The VA Connecticut Healthcare System is a cornucopia of medical resources. It has a large medical center, in West Haven, and its faculty include specialists of every kind, most of whom are on faculty at Yale School of Medicine. VA Connecticut is home to a VA Clinical Resource Hub (CRH), which is using telemedicine to spread Yale’s wealth of specialty expertise to underserved areas throughout New England and the rest of America.
Patients in many communities—especially those in rural areas or without academic affiliates such as Yale—have limited access to medical specialists. Cities, with more people and more patients, tend to have more specialist, while sparsely populated areas may not have enough patients to employ specialists, who may treat relatively rare conditions, full time. This can lead to delayed treatment for conditions that require prompt attention. This mismatch between where many Americans live and where specialty care providers live is particularly relevant to Veterans, who are about 50% more likely than non-veterans to live in a rural communities.
“Rural parts of America may have drastically decreased access to health care, especially specialty medicine health care, and that's part of the reason why the health outcomes in rural areas are worse,” said David Moore, MD, PhD, the CRH’s director and assistant professor of psychiatry at Yale School of Medicine (YSM). “We’re really trying to focus on access, and making sure there’s not delayed care.”
The CRH at VA Connecticut began in 2017 as a mental health program providing therapy and psychiatric care to rural sites in Maine and New Hampshire. Since late 2019, it has offered primary care services through telemedicine to VA hospitals throughout New England. In 2020, it has expanded specialty services, providing treatments for opioid use disorder across New England and offering specialty medicine services in cardiac, liver, and kidney medicine to places as far-flung as Oklahoma and Massachusetts.
The Veterans Health Administration (VHA), the federal healthcare system for veterans, is centered around primary care. Patients see their primary care physicians, and if they have complex problems, their physicians may refer them to specialists. Larger VA medical centers, such as the VA Connecticut Healthcare System, tend to have a roster of full-time specialists. But outpatient clinics, where rural residents are more likely to go for care, may not have specialists available full time. Without telemedicine, when a patient needs to see a specialist, that patient either waits for a specialist to visit the clinic, travels to a VA medical center, or sees a provider outside the VA. However, in underserved communities, non-VA specialists are also unavailable, which can result in delayed care, Moore said.
Because of the relative complexity of specialty care, each visit is a collaboration between the specialist in West Haven and clinical staff who are physically with the patient including technicians, nurses, and Advanced Practice Providers. Before the visit, the physician in West Haven can order labs, imaging studies, or other tests for the patient and can remotely access the results. The specialist in Connecticut can direct the on-site clinical staff with the patient to perform any necessary hands-on tests. Specialized equipment allows the physician to be the eyes and ears at the visit, listening to the patient’s chest through a telemedicine stethoscope, for example, even as a nurse is the hands. Based on the results of tests and the exam, the physician makes a recommendation about what to do next and whether or not the patient needs to see someone in person.
Using this collaborative model, the CRH at VA Connecticut is bringing increasingly complex specialty care to patients who need it at underserved VAs around the country.
Cardiovascular Care and Cardiac Device Monitoring
Patients with pacemakers and defibrillators need to have them checked by a cardiac electrophysiologist two to four times a year to ensure that they are working properly. After the cardiac electrophysiologist at the VA in Manchester, New Hampshire retired, 120 patients were left without a VA provider to check their cardiac devices. To fill the void, the CRH has stepped in and now holds half-day clinics on Friday mornings when patients at the Manchester VA can get their cardiac devices checked by a VA Connecticut electrophysiologist. A nurse practitioner in Manchester presses a programmer to the patient’s chest, which collects data from the cardiac device about its functioning. Advanced practice registered nurses (APRNs) at VA Connecticut examines the data to determine if the device is working properly and, if it’s not, directs the nurse practitioner to make changes, again using the programmer. “It's allowing us to kind of take these super specialists, and through a video connection, reach patients two states away to help direct their care,” said Steven Pfau, MD, chief of Cardiology at VA Connecticut; and professor of clinical medicine at YSM.
