Intermediate Care Technicians-A Novel Workforce for Veterans Affairs Geriatric Emergency Departments

Box 1: Case Description

A 75-year-old Vietnam Veteran presented to the emergency department (ED) after a witnessed fall. He denied injury and refused a workup, but staff was concerned for unmet needs. An Intermediate Care Technician (ICT) introduces himself, informing the patient that he too is a Veteran and would like to interview the patient and discuss Department of Veterans Affairs (VA) resources. The Veteran opens up and the ICT finds the patient is afraid of falling and is not getting into the bathtub or walking downstairs to do laundry. He had not brought it up to his primary care doctor because he did not feel comfortable asking for help. The ICT performed activities of daily living (ADL)/Instrumental ADL (IADL) and fall risk screens. The ICT provided a walker, trained the Veteran on use, and ordered a tub transfer chair. The Veteran agreed to home physical therapy and a VA home safety evaluation, resulting in installation of bathroom grab bars, a front entrance ramp, and a stair glide for basement access.

Introduction

Intermediate Care Technicians (ICTs) are former military Navy Corpsman, Air Force and Coast Guard Medical Technicians, or Army Combat Medics integrated into interdisciplinary care teams within VA to provide high-level clinical support.^1-4 While in the military, corpsmen and medics provide primary care and emergency medical treatment such as intubation and central line placement during critical situations and evacuation from point of injury or illness for all Armed Forces and Coalition Forces personnel. Medics and corpsmen receive hundreds of hours of standardized medical training to support military field operations, but this training does not result in licensure.¹ VA started a program in 2012 to employ these former corpsmen and medics as ICTs in ED.¹ Similar to hospital based paramedics, ICTs work under the direction of a licensed provider.^1,4 ICTs specific scope of care allows them to perform skilled tasks such as ultrasound guided IV placement, laceration repair, or splinting.^{2, 3} Currently, there are 325 ICTs working in 72 VA medical centers in 17 different clinical areas, funded locally as healthcare facility staff.

In 2016, the Louis Stokes Cleveland VA Medical Center (LSCVAMC) and Geriatric Research Education and Clinical Centers started a pilot program to train ICTs to perform geriatric screens, ED care coordination, home visits and telephone follow-up as part of a plan to achieve Geriatric ED (GED) Accreditation through the American College of Emergency Physicians (ACEP).^4,5 Since ICTs in the military receive little geriatrics training, we developed a multimodal educational curriculum on eight domains of geriatric emergency medicine, case based discussions, standardized patient simulation experiences, observed patient screening encounters and shadowing.⁴ ICTs do not have a license so there is a specific competency process for each screen and discrete task they perform, allowing ICTs to perform screens for identifying high risk older adults, cognitive impairment, delirium, caregiver burden, elder mistreatment, polypharmacy, ADL/ IADL, fall risk, food insecurity, and depression.^4,5 To empower this novel workforce, we developed a handheld

playbook that includes flow charts for each screen.⁵ The playbook allows ICTs to approach VA ED providers

with a plan for care coordination and GED specific order sets.⁵

In addition to being competent screeners and care coordinators, ICTs connect with patients as one Veteran to another. As Veterans themselves they quickly establish trust even under emergent situations, help patients navigate a complex healthcare system, assist providers and Veterans to identify what matters, advocate for Veteran-centered care and help patients understand existing healthcare resources that VA provides.^2,4 ICTs connect with ED and hospital social workers, physical therapists, pharmacists, nurses and providers to develop care plan proposals while the patients are in the ED and after discharge. ED providers and GED medical directors approve and activate care plans based on the ICT presentation of the screening outcomes, patient interviews, and electronic health record reviews, the ICT documentation in the patients’ electronic medical record, and ED provider patient assessment. After the LSCVAMC transitioned from pilot to permanent program in 2017, we supported additional VA EDs with onboard Geriatric ED programming on a voluntary basis.

A future direction sparked by healthcare modernization during the COVID-19 pandemic is Supporting Community, Outpatient, Urgent Care & Telehealth Services (SCOUTS) pilot, a home-based post ED care model where GED trained ICTs assist older Veterans with challenges like social isolation, functional decline, fall risk, caregiver strain, and digital divide. Through in-home geriatric screenings and telehealth connections to VA EDs and home support services, ICTs build trust while helping Veterans remain at home with optimal independence security, safety, and dignity. The SCOUTs pilot if funded through VA Central Office through fiscal year 2022 at 10 VA sites with Geriatric EDs.The VA national program offices of Emergency Medicine and of Geriatrics & Extended Care are collaborating to transform urgent and emergency care of older Veterans. The standardized GED training for ICTs has been supported and promoted by these national Program Offices through the National VA GED Council to all 110 EDs and 31 Urgent Care Centers and is integrated within the ICT National Foundational Training curriculum, a course that will be required for all EM ICT personnel to complete. ACEP recognized the ICT role and approved ICT geriatric champions as an alternative to nurse champions, one of the criteria for GED accreditation in 2019. This allowed the LSCVAMC to be the 9^th hospital nationally and the first within the VA to achieve Level 1 Geriatric ED Accreditation. Shortly after, The Palo Alto VA Health Care System, in California received Level 3 GED accreditation with ICT geriatric champions. Currently, ICTs are working as geriatric champions, case managers, or screeners in 25/50 VA EDs that have received GED accreditation or are working toward accreditation. Ongoing assessment of the ICT impact on VA GED programming and GED accreditation is part of a planned analysis of the VAs GED program expansion from the initial pilot at the LSCVAMC to all 110 GEDs over the next 2 years.

Box 2: Ten Steps to Train Intermediate Care Technicians to be Geriatric Champion Case Managers

Identify ICTs as highly motivated individuals who thrive in challenging situations while providing compassionate care.
Develop a multi-model curriculum aimed at adult learners.
Provide an avenue for self-directed foundational knowledge.
Use case-based discussions and video examples of screens and tasks.
Provide standardized patient simulation platform for the learner to gain experience in a safe environment.
Have a specific competency check list for each discrete task.
Use a combination of verbal discussion and direct observation to complete competencies.
Provide a workflow playbook to empower your novel workforce.
Perform periodic reassessment to reinforce skills and knowledge.
Invite the ICT to participate in both the educational and clinical Geriatric Emergency Medicine continuous quality improvement process.

Key Words

Geriatric emergency care, domain management model, transitional care, ACE model

Affiliations

Colleen McQuown, MD
Acute Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center

Kristina Snell
Office of Primary Care, U.S. Department of Veterans Affairs, Washington, District of Columbia

Thomas Edes, MD, MS
Office of Geriatrics & Extended Care, U.S. Department of Veterans Affairs, Washington, District of Columbia

Author Contributions

All authors listed have participated in drafting and editing of this manuscript.

Corresponding Author

Kristina Snell; kristina.snell@va.gov, Colleen McQuown, MD; colleen.mcquown@va.gov

Conflicts of Interest

All authors have no conflicts of interest to disclose.

Acknowledgements

We thank Jill Huded, Jennifer Blatnik, Barbara Health, Carole Fuseck, Robin Jump, Albert Lee, Mustafa Ascha, Sunah Song, Denise Kresevic, Todd Smith, Gerald Maloney, Jose Rivera, Robert Bonomo, Brigid Wilson and the Cleveland GRECC for their contribution to the Louis Stokes Cleveland VA Geriatric Emergency Medicine Program (GERI-VET) development, educational tools, and program evaluation. We thank Jennifer Blatnik, lