Original Research
Experiences of Veterans With Diabetes From Shared Medical Appointments
Camaraderie and shared narratives, coupled with clinical guidance, may help motivate veterans to better manage their diabetes.
Clinical video telehealth (CVT) uses live, interactive audio and video technology to connect patients with health care providers (HCPs) at remote facilities, allowing the patient to be examined and interviewed by a provider. An immediate evaluation of the patient is facilitated by the HCP’s ability to answer any questions, provide recommendations, and interact directly with the patient.
This article describes the VA’ s commitment to and uses of CVT, outlines various physical therapists’ roles in CVT, and details a specific physical therapist’s CVT practice.
The VA is recognized as a leader in this growing method of delivering direct patient care, combining the benefit of face-to-face interaction with the convenience of reduced travel. In 2013, the VA spent $500 million nationally on a telehealth expansion project to improve veteran access to health care. This expansion has continued, and telehealth capabilities have reached 152 VAMCs and clinics throughout the U.S.1 The VA was most recently recognized for its efforts in Hospitals & Health Networks, deeming VA as a “2014 most wired” U.S. hospital.2
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To date, CVT has grown in the VA to include a multitude of specialty services. Clinical video telehealth fills an important niche in the VA community, providing flexible care to veterans when and where they need it. Providers use CVT to make diagnoses, manage care, perform checkups, and educate patients. It allows patients to come to many of the VA community-based outpatient clinics (CBOCs) and receive care from specialists or providers who may be located in the main facility, another state, or even across the country. Publications documenting successful video telehealth technology in the VHA include positive patient and provider satisfaction, accuracy of measuring physical function, merits in providing group weight loss programs, effective cognitive-behavioral and physical therapy group protocol, as well as a telehealth collaborative care program for persons with HIV in rural areas.3-7
Physical therapists (PTs) are making use of technology that brings care to the patient rather than the patient to the care. For instance, PTs have used this service for patients with spinal cord injuries for whom prolonged sitting during travel has the potential risk of worsening a sore or ulcer.6 By incorporating CVT into their practices, PTs can address current, evolving, and future health care needs.
PT’s Perspective
Yevgenia Gitlin-Nitti, PT, of the Miami VA Healthcare System (MVAHCS) works at the Key West CBOC, which consists of 1 primary care physician, 1 nurse practitioner, 2 registered nurses, 2 social workers, 1 psychiatrist, 1 PT, and 3 support staff. Over 160 miles from the Miami VA HCS where all the specialists are located, Key West CBOC needs remote services.
Working with 3 different clinics—spine, diabetes, and MOVE! (Management of Overweight and/or Obesity for Veterans Everywhere)—has allowed the PT to develop a thorough understanding of the need for telehealth services. Specifically, the spine clinic visits are designed to have a patient consult with a physical medicine and rehabilitation physician regarding any spine issues. The PT’s role in the spine clinic CVT is to serve as the extension of the evaluating physician’s hands. Physical therapists are trained to perform various orthopedic and neurologic tests and other vitals such as weight, blood pressure, and pulse. The PT is also trained to palpate and feel for soft tissue abnormalities, joint and quality of movement, and bony anomalies on behalf of the physician at the remote location.
Related: A Call to Action: Intensive Lifestyle Intervention Against Diabesity
The spine clinic typically meets for 1 hour, once a month, with 2 scheduled patients individually evaluated. The PT presents the patient to the physician via CVT and takes the patient through a comprehensive physical evaluation as per the physician’s requests. The Computerized Patient Record System allows both parties to view magnetic resonance images, X-rays, and other pertinent test results. The physician may then order additional tests, procedures, and/or consults with other specialty clinics.
The PT also leads a monthly diabetes CVT group session for Key West patients. A nutritionist and a certified diabetes educator nurse attend the session from the MVAHCS via CVT. The PT can be present in the room with the patient while the other specialty clinic provider is remote. The PT’s role is to educate the participants about exercise for better blood sugar control and to maintain foot care.
Related: Experiences of Veterans With Diabetes From Shared Medical Appointments
Oftentimes, the PT may make referrals to podiatry at the MVAHCS and may need to conduct a CVT session to help with the podiatry physical examination. Similarly, the PT also contributes to a weekly MOVE! class, which consists of Key West patients in a group appointment that includes a Miami-based nutritionist joining via CVT. Some MOVE! classes are set up with the PT educating patients remotely at other CBOCs on exercise and even performing exercises together via CVT. Other clinics are set up in Key West with the PT alongside the patient while another HCP observes via CVT. In the Key West CVT service, the PT educates patients on exercise with a focus on managing weight and staying healthy.