The CRH is also working with podiatrists at a VA in Upstate New York to evaluate peripheral artery disease, which is a common cause of disability and even amputation. Some foot wounds are caused by blood vessel blockages (others stem from nerve problems). If the podiatrist thinks a vascular blockage might be causing the foot wound, the patient might otherwise need to travel several hours to the Bronx VA to see a cardiologist. In addition to being inconvenient, travel, for a patient with a foot injury, may be especially painful and difficult. Through the CRH, a local technician with the patient in New York performs an ultrasound of the foot while the cardiologist in Connecticut listens to it in real time to diagnose the problem. About a third of the time, Pfau estimates, the problem is due to a blockage in a large artery in the leg and patients need to have surgery to have a stent placed. In that case, the patient has to travel to the Bronx. But for the other two-thirds of patients with foot wounds due to other causes, the video visit saves a long and unnecessary trip.
The CRH is also developing a program for CRH cardiologists to remotely read electrocardiograms (EKGs), measurements of the heart’s electrical activity through which a cardiologist can assess heart function. Primary care doctors often order EKGs when patients report chest pain or other symptoms that could be heart-related. VAs usually have professionals who can take the EKGs, but they may not have a cardiologist available to interpret the results, Pfau said. That’s where the CRH can help.
Kidney Medicine
In the domain of kidney medicine (nephrology), VA Connecticut and VA Boston have collaborated to provide telemedicine services to areas where access to nephrologists is limited.
“We’ve got, essentially, a plethora of nephrologists here that could lend their expertise to regions that don’t have any,” said Susan Crowley, MD, MBA, chief of the kidney medicine section at VA Connecticut; VHA national program director for kidney disease and dialysis; and professor of medicine (nephrology) at YSM.
A primary care physician might suggest a consultation with a nephrologist if the clinician suspected based on lab results or other tests that a patient had kidney disease. Through CRH, by analyzing lab results and learning about patients’ medical histories, VA nephrologists can make that determination. If patients have early-stage disease, nephrologists can prescribe medications to help patients manage it so that it does not progress to end-stage kidney failure. Other conditions nephrologists help patients manage include anemia, high blood pressure, and kidney stones, Crowley said.
In less than a year, Crowley said, the VA Connecticut/VA Boston CRH telenephrology service has served 500 veterans at three sites: Grand Junction, Colorado, and Oklahoma City and Muskogee, Oklahoma. VA Connecticut nephrologists hold half-day telenephrology clinics every Tuesday. “The telenephrology service has resulted in reduced wait times for nephrology appointments, and averted disease progression,” Crowley said.
Liver Medicine
Since February 2021, liver specialists at CRH have been providing excellent care to veterans throughout Connecticut and to patients in Northampton, Massachusetts, during Thursday liver clinics. Guadalupe Garcia-Tsao, MD, FRCP, chief of digestive diseases at VA Connecticut and professor of medicine (digestive diseases) at YSM, leads this program. In May, 2021, she visited the clinic to give the primary care doctors grand rounds and teach them about the goals of the CRH liver care program and how to work toward referrals to the CRH Liver Clinic. In its first year, the CRH liver program consulted with 65 new patients, according to Garcia-Tsao.
"We talk to the patient on the video screen. We examine the patient through the nurse who is on the other side. And then we decide what we want to do,” said Garcia-Tsao. That could mean doing more tests or prescribing medications or scheduling a follow-up visit. Results of lab tests and imaging studies can be easily obtained and orders can be placed through a shared electronical medical record system.
Primary care physicians tend to refer patients to a liver specialist when routine blood tests indicate a possible liver problem. Any chronic liver disease, whether caused by hepatitis, alcohol abuse, metabolic syndrome or something else, causes liver scarring. When enough scars build up, stiffening the liver, it is called cirrhosis. Cirrhosis causes pressure in the portal vein, which carries blood to the liver, to rise, and that increased pressure can cause the release of fluid in the belly (ascites) and bleeding from the blood vessels of the esophagus (varices). Cirrhosis also increases the risk of liver cancer.
