Palliative Care Education in US Physical Medicine and Rehabilitation Residency Programs: Current Practices, Perceived Needs, and Barriers.

Background: Physical medicine and rehabilitation (PM&R) clinicians commonly care for patients with serious illness/injury and would benefit from primary palliative care (PC) training. Objective: To assess current practices, attitudes, and barriers toward PC education among U.S. PM&R residencies. Design: This is a cross-sectional study utilizing an electronic 23-question survey. Setting/Subjects: Subjects were program leaders from U.S. PM&R residency programs. Results: Twenty-one programs responded (23% response). Only 14 (67%) offered PC education through lectures, elective rotations, or self-directed reading. Pain management, communication, and nonpain symptom management were identified as the most important PC domains for residents. Nineteen respondents (91%) felt residents would benefit from more PC education, but only five (24%) reported undergoing curricular change. Lack of faculty availability/expertise and teaching time were the most endorsed barriers. Conclusion: PC education is heterogeneous across PM&R programs despite its perceived value. PC and PM&R educators can collaborate to build faculty expertise and integrate PC principles into existing curricula.

Virtual Management of Chronic Conditions During the COVID-19 Pandemic: Insights From Primary Care Providers and Clinical Pharmacists.

INTRODUCTION: The abrupt change in care delivery caused by the coronavirus disease 2019 pandemic may have left some patients, particularly those with chronic conditions, unable to receive timely and appropriate routine care. Understanding the effect of the pandemic and the switch to virtual care for patients with chronic conditions requires in-depth qualitative feedback from providers who care for these patients. MATERIALS AND METHODS: We interviewed 13 primary care providers and clinical pharmacists from the Veterans Health Administration. Interviews elicited experiences managing patients with chronic conditions, specifically diabetes and hypertension, during the coronavirus disease 2019 pandemic. We employed a rapid analytic approach for data analysis. RESULTS: In general, interview participants maintained that most patients' chronic conditions could be managed remotely without significant disruption. However, patients who lack familiarity with technology and/or reliable broadband access, patients not compliant with recommended self-assessments, and older patients with hearing loss or cognitive disorders may be more difficult to manage virtually. Although providers reported minimal disruptions to care because of the pandemic, they did note that the closure of labs and experiences of social isolation may have negatively impacted patients. Providers suggested optimizing virtual management through more robust patient instruction on virtual care technology, increased use of Veterans Affairs home health services, and removing institutional barriers that may de-incentivize virtual care modalities. CONCLUSIONS: For many patients with chronic conditions, virtual care is a promising approach to provide ongoing management in primary care. However, more tailored strategies may be needed to care for sicker, more vulnerable patients.

A Primary Care Telehealth Pilot Program to Improve Access: Associations with Patients' Health Care Utilization and Costs.

Background: The Veterans Health Administration (VHA) piloted an innovative video telehealth program called Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) in fiscal year (FY) 2014. V-IMPACT set up one regional "hub" site where primary care (PC) teams provided regular PC through telehealth services to patients in outlying "spoke" sites that experienced gaps in provider coverage. We evaluated associations between clinic-level adoption of V-IMPACT and patients' utilization and VHA's costs for primary, emergency, and inpatient care. Materials and Methods: This observational study used repeated cross-sections of 208,612 unique veteran patients assigned to a PC team in 22 V-IMPACT spoke sites from FY2013 to FY2018. V-IMPACT adoption in a spoke site was indicated if more than 1% of patients assigned to PC in a site used V-IMPACT services during the year. Association between V-IMPACT adoption and outcomes were assessed using mixed-effects models. Results: V-IMPACT adoption was associated with increased telehealth visits for PC (incidence rate ratio [IRR] = 2.42 [1.29 to 4.55]) and for primary care mental health integration (IRR = 7.25 [2.69 to 19.54]). V-IMPACT adoption was not associated with in-person visits, or with total visits (in-person plus video telehealth). V-IMPACT adoption was also not associated with acute hospital stays, emergency department visits, or VHA costs. Conclusions: Programs such as VHA's V-IMPACT can increase telehealth visits for PC, allowing successful transition across modalities and facilitating continuity of care without impacting total care. Programs should track substitution of in-person visits with telehealth visits and examine its effects on patients' health outcomes, satisfaction, and travel costs.