I appreciate the opportunity to participate in the program and share some of what we are
doing in the Office of Specialty Care and Specialty Care Transformation with you all
today.
I hope in the next twenty minutes that I'll be able to share with you this innovative
program and also do a demonstration of this program as well.
As Dr. Agarwal pointed out, this is a program initiative that really is targeted at enhancing
specialty care delivery in some of our more rural and remote areas of our country and
the Veterans that we serve in those more than 850 community based outpatient clinics that
have difficulty at times accessing specialty care.
This is an enhanced or different way of using the Telehealth technology to train and educate
primary care providers, who then over time, within one specialty care area, cardiology,
hepatitis C, HIV, become many experts or are able to deliver some basic specialty care
that is available through those primary care clinicians.
So I'm going to share with you a few words about or some specifics about the program
and then what I'd like to do is really demonstrate this program and what it's like you all will
be the audience and the primary care and will serve as one primary care provider participating
and we will get on up on the screen here our heart failure team in Cleveland as well as
a primary care provider in Warren, Ohio.
Who regularly participates in the heart failure SCAN-ECHO program.
This is based on a private sector program.
Dr. Aurora and project echo demonstrated the effectiveness of Hepatitis C ECHO and this
is an adaptation of this for not only for Hepatitis C but I'll show you some other specialty
care areas which we are adopting and adapting scan our version called SCAN ECHO for.
We see this as a knowledge transfer program where there is not physically a patient present
although telehealth technology is used as you'll see demonstrated on the screen multiple
providers dial in and have an opportunity to discuss cases so it is about patients and
real patients, although patients are not physically present at that time
This slideshow is a smaller version of what we have up on our map that we have better
on the table over there, which highlights some specific area that's where we are implementing
SCAN ECHO and what conditions we're doing that for.
Hepatitis C, pain management, diabetes, heart failure, chronic kidney disease, COPD and
even some preoperative vascular surgery some conditions that are extremely common in primary
care practice This is a map of the 11 centers that have
been funded in the locations across the country that serve as the specialty care hubs.
They are extended then to service not only in their own network but with the partnership
of office of rural health.
Rural health has enabled centers, excuse me, primary care providers that are not in a network
that have a center to also participate through that telehealth equipment
So I'll give you a few words about the process and then we're going to go to our live demonstration.
The primary care provider submits a case to the specialty care team and the team is not
only a specialist cardiologist but the team also is includes the clinical pharmacy specialist
that has expertise in heart failure.
A health psychologist as we'll see you on the screen in a moment who also has expertise
in heart failure as well as nurses and nurse practitioners who participate as a team-based
approach for heart failure care.
Multiple primary care providers will dial in and participate with that and there will
be a case or many cases that are discussed based on real patients that those providers
are encountering in their community based outpatient clinics.
In addition there will be a didactic session for which any providers that participate that
continuing medical education up within and those of didactic sessions are enduring materials
that have been developed to be used across nursing, pharmacy, for physicians, physician
assistants to get credit and they are based on the VA and Department of Defense clinical
practice guidelines.
Benefits of the program thus far we've seen some benefits in terms of the number of miles
that patients save because they are able to see a primary care provider and get some of
that heart failure care in conjunction with the specialist in their local community based
outpatient clinics And we're looking at improvements in terms
of patient indicators over the next period of time and really looking at the impact of
this program at the patient level and that they are getting the care from a provider
who knows them relatively well, who is connecting with the specialist and that relationship
enhances the care that gets delivered.
From the provider level, we've gotten in some preliminary data about how really successful
this is from and satisfied providers are from both a specialist side as well as a primary
care side and I think that we're going to continue to look for lessons learned how to
support enhanced this program.
What I would like to do now is turn to our live demonstration if you could pull up the
bridge please and I think I'm going to ask one of our audience members to come up and
read the case.
He is Danny Boller and he is representing AMVET, is that correct Mr Boller?
He has been very gracious to serve as our primary care provider and read a couple of
sentences to our heart failure team and Dr. Bassiano who is on the line as well if we
could pull up the heart failure team as well that would be great.
Danny Boller: A 55-year-old male veteran has a history of heart failure for two years,
he's been complaining of abdominal fullness and his water pills are working.
