GRECC Connect - Overview
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 15 sites having established consultation and support for rural providers in their catchment area.
- Atlanta/Birmingham VAMCs
- Bedford VAMC
- Bronx VAMC
- Canandaigua VAMC
- Central Iowa VAMC
- Durham VAMC
- Eastern Colorado VAMC
- Little Rock VAMC
- Madison VAMC
- Miami VAMC
- Palo Alto VAMC
- Pittsburgh VAMC
- Puget Sound VAMC
- Salt Lake City VAMC
- San Antonio VAMC
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, 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 GRECC Connect 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.
- Served through provider education or consultation a total of 887 and 1099 Veterans (in FY14 and 15 respectively), among which 786 and 976 were Veterans from rural or highly rural areas (in FY 14 and 15 respectively).
- Provided education and support to 266 providers and staff in FY14 and 549 in FY15.
- In FY15, our consultations helped identify additional care needs for older Veterans; including such services as HBPC, home nursing care, respite care, meals on wheels, neuropsychological testing, counseling, and caregiver support in summary, about 11% of Veterans had VA or non-VA additional services (such as HBPC, home nursing service, respite services, meals on wheels or others) recommended or ordered, 12% had neuropsychological testing (recommended, ordered or provided remotely), 16 % received counseling on geriatric issues such as falls prevention, dementia caregiving and recommendations for driving cessation.
- Additionally, consultation with GRECC teams have led to improved use of medications including avoiding potentially inappropriate medications, addition of appropriate medications, or adjustment of doses of medications (approximately 0.5 medication change per Veteran served).
- Feedback from providers and staff participating in the case based education series indicate that overall satisfaction was high (on average 4.4 on a scale of 1 to 5 (1=strongly disagree and 5= strongly agree)); providers and staff reported learning new knowledge and skills (on average 4.2 on a scale of 1 to 5).
- We estimated from a sampling of surveyed Veterans utilizing CVT that Veterans satisfaction was high (4.3 on a scale of 1 to 5), and most agreed that they would continue video telehealth rather than travel long distances (4.4 on a scale of 1-5).
- Total mileage saved for Veterans served in FY14 and 15 was 89,692 miles and 94,470 miles respectively, with an average of 101 and 86 miles per Veteran served, thereby improving access of geriatric care to rural Veterans.