Program Profile

Clinical Video Telehealth for Gait and Balance

A clinical video telehealth program increases veterans’ access to specialty services and reduces travel time and related costs.

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The VHA has about 700 community-based outpatient clinics (CBOCs). Often these remote clinics lack onsite specialty services. In 2014, about 3 million of the 9 million veterans in the VHA were enrolled in rural locations, according to the VHA Support Service Center Office of Rural Health. This rural cohort is a substantial veteran population for whom meeting specialty medical care needs can be challenging. Rural veterans often travel long distances to a hub medical center when accessing specialty care. This article describes the North Florida/South Georgia Veterans Health System (NF/SGVHS) telehealth solution to provide veteran-centric specialty care access for rural veterans. The program addresses falls, a major public health problem in the elderly.

The VA is a world leader in clinical video telehealth (CVT). Videoconferencing between clinic sites allows clinicians to make diagnoses and provide and manage care without requiring long distance travel. Clinical video telehelth allows veterans to come to the CBOC, connect to a specialist in a remote VA hospital for consultation and treatment, and save transportation time and related costs. The VA has real-time CVT for polytrauma, mental health, rehabilitation, surgery, weight loss, and numerous other specialties.1,2 The CVT rehabilitation modalities have been successfully used both within the VA and in the community for about 15 years, although rigorous economic and functional outcome data are limited.3-6

Gait and Balance Clinic

The NF/SGVHS spans 50 counties and is one of the VA’s largest health systems for clinical workload and rural geography. In 2014, NF/SGVHS had about 160,000 enrolled veterans, and nearly 70,000 were rural, a slightly higher percentage than the VA nationally.

The Gait and Balance Clinic of the Malcom Randall VAMC in Gainesville, Florida, focuses on evaluating and preventing falls and fall-related injuries in the aging veteran population for all enrolled veterans regardless of location. The NF/SGVHS has a robust CVT program, and in 2014, the physical therapist (PT) initiated a CVT Gait and Balance Clinic pilot. This program increased veteran access from remote clinics to these fall prevention services at NF/SGVHS and positively impacted travel time and related costs.

Clinicians refer veterans with falls, dizziness, and vestibular and gait disorders to the Malcom Randall VAMC Gait and Balance Clinic where specially trained PTs provide expert diagnosis and management. The Gait and Balance Clinic is staffed by 2 vestibular-trained PTs and a health technician. The assessments include sophisticated, specialized testing of balance function, determining biologic systems affecting balance. These include the vestibular, visual, sensory, and musculoskeletal systems (Table 1). Therapists provide customized veteran and caregiver education for in-home vestibular exercise programs, fall-reduction strategies, and as-needed adaptive equipment.

Veterans requiring in-depth evaluation attend a weekly Gainesville-based multidisciplinary clinic, staffed by a part-time neurologist, neurology resident trainees, a geriatric medicine fellow, and pharmacy residents and preceptor. Factors affecting gait and balance systems that potentially improve with exercise, such as muscle weakness or vestibular impairments, are mitigated by incorporating into the veteran’s care plan personalized home fall-reduction strategies, exercise programs, and patient and caregiver education.

Specific exercises are designed for each patient’s home environment. The home exercise programs typically include a combination of balance and strength training, vestibular maneuvers, and progressive walking for endurance. In addition to improving patients’ functioning by addressing impairments found on examination, the PTs commonly prescribe assistive devices: rollator walkers, canes, and lower extremity orthoses that reduce fall risk by compensating for deficits in sensory motor systems.The Gait and Balance Clinic receives more than 400 consults annually and experiences a yearly consult growth rate between 2% and 4%, commensurate with the increase in unique veterans due to new NF/SGVHS CBOC and outpatient clinic activations. Thus, there was an imperative to increase access to this focused consult service for an aging veteran population throughout this large health system. The NF/SGVHS improved timeliness and access to this specialty service within the VA by redesigning its Gait and Balance Clinic and initiating a CVT pilot that connected to selected affiliated remote CBOCs.

Falls

Falls are a major public health problem in the aging U.S. population. Sixty-five percent of individuals aged ≥ 60 years experience dizziness or balance loss daily. About 12 million Americans aged ≥ 65 years have dizziness or balance problems that significantly interfere with their quality of life. Resulting falls are a major cause of both nonfatal and fatal injuries in older adults.7-11 Dizziness also is a common experience among patients aged > 75 years.12 During 2014, the VA saw about 140,000 veteran outpatients for the primary diagnoses of accidental falls, dizziness, and gait abnormality (VHA Support Service Center). The PTs at the Malcom Randall VAMC Gait and Balance Clinic address these important clinical problems in their aging patients.

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