Behavioral Health Integrated Support Network (BHISN).

INTRODUCTION: This article reviews process and performance of an innovative effort leveraging virtual health to manage unmet demand for behavioral health and substance use disorder services across a large military region. This effort began in June 2022 and included nearly all of the Defense Health Agency Region-Europe's military behavioral health and substance abuse clinics participating. The two goals of improving access to behavioral health and substance use services for active duty service members and improving utilization of the military clinics were employed. Operational and remote locations with known care gaps could access services as well. Connecting services to the point of need is an established strength of virtual health delivery systems of care. MATERIALS AND METHODS: A team consisting of clinical leaders and Virtual Medical Center-Europe staff developed a centralized screening process and simple business rules. When a clinic was unable to meet its access-to-care standard of 28 days, the patient requesting or referral from a remote location, was offered a virtual video option with a provider from another clinic with availability. Centralized screening was created and staffed by three technicians. The Behavioral Health Integrated Support Network (BHISN) screening clinic assessed appropriateness of virtual care using established exclusion criteria. Once screened, the patient was scheduled for an appointment with one of the 31 therapists in 14 participating clinics in a 3- to 5-day window. The military health system's video connect platform was used. RESULTS: Between June 2022 and November 2023, 131 patients who were unable to find routine care in their home clinic were screened, scheduled, and completed a virtual visit with one of the 31 participating therapists from 14 behavioral health and substance use clinics. Seventy-eight (59%) participants were active duty empaneled to military treatment facilities in Europe and 53 (39%) were active duty enrolled in Tricare Prime Remote and deployed to remote locations with limited care. Forty-four percent of patients were recommended for continued virtual therapy or counseling kept their first follow-up demonstrating good follow-up care using a virtual option. The overall no-show rate was low at 7%. Care and consultation were successfully delivered using video visits to location in 18 countries in three geographic Europe, the Middle East and, Africa. CONCLUSION: The Virtual Medical Center-Europe, Army Europe Behavioral Health, and Substance Use leadership work collaboratively to plan and optimize program performance. For BHISN to function as intended requires key dedicated support staff, such as mental health and social services assistants to screen and coordinate virtual care. Scheduling can be performed by a central cell requiring clinics to relinquish some local control in the interest of meeting patient demand in large and diverse area that covers three continents. BHISN shows promising initial success by providing a process of managing demand and connecting requests for behavioral health and substance use care leveraging capacity from all clinics using a virtual video service in a diverse operating environment.

Section 718 (Telemedicine): Virtual Health Outcomes From Regional Health Command Europe.

BACKGROUND: Section 718 of the Fiscal Year 2017 (FY17) National Defense Authorization Act (NDAA) outlines many reportable telemedicine outcomes. While the Military Health System Data Repository (MDR) and the Management and Reporting Tool M2 provide some telemedicine analyses, there are many outcomes that neither the MDR nor M2 provide. Understanding patient and provider attitudes towards telehealth and specialty-specific usage may assist initial or ongoing telehealth lines of effort within Defense Health Agency Medical Treatment Facilities (DHA MTFs). METHODS: A retrospective descriptive analysis of synchronous virtual health (VH) encounters and results from three internally developed telehealth surveys for calendar year (CY) 2016 was conducted. RESULTS: Three thousand seven hundred and seventy-eight synchronous VH visits for 2,962 unique patients were completed by 142 providers located within 27 distinct specialty clinics. 89.8% of patients were adults and 75.9% were Active Duty. Skill type I and II medical providers conducted 1,827 new consultations, 1,187 follow-up visits, and 371 readiness exams. Overall, specialty-specific VH use ranged from less than 1% to 39.9%. Patient satisfaction was 98% while provider satisfaction ranged from 91% to 93%. Additionally, significant intangible savings were recognized. CONCLUSION: Regional medical centers conducting synchronous VH will require both internal and external data sources to report Section 718 outcomes required by Congress. As the anticipated demand for direct provider-to-patient telehealth increases, understanding these outcomes may aid initial and ongoing efforts in other military treatment facilities conducting synchronous VH.

Military Medicine Implements In-home Virtual Health in Europe.

