Original Research

Trends in VA Telerehabilitation Patients and Encounters Over Time and by Rurality

Telerehabilitation fills a need and helps ensure treatment adherence for rural and other veterans who find it difficult to access health care.

Fed Pract. 2019 March;36(3):122-128

Author(s):

Diane C. Cowper-Ripley, PhD

Huanguang Jia, PhD

Xinping Wang, PhD

I. Maggie Freytes, PhD

Jennifer Hale-Gallardo, PhD

Gail Castaneda, PhD

Kimberly Findley, RN

Sergio Romero, PhD

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References

1. Shane L. What’s in the VA secretary’s 10-point plan to reform his department? https://rebootcamp.militarytimes.com/news/pentagon-congress/2017/02/28/what-s-in-the-va-secretary-s-10-point-plan-to-reform-his-department. Published February 28, 2017. Accessed November 21, 2018.

2. Burgess JF, DeFiore DA. The effect of distance to a VA facility on the choice and level of utilization of VA outpatient services. Soc Science Med. 1994;39(1):95-104.

3. LaVela SL, Smith B, Weaver FM, Miskevics SA. Geographical proximity and health care utilization in veterans with SCI&D in the USA. Soc Science Med. 2004;59:2387-2399.

4. Piette JD, Moos RH. The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction. Health Serv Res. 1996;31(5):573-591.

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7. McCarthy JF, Blow FC, Valenstein M, et al. Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers. Health Serv Res. 2007;42(3):1042-1060.

8. Mooney C, Zwanziger J, Phibbs CS, Schmitt S. Is travel distance a barrier to veterans’ use of VA hospitals for medical surgical care? Soc Sci Med. 2000;50(12):1743-1755.

9. Friedman SA, Frayne SM, Berg E, et al. Travel time and attrition from VHA care among women veterans: how far is too far? Med Care. 2015;53(4)(suppl 1):S15-S22.

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14. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil. 2017;31(5):625-638.

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18. Tousignant M, Boissy P, Corriveau H, Moffet H. In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of- concept study and costs estimation. Disabil Rehabil Assist Technol. 2006;1(4):209-216.

19. Sanford JA, Griffiths PC, Richardson P, et al. The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: a randomized clinical trial. J Am Geriatr Soc. 2006;54(11):1641-1648.

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Historically, the Veterans Health Administration (VHA) has excelled at improving veterans’ access to health care and enhancing foundational services, such as prosthetics and other veteran-centric services, and this continues to be the VHA’s top priority.¹ Travel distance and time are often barriers to accessing health care for many veterans.^2-11 For veterans with disabilities who must overcome additional physical, cognitive, and emotional obstacles to access vital rehabilitation services, these geographic obstacles are magnified. Further compounding the challenge is that rehabilitation therapies frequently require multiple encounters. Telerehabilitation is a promising solution for veterans in need of rehabilitation to regain optimal functioning. This alternative mode of service delivery can help veterans overcome geographic access barriers by delivering health care directly to veterans in their homes or nearby community-based outpatient clinics.^12,13

A growing body of evidence supports telerehabilitation. In a 2017 systematic review and meta-analysis, Cottrell and colleagues reviewed and analyzed data from 13 studies that met their inclusion criteria; specifically, their meta-analytic sample comprised adults aged ≥ 18 years presenting with any diagnosed primary musculoskeletal condition; treatment interventions via a real-time telerehabilitation medium, trials that had a comparison group with the same condition; provided clinical outcomes data, and included published randomized and nonrandomized controlled trials.¹⁴ Based on their aggregated results, they concluded that real-time telerehabilitation was effective in improving physical function (standardized mean difference [SMD], 0.63; 95% CI, 0.92-2.33; I², 93%), and reducing pain (SMD, 0.66; 95% CI, −0.27- .60; I², 96%) in patients with any diagnosed primary musculoskeletal condition.¹⁴

Two other systematic reviews conducted by Pietrzak and colleagues and Agostini and colleagues also demonstrated the clinical effectiveness of telerehabilitation.^15,16 Clinical effectiveness was defined as changes in health, functional status, and satisfaction with the telerehabilitation services delivered. The studies examined in the review included those that provided online self-management and education in addition to exercise via teleconferencing in real time.

Pietrzak and colleagues found that Internet-based osteoarthritis self-management interventions significantly improved 4 of 6 health status measures reviewed (ie, pain, fatigue, activity limitation, health distress, disability, and self‐reported global health).¹⁵ User acceptance and satisfaction were high (≥ 70% satisfied) in all studies meeting the inclusion criteria.

Agostini and colleagues found that telerehabilitation was more effective than other modes of delivering rehabilitation to regain motor function in cardiac (SMD, 0.24; 95% CI, 0.04-0.43) and total knee arthroplasty (Timed Up and Go test: SMD, −5.17; 95% CI, −9.79- −0.55) patients.¹⁶ Some evidence from VHA and non-VHA studies also support the use of telerehabilitation to reduce health care costs,^17-19 improve treatment adherence,^12,20 and enhance patient physical, cognitive and mobility function, as well as patient satisfaction and health-related quality of life.^13,21-24

Since the first recorded use of telehealth in 1959, the application of technology to deliver health care, including rehabilitation services, has increased exponentially.¹⁴In fiscal year (FY) 2017 alone, the VA provided > 2 million episodes of care for > 700,000 veterans using telehealth services.²⁵

Although the process for accessing telerehabilitation may vary throughout the VA, typically a few common factors make a veteran eligible for this mode of rehabilitation care delivery: Veterans must meet criteria for a specific program (eg, amputation, occupational therapy, and physical therapy) and receive VA care from a VA medical facility or clinic that offers telehealth services. Care providers must believe that the veteran would benefit from telerehabilitation (eg, limited mobility and long-distance travel to the facility) and that they would be able to receive an appropriate consult. The veteran must meet the following requirements: (1) willingness to consent to a visit via telehealth; (2) access to required equipment/e-mail; and (3) a caregiver to assist if they are unable to complete a visit independently.

In this article, we provide an overview of the growth of telerehabilitation in the VHA. Data are presented for specific telerehabilitation programs over time and by rurality.