His injection fraction is 35% Dr. Kirsh: Thank you very much primary care
provider Dr. Boller.
(Applause) He was asking a lot of questions at the heart
echo table so I appreciate your participation.
So our heart failure team there in Cleveland , Dr. José Ortiz who's a cardiologist in
the center on the left doctor is Dr. Kim Schwab who is a health psychologist and Dr. Sherry
Laflores who's the clinical pharmacist specialist This is the SCAN ECHO room in Cleveland Ohio
which they will sit in end and if you'd like to respond to that that patient presentation;
we would love to hear that I think the audience will as well.
Dr. Ortiz: Well first Mr. Danny Boller is a great presenter.
If he ever needs a job as a presenter, he should apply in Cleveland.
The presentation is relatively about a younger patient and younger patients tend to have
more abdominal symptoms and elder patients with heart failure.
It really sounds like that the patient is volume overloaded and he may have what it
is called, diuretic resistance.
I think that's a great point to talk about in a second.
Oh note, if his weight are not changing and he eating less, that one type that we may
be confused and think the person is ok but he may be losing real weight and gaining water
gain, which is more concerning.
So Sherry can you talk with us about diuretic resistance?
Dr. Laflores: Sure, diarrheic resistance occurs with certain diuretics such as the one that
he is taking.
When patients actually have swelling in their abdomen and therefore their medications are
not absorbed as well, and the often don't get good profusion into the kidneys and the
kidneys can't work as well even when they take their medication.
Dr. Ortiz: So one possibility that you would suggest to our provider is to change the diuretic
to a stronger diuretic?
Dr. Laflores: Absolutely.
There are other medications that are better absorbed when they have extra fluid in their
belly and we can certainly try that.
Dr. Otiz: Excellent point, we should never forget that patients don't necessary need
medication changes or medication adjustments.
Sometimes we need to look into all the details and asking if not more important that just
know medication management.
Kim do you have any other input?
Dr. Schwab: I do, one of the things that primary care providers should consider is that when
medicines are viewed as ineffective by their patients, then it tends to lead to more intentional
non adherence.
So patients don't take their medicines when they don't believe they are working.
And so that takes some careful interview and asking patients about how they are taking
their medications and potentially some adjustments to the schedules.
Dr. Ortiz: Good point.
Dr. Kirsh: Great so I hope that, Dr. Boller that answered some of your questions regarding
this patient.
I would like to turn before we come back to the heart failure team in Cleveland that Dr.
Rocco Bassiano who's a primary care physician and Warren Ohio who is a real participant
and a regular basis with the heart failure team and I asked him to share some of his
thoughts regarding this program.
Dr Bassiano Dr. Bassiano: Thanks it's been a real privilege
for me to be a part of this cardiac SCAN ECHO program in Cleveland.
I'm an internist and a geriatrician which means that I am the primary care physician
that everybody's asked about my perspective of the program is really from the front line
here and I believe for us the beauty and strength of this program is been pretty much twofold.
First we can we can deliver higher-quality cardiac care from the start and we can do
it here in our own community.
The didactic training sessions of the SCAN ECHO have dramatically improve my ability
to handle complex cardiac care and you haven't got that much of a glimpse of Dr. Ortiz and
his team but he's a dynamo and I learned a lot it's been it's been a great experience
but even more importantly than improving my skills and it allows me to interact with my
colleagues here.
We have two other physicians and a nurse practitioner Dr. Tino and Dr. Roberts and Debbie Warlnowski
and it allows me to be a instant access specialist in training here at the at the Warren clinic
and that makes it less stressful for really all of us.
I mean they know they can just knock on my door I know with their SCAN ECHOs I can knock
on their door and it couldn't be more simpler.
So acquiring and passing knowledge is really been a lot of fun for us here it's nice to
know someone's thinking about the primary care physician care we consider ourselves
the grunts of the system but it's been a great thing from that standpoint.
The second thing and even more importantly is the patients have been incredibly appreciative
of the capabilities of obtaining some other care here as opposed to driving to Cleveland.
Alot of the veterans here 60 to 100 miles away and they are frequently elderly, there
frequently debilitated they by definition have a life-threatening illness and it's very
stressful for them to decide to make the trip to Cleveland so that has been a godsend for
a lot of them.
