comprehensive care for multiple sclerosis delivered by clinical video telehealth paul m. hoffman,...
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Comprehensive Care for Multiple Sclerosis Delivered by Clinical Video Telehealth
Paul M. Hoffman, M.D.Director, Veterans Rural Health Resource Center –Togus
October 1, 2015
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Lake City VAMC
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• Neurology• Medicine• Physical Therapy• Occupational Therapy• Speech, Swallowing• Social Work
Hospital Referrals• Psychiatry• Neuropsychology• Urology• Nutrition
MS Clinic
‘National Multiple Sclerosis Society
Affiliated Center of Comprehensive Care’
at Lake City, FL VAMC
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MS Patient Population seen at NF/SGVHS
• 283 patients with MS seen at NF/SGVHS• 120 MS patients followed at Lake City MS Clinic• > 45% live in rural or highly rural zip codes• Majority are progressive (primary or secondary)• VA MS population is older, more male and disabled than non-
VA population• Access is a major issue due to disability and travel distance
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MS CVT NEUROLOGY FOLLOW-UP
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Care CoordinationRural Mobility Evaluation Clinic
• Evaluation and comprehensive care for rural veterans withALS, MS, SCI, PD, andneurodegenerative disorders
• Maximize independence andsafety in the home and community
• Provide VA specialty care closest to the Veterans’ home
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History of Mr. A
• 39 year old male, history of Relapsing Remitting MS• 1996 - Onset (age 20) with, optic neuritis, and fatigue with multiple exacerbations
treated with IV and oral steroids in 1st year• 1998 - Dx of MS started on Interferon-a1 and continued for 3 years with relapses• 2002 - exacerbations continued, wheelchair required, started on
immunosuppressant which was D/C because of cardiotoxity• Co-polymer-1 failure due to injection site reactions; Interferon-1b ineffective and
increased depression• Returned to Memphis, started on Natalizumab in 2013• Moved back to Florida - 5.0 hour RT drive from home to Lake City VAMC for
monthly infusion• He is an artist who teaches painting despite ataxia and weakness in his dominant R
hand
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Exam of Mr. A
• Has weakness in RLE (hip and knee and foot) for which he uses a Bioness unit
• Walks with cane, walker, has fatigue and heat intolerance.• Intermittent anxiety and depression during Natalizumab
treatment have been alleviated with diet and exercise • Has mild clumsiness and incoordination in R hand, but
teaches painting and drawing despite his disability
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Distribution of Veteran and non-Veteran MS patients in North Central Florida
MS Patients Self-Reported to NFNMSS
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Participating Sites MS-CVT-Neurology Follow-up
• Albany, NY• Buffalo, NY• Baltimore, MD• Washington, DC
• Lake City, FL• Seattle, WA• St. Louis, MO• Birmingham, AL• Denver, CO
Eastern Region Coordinator—ORH/MSCOE-EAST
Amy Kunce
Western Region Coordinator—ORH/MSCOE-EAST Affiliate
Sean C. McCoy
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Rural Veteran TeleRehabilitation Initiative (RVTRI)
• The RVTRI:– Completed 205 initial evaluations– Enrolled 127 veterans for ongoing care– Generated a workload of 2134 encounters – Reached Veterans in 30% (40/137) of our rural zip codes
(Veterans served lived an average of 93 miles from the medical center)
• VHA Systems Redesign Champion Award –Outpatient Category
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Clinical Video Telehealth (CVT)
Home-based Physical TherapyExercise Intervention
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CVT-REHAB – Hub to Home
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MS–CVT Promising Practice FY 2016
• Rural Veterans with MS and limited access because of disability and/or geography• CVT to home or CBOC closer to home for Follow-up care, care-giver support,
rehabilitation and wellness• Requires Collaboration between Neurology and PM&R Services• Follow-up MS care (DMT and Symptom management) by Neurology, rehabilitation
services for disability• CVT to home or CBOC closer to home for Follow-up care, care-giver support,
rehabilitation and wellness• Outcome measures include QOL, functional measurements, caregiver stress
reduction, others• Current sites include MSCoE hubs at Baltimore, Buffalo, East Orange, Lake City,
Washington DC, and Seattle• Expansion to Charleston and Memphis is planned for FY 2016
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Why is Telehealth Important to Patients with MS and ALS?
Use of Clinical Video Televideo (CVT) can:• Improve the early diagnosis and treatment of MS• Provide comprehensive Care to MS and patients living in rural
and remote areas• Improve compliance for MS disease modifying therapy• Allow rehabilitation and wellness programs to be delivered to
the home• Provide caregiver support • Improve quality of life, prevent or delay disability and
ultimately reduce costs for MS care
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ACP Recommendations for Telehealth that are Particularly Important for ALS and MC CVT
• Telemedicine can be most efficient and beneficial between a patient and physician with an established, ongoing relationship.
• Telemedicine is a reasonable alternative for patients who lack regular access to relevant medical expertise in their geographic area.
• There is a need to develop evidence-based guidelines and clinical guidance for physicians and other clinicians on appropriate use of telemedicine to improve patient outcomes.
• Physicians should ensure that their use of telemedicine is secure and compliant with federal and state security and privacy regulations.
• Telemedicine should be held to the same standards of practice as if the physician were seeing the patient in person.
Source: Annals of Internal Medicine, 8 September 2015
