VA Tele-Emergency Care: Moving from VA research to rollout in Cleveland and across nation
VA research has led directly to improved Veteran non-critical emergency care. Three years of VA research begun at the LTC Charles S. Kettles VA Medical Center in Ann Arbor, Michigan has led to nationwide rollout of new telephone-access Tele-Emergency (Tele-EC) services.
All Veterans enrolled in the VA Northeast Ohio Healthcare System can access the service for non-life-threatening urgent and emergency care by calling the Louis Stokes Cleveland VA Medical Center main switchboard number, (216) 791-3800, and then pressing “3”.
The patient call, typically stemming from a symptom-based complaint is assessed using a standard triage protocol. Based on responses from the Veteran, the protocol guides triage nurses and emergency department physicians to recommend how urgently the Veteran should be seen – ranging from calling 911 for the most serious concerns, to same-day care, self-care, or routine follow-up for low-acuity concerns.
Where it began, and why
Interestingly, this new service was first conceived and researched starting in 2021 within the VA Ann Arbor Healthcare System (VAAAHS). The idea originated in observations that Veterans experiencing non-life-threatening symptoms were frequently seeking care at a local emergency department where long wait times could confound their timely access to care that could be delivered effectively via telephone.
A 2021 Michigan test period investigated the approach, and later research findings, published in the journal Academic Emergency Medicine, showed Veterans who utilized this new tele-emergency service delivery were nearly half as likely to visit an emergency department in-person and showed reduced need for short-term Veteran visits to their local hospital’s emergency departments.
The study had important implications for emergency care, leading to the new Tele-EC rollout, including reducing the cost of VA health care, reducing the overall burden on VA and non-VA emergency departments, and more appropriate handling of the high number of potential patient visits presenting symptoms and conditions that might be better addressed by urgent care or primary care.
When it works best, and how it's better
“Tele-emergency care is really about talking patients through a risk-benefit calculation about whether they should go to an emergency department,” said Dr. Kathy Li, Acting Instructor at the University of Washington’s Department of Emergency Medicine, and former member of Michigan Medicine’s Clinical Faculty.
Dr. Li, who led the research study, drew results from the pilot Tele-EC service at VA Ann Arbor Healthcare System (VAAAHS) between January and December of 2021.
More specific to Dr. Li’s study, Veterans who were recommended by a triage nurse to seek care within 24 hours were offered a tele-emergency care visit. Essentially, the Veteran could speak with an emergency physician by video or phone call without physically visiting the emergency room. Veterans who were advised to immediately call 911 because of the seriousness of their symptoms were only offered a tele-EC visit if they declined to seek immediate, in person emergency care.
“As someone without medical training, it can be hard sometimes to know if your symptoms may be dangerous or not. You don’t want to go when it’s not necessary, but you also don’t want to stay home if it’s dangerous,” explained Dr. Li.
Dr Li’s study compared the number of Veterans who visited the ED in-person after speaking only with the triage nurse against those who also had a tele-EC visit with a physician. Thirty-five percent of Veterans who spoke only with the triage nurse made an in-person ED visit within 7 days of their initial phone call. However, only 18% of Veterans made an in-person ED visit if they consulted first with an emergency physician utilizing tele-EC.
Importantly, there were also lower associated rates of hospitalization among the tele-EC group, and no deaths in either study group. These findings led to a close examination of the cost benefits and Veteran health care enhancements of the program—and to the recent rollout of the service offering nationwide within the VA.
“[Tele-EC] has a measurable impact on the number of [non-urgent] ED visits. Those … visits don’t add a lot of value for the patient or provider, and Tele-EC visits are able to prevent those,” explained Dr. Li. “It’s not just valuable for [non-urgent] visits though. On the flip side, I have also used [Tele-ED] to convince Veterans who were hesitant to go to the ED why they really needed to go, which can prevent potentially dangerous delays in care.”
Using Tele-EC consultations to reduce the number of visits to local hospital emergency departments can both improve timely delivery of care to Veterans, and reduce VA spending, making the solution a win-win for all parties.
“This is not a computer algorithm telling you to go to the emergency room or not. [Relying on a human triage nurse or ED physician] can add that humanness and patient-centeredness back into that decision. You have a real risk-benefit discussion with real people,” Dr. Li said.
How to use Tele-Emergency Care
The Tele-EC services are available immediately to all Veterans enrolled in the VA Northeast Ohio Healthcare System by calling the Cleveland VA Medical Center at (216) 791-3800, and then pressing “3”.