OBJECTIVE: This report outlines a multispecialty implementation effort which included 12 specialty practices and 28 clinicians within Regional Health Command Europe (RHCE) and Landstuhl Regional Medical Center (LRMC) to pilot an in-home virtual health (VH) program using existing resources. METHODS AND MATERIALS: Synchronous VH encounters were performed using an Acano desktop conferencing client (Cisco Systems, Inc, San Jose, CA) and a USB web camera at the provider (distant) site and the patient's own computer or device in the home. A web real-time conferencing (Web RTC) server provided the connections. RESULTS: Between October 2016 and May 2018, 310 synchronous VH appointments to patients' homes in 23 geographic locations in 9 countries on 3 different continents were completed; 28 skill type I and II specialty providers at LRMC, SHAPE Belgium Army Health Clinic (AHC), and Vilseck AHC, Germany Primary Care Clinic participated. The providers represented 9 distinct specialties and primary care. Appointment types were as follows: 85 (39%) follow-up type appointments; 70 (32%) group type appointments; 65 (30%) initial specialty care appointments. The 3 most active clinics were Pediatric Gastroenterology with 88 (28%), the Nutrition Clinic with 82 (26%), and the Traumatic Brain Injury Clinic with 63 (20%) encounters. Full audio and video connectivity rate was 97%, excluding reconnects after dropped calls which occasionally occurred. Patient satisfaction scores were high 16/17 (94%) with 5% of patients surveyed. CONCLUSION: Low complexity synchronous VH appointments were successfully accomplished across a broad spectrum of health care services and appointment types. Landstuhl RMC specialists received consults from sites across a vast geographic area including Europe, the Middle East, and Africa. An in-home VH option gives providers a special tool to extend services far beyond traditional boundaries. This pilot project helped RHCE and LRMC providers gain valuable experience extending care to the home and will provide foundational knowledge for future VH efforts targeting groups and outcomes.

Multispecialty Synchronous Telehealth Utilization and Patient Satisfaction Within Regional Health Command Europe: A Readiness and Recapture System for Health.

BACKGROUND: Telehealth implementation within the Military Healthcare System continues to advance toward the goal of a mature regional health platform; however, specialty-specific usage or patient satisfaction regarding synchronous or "real-time" telehealth at the regional military hospital level has not been described. METHODS: A retrospective review of synchronous telehealth encounters and patient satisfaction surveys from Landstuhl Regional Medical Center (LRMC) specialty clinics engaging in synchronous telehealth to regional Army Health Clinics (AHCs) during 2015 was conducted. RESULTS: 2,354 synchronous telehealth encounters were conducted for 1,886 unique patients. The majority of patients were adults (88.4%), male (71.1%), and active duty (75%). Twelve distinct distant locations were engaged in synchronous telehealth with 31 distinct specialties. 1,552 (62.5%) patients had a single telehealth visit with a median (range) of 1 (1-7) visit. Median (range) visits per specialty was 25 (1-582) with sleep medicine (24.7%), general surgery (13.1%), nutrition (9.7%), orthopedics (9.0%), and ENT (6.0%) representing 62.5% of all encounters. Median (range) number of encounters per location was 146 (13-685). Surgical specialties preferentially evaluated patients at locations with a specialty-trained presenter (p < 0.001), whereas nonsurgical specialties did not (p > 0.05). Fifteen percent (372/2,354) of patients completed an anonymous survey at the time of their telehealth visit. Mean responses on a 5-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (5) was 4.8 ± 0.5 for both recommending and being satisfied with their telehealth visit. The 2,354 telehealth visits represented 2.4% (2,354/100,094) of all visits to LRMC during 2015 for 25 of 31 specialties whose total outpatient visits could be determined. CONCLUSION: Clinic utilization varied between specialties as well as whether a specialty-trained patient presenter was preferred. This robust multispecialty synchronous telehealth experience provides insight into both specialty-specific utilization and patient satisfaction which may aid regional medical centers recognizing avenues for specialty-specific telehealth initiatives.

Clinical assessment and management of general surgery patients via synchronous telehealth.

Objective This paper describes how a clinical team at Landstuhl Regional Medical Center (LRMC) successfully integrated synchronous telehealth (TH) into their routine clinical practice. Methods and materials Synchronous TH encounters were performed using Polycom® software on surgeons' computers with high-definition (HD) cameras on monitors at distant sites and PolyCom HDX9000® Telehealth Practitioner Carts at originating sites. Patients provided consented and were presented to general surgeons by nurses and medical technicians at Army health clinics throughout the European Theater. Results In calendar year (CY) 2014, five general surgeons and two surgical physician assistants (PAs) at Landstuhl Regional Medical Center along with registered nurses (RNs) at six originating clinic sites throughout Europe completed 130 synchronous TH encounters for 101 general surgery patients resulting in 73 completed and 16 recommended surgeries. Eighty-eight percent of patients had a completed or recommended surgery. No surgeries or procedures planned after initial TH evaluation were cancelled. Originating site clinics ranged in distance from 68 miles to 517 miles. Acceptance by providers, patients and clinic staff was high. Conclusion Synchronous TH was effective and safe in evaluating common general surgical conditions. We excluded sensitive and complex conditions requiring a nuanced physical examination. The TH efforts of the general surgery staff have resulted in high-quality, seamless and predictable TH activities that continue to expand into other surgical and medical specialties beyond general surgery. Seven surgeons and two PAs use synchronous TH regularly serving patients over a broad geographic area.