The other factor is that theirs is a great familiarity and comfort with them here at
our clinic because they knowtheir primary care teams are right around the corner so
if I need to grab their doctor and get them involved we can do that in a heartbeat.
And I guess lastly this is my hometown my father was a marine in the Pacific but he
worked in the steel mills here in Warren and I worked in the steel mills here in Warren
and every time I treat one of these gentlemen and ladies I think of I think of my father
and at least we can do is deliver some high-quality care to them.
This program has really helped us do that.
Dr. Kirsh: Thank you Dr. Bassiano for sharing your thoughts regarding the impact of both
of the provider and patient level.
I think that really resonates with those of us that are so committed to this program.
I'm wondering with a couple of minutes if the heart failure team in Cleveland want to
share some of their observations regarding some of the impact at the provider and the
patient level Dr. Ortiz: Sure thanks Sue.
One of the issues that I learned when I went to get the initial training for the scan program
was the fact that this new vision was very different even though it used the health technologies,
the health technologies, with the same system that we are most familiar with and it is not
one to one, it is not a specialist to a provider but to a specialist to a larger group of providers,
12 15 18.
We in Cleveland for example, don't even have the size yet, mutual capabilities for the
polycomm, and they log on using telephone lines.
So this continues to be growing.
This is the best example of peoples and force multipliers and really embrace that idea.
At the end of the day when we review 2 to 3 cases, each provider got the knowledge about
that particular patient and then can export that information that we the experts have
given to them.
We have given to them the tools on how to improve the care locally and also by Dr. Bassiano
said, and thank you for talking so nicely about me, like he said, getting this larger
family has allowed local providers to have a direct communication with us, not that nobody
can page or contact me but because we interact visually through the sessions, we kind of
feel that we are closer than any particular time of the day for any questions.
I think that my biggest summary is allowing communication with specialist from around
the region.
Dr. Shwab: So I think when I think about SCAN ECHO, what comes to my mind is that it symbolizes
the best VA care is.
One of the things that I feel most satisfied about is that we provide integrated care for
patients here in Cleveland.
Psychology is integrated into medicine, we treat patients in real time and at the same
time so we take evidence based practice and tailor it and individualize it for the patient.
What SCAN ECHO does is that it extends that reach into primary care facilities and lets
me as a psychologist take that care out into the community based outpatient clinics where
I don't typically work.
Probably the best example of that was a scanned patient who was presented and after conversation
with the PCP we began we began to conclude that he had some cognitive impairment.
While there was no one necessarily in the CBOT who was qualified to perform a real in
depth cognitive evaluation I was able to supervise it and assess the results from Cleveland.
So we are able to keep the patient at home for that evaluation but yet still provide
good quality care.
Sherry?
Dr. Laflores: So as a clinical pharmacy specialist, again my role is similar to Kim's as that
I provide specialized care up here in Cleveland.
But there isn't always a counterpart of mine in the local community settings so having
the primary care doctors who then participate are very aware of how important medication
titrations and of subtle changes in medications can be in terms of keeping patients potentially
from being readmitted in the hospital has been a huge asset.
And I think we have provided better education, better care, to the veterans particularly
in the setting of post hospital discharge through this program.
Dr. Kirsh: Thank you so much all the participants.
I'm going to make a few concluding comments but appreciate everyone's participation in
sharing really frontline and in the clinical team what's happening at your level of think
that's important for us to hear in this group here in today.
I want to conclude by summarizing that I think that this program really is in a position
to lead change in within the VA and impact veterans and really impact them at the front
lines where they have improved access to a number of specialty care.
Our table over there has more in depth information if you want to stop by and get a fact sheet
about all a different specialty care areas that this is a working and where the locations
of that care.
I think we heard something important themes and terms of this presentation and earlier
this morning.
We're building bridges from primary care and specialty care that not only impacts this
program but those interactions and communication is that is really enhanced and will allow
us even if when we are separated by hundreds of miles as we saw in Colorado Montana Alaska
those veterans still have an ability to get better care to transform the way that we're
doing this kind of work.
And I really want to think the those folks that support me in this work and our offices
specialty care as well as we're partnering with primary care healthcare transformation
and the office of rural health together we can able to really pull this program together
and I feel significantly impact the way the veteran care is delivered.
Thank you so much