Physical Therapy (PT) evaluation and
home exercise program

13. VETERANS RURAL HEALTH RESOURCE CENTER – EASTERN REGION (VRHRC-ER) - 13

14. VETERANS RURAL HEALTH RESOURCE CENTER – EASTERN REGION (VRHRC-ER) - 14

15. VETERANS HEALTH ADMINISTRATION (VHA) – OFFICE OF RURAL HEALTH (ORH) - 15
• Albany, NY
• Buffalo, NY
• Baltimore, MD
• Washington, DC
• Lake City, FL
• Seattle, WA
• St. Louis, MO
• Birmingham, AL
• Denver, CO
Participating Sites MS-CVT-Neurology Follow-up
Eastern Region Coordinator—
ORH/MSCOE-EAST
Amy Kunce
Western Region Coordinator—
ORH/MSCOE-EAST Affiliate
Sean C. McCoy

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Specific Aims
Demonstrate that Neurology Follow Up Visits can be
accomplished via telemedicine.
• Assess patient and provider satisfaction with telemedicine
follow-up visits
• Quantify the decreased travel time for rural Veterans
• Quantify the decreased transportation expenses for patient
and hospital
• Increase access to specialty care providers for rural Veterans
• Assess connectivity, dropped calls, and video clarity from hub
to spoke sites.

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NEUROLOGY CVT - FY 2013 & 2014
FY 2013
• 59 Unique Veterans Served ALL Sites
• 46% Rural Veterans
• Average of 3 hours of roundtrip travel/Veteran
• >95% Veteran Satisfaction
FY 2014
• 36 MS Veterans Served NF/SGVHS
• 16 Rural MS Veterans
17

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Rural Veteran TeleRehabilitation Initiative
(RVTRI)
• The RVTRI:
– Completed 205 initial evaluations
– Enrolled 127 veterans for ongoing care
– Generated a workload of 2134 encounters
– Reached Veterans in 30% (40/137) of our rural zip codes
(Veterans served lived an average of 93 miles from the
medical center)
• VHA Systems Redesign Champion Award –
Outpatient Category

19. Clinical Video Telehealth (CVT)
Home-based Physical Therapy
Exercise Intervention 19

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FY 2013 NF/SGVHS
• 37 Unique Veterans
• 210 Total Rehabilitation
Encounters
• Saving over 40,000 Travel
Miles and $18,500 in
reimbursement
FY 2014 NF/SGVHS
• 16 Unique Veterans
• 59 CVT Rehab Encounters
• Saving over 10,696 Travel
Miles and $4947 in
reimbursement
CVT-REHAB – Hub to Home NF/SGVHS

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CVT-REHAB – Hub to Home