A Primary Care Telehealth Experience in a US Army Correctional Facility in Germany.

OBJECTIVE: To assess the feasibility of using telehealth (TH) equipment and infrastructure within the US Army's European Theater to evaluate and treat inmates with general medical complaints, and perform physicals and medical safety checks in a US Army Correctional Facility (CORFAC). METHODS AND MATERIALS: Synchronous TH encounters were performed using Polycom RealPresence software on providers' computers with high definition cameras on monitors at distant sites and PolyCom HDX9000 Practitioner Cart along with AMD Global Telemedicine devices at the originating site within the CORFAC. These devices included an AMD-2500 General Exam Camera, AMD Fiber optic Otoscope, and AMD Telephonic Stethoscope. Patient consent for TH was obtained, and they were seen in the Medical Dispensary with Army Medics presenting the patients to the providers via TH. RESULTS: From May 22, 2014, to January 12, 2015, a physician assistant, nurse practitioner, and 4 physicians completed 177 synchronous TH encounters primarily at a CORFAC in Mannheim, Germany. Of these 177 encounters, 114 were Special Housing Unit (SHU) safety checks and 63 encounters were for physicals, medication management, and a variety of medical complaints including acute infections, abdominal pain, and musculoskeletal and dermatological complaints. CONCLUSION: Synchronous TH was an effective option for the delivery of high quality routine medical care for minor illnesses, injuries, and other nonurgent conditions, as well as for general physicals and SHU checks in a correctional facility. Acceptance by providers and clinic staff was found to be high. Inmates were generally satisfied with their TH encounters. However, some inmates reported a preference to see providers in-person, highlighting one of the challenges with acceptance of telehealth programs.

Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties.

OBJECTIVE: The objective of this study was to assess the feasibility of utilizing negative pressure wound therapy (NPWT) for the treatment of wartime soft-tissue wounds during intercontinental aeromedical evacuation. BACKGROUND: Attempts to use NPWT during early phases of overseas contingency operations resulted in occasional vacuum system failures and potentially contributed to wound complications. These anecdotal episodes led to a perception that NPWT during aeromedical evacuation carried a high risk of wound complications and limited its use. As a result, NPWT was not frequently applied in the management of soft-tissue wounds before US casualty arrival in the continental United States (CONUS) for wounds sustained in the combat theaters. Concurrently, early NPWT on the traumatic wounds of host nation casualties not requiring aeromedical evacuation seemed to provide many benefits typically associated with the therapy such as decreased infection rates, earlier wound closure, and improved pain management. METHODS: On a daily basis, study investigators reviewed the trauma in-patient census at Landstuhl Regional Medical Center, Germany, to identify patient candidates with soft-tissue extremity or torso wounds that required packing. Patient demographics, injuries, and previous wound treatments were recorded. Surgeons inspected wounds in the operating room and applied a NPWT dressing if deemed appropriate. NPWT was continued throughout the remainder of the patient's hospitalization and also during aeromedical evacuation to CONUS. A study investigator escorted the patient during aeromedical evacuation to educate the flight crews, to record the impact on crew workload, and to troubleshoot the system if necessary. RESULTS: Thirty enrolled patients with 41 separate wounds flew from Germany to CONUS with a portable NPWT system (VAC Freedom System; Kinetic Concepts Incorporated, San Antonio, TX). All 30 patients arrived at the destination facilities with intact and functional systems. No significant in-flight complications were identified, impact on flight crew workload was negligible, and subjective feedback from both flight crews and patients was uniformly positive. For 29 patients, the NPWT dressing was replaced (frequently with serial exchanges) during initial surgical treatment in CONUS; the 30th patient underwent delayed primary closure of his right forearm fasciotomy. Receiving care teams reported no complications attributable to NPWT during aeromedical evacuation. CONCLUSIONS: NPWT is feasible during intercontinental aeromedical evacuation of combat casualties without an increase in wound complications or a significant impact on air crew workload. Further studies are indicated to evaluate the efficacy of NPWT in combat wounds compared with other wound care techniques.