In the early stages of liver disease, a patient may have compensated cirrhosis, which is mostly asymptomatic because the body compensates for it, as the name suggests. Compensated cirrhosis is usually diagnosed detected by transient elastography, a device (Fibroscanâ) that measures the stiffness of the liver. The Massachusetts clinic does not own such a device, but Garcia-Tsao hopes they can get one that would service the whole area of central and western Massachusetts.
Patients with compensated cirrhosis have a life expectancy of longer than a decade. Life expectancy for patients with decompensated cirrhosis (i.e. those that develop fluid in the belly or bleeding from varices) is about two years. “It’s a game changer once they decompensate,” Garcia-Tsao said. “So the main objective is identifying patients who are still compensated and are at high risk of decompensating and treating them with drugs that will decrease portal pressure to prevent decompensation” she said.
A combination of noninvasive tests including blood tests, ultrasound and transient elastography could tell clinicians whether the patient has cirrhosis and high pressure in the portal vein. In the past, this would require performance of upper endoscopy, an invasive procedure not widely available in these rural areas. The availability of transient elastography device in these rural areas “could prevent a whole bunch of endoscopies from being done,” Garcia-Tsao said.
In patients with decompensated cirrhosis, the goal is, treat their complications, and get them on liver transplant lists. All patients with cirrhosis have an increased risk for liver cancer, so they all need regular ultrasounds of the liver in order to catch early any cancer that might develop. Workup for liver transplant and screening ultrasounds for liver cancer can also be done remotely via the CRH program.
Substance Abuse Treatment
VA Connecticut is a national leader in Addiction Medicine and Addiction Psychiatry. In response to the worsening opioid overdose crisis, the CRH at VA Connecticut has prioritized making buprenorphine available to Veterans struggling with opioid addiction. Buprenorphine is an oral treatment for opiate use disorder that partially stimulates the neurochemical pathways triggered by opiates like heroin and fentanyl, Moore said, reducing opioid cravings. “All the evidence out there tells us that it really reduces the chances of relapse and reduces the chance of fatal overdose if people are prescribed buprenorphine. Telemedicine is a great opportunity to get this into areas that may, for whatever reason, not have local providers able to provide it,” Moore said.
The CRH in West Haven first provided buprenorphine to highly rural clinics in Northern Maine. These were communities with very high overdose rates but few treatment options for Veterans with opioid use disorder. Since then, the CRH has expanded buprenorphine services to include sites in New Hampshire, Western Massachusetts, and even a residential treatment program in outside of Boston.
One role of CRH has been to help other VAs when they need it—and then leave when those clinics become self-sufficient and staff a vacant position. “Our role was to make sure that they had good coverage until they could fill that position,” Moore said. In some cases, the CRH acts as a catalyst for local adoption of specialty services. In Northern Maine, the clinics receiving buprenorphine through the CRH had never had on-site treatments for opioid use disorder. The local VA in Maine took over buprenorphine services. “It's a nice way to disseminate best practices,” Moore said.
A Win-Win Situation
For patients and providers, CRH is a win-win, said Christopher Ruser, MD, associate chief of medicine at VA Connecticut and associate professor of medicine (general medicine) at YSM. In addition to helping patients access care, CRH also helps doctors access patients. Connecticut is a relatively small state, Ruser noted. While first-class physicians graduate from Yale’s training programs every year, Connecticut’s veteran population is not growing. “At some point, our ability to hire and recruit great providers may be offset by our inability to have patients for them to take care of,” Ruser said. CRH is a solution to that problem.
"You're taking this rich resource of specialty care and primary care and mental health providers who are top notch, and you're finding patients in a much larger geographic catchment area. And at the same time, you're bringing high quality care to those patients who might not otherwise have access to it,” Ruser said. “It's a pretty amazing intervention in that way.”
The Department of Internal Medicine at Yale is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, and educators in one of the world's top medical schools. To learn more, visit Internal Medicine.