What facility configurations make a difference in implementing a TeleNeurology program? A mixed methods approach

The Veterans Affairs National TeleNeurology Program (NTNP) was developed to improve access to outpatient neurology care by leveraging telehealth to create efficient, cost-effective virtual video clinics. Studies suggest that NTNP led to shorter wait times, fewer community care neurology (CCN) consultations, reduced travel burden, and high patient/provider satisfaction.

This evaluation aimed to identify combinations of facility-level conditions that uniquely distinguish VA Medical Centers (VAMCs) with higher and lower usage of NTNP consults for stroke patients.

We conducted a mixed-methods evaluation of a Veterans Affairs (VA) quality improvement program extending access to outpatient neurological care through telehealth to Veterans receiving care in facilities with highly rural populations. The sample included consults placed to NTNP or CCN for outpatient stroke diagnoses. We applied configurational comparative methods to identify explanatory factors related to implementation success. The analysis used categorical factors to distinguish facilities with higher usage of VA NTNP consults compared to CCN. The primary outcome was the ratio of NTNP consults (video plus e-consults) placed to all consults (NTNP plus CCN) for Veterans with stroke. The proportion of consults placed to NTNP ranged from 3.3% to 49.3%, with a gap between two categories: the eight highest (over 22.4%, "higher") and the four lowest (under 14.2%). Data sources included administrative records, facility characteristics, leadership engagement ratings, and interviews with NTNP leadership/TN providers.

Among 12 VA facilities evaluated, those with high NTNP consult usage (≥22.4%) exhibited three specific facility configurations, each of which were sufficient for the outcome to occur: an absence of local VA neurology providers, higher number of NTNP clinic days (≥0.65 per week), or a lower annual volume of stroke patients. These findings indicate that targeted adjustments in staffing or clinic availability may effectively increase NTNP adoption, especially in facilities with limited access to local neurology resources.

This mixed-methods evaluation offers a strategic framework to enhance NTNP implementation by aligning facility resources with program goals based on stroke volume and local neurology resources. High-usage implementation of VA NTNP was observed to have simpler pathways to success compared to more complex reasons for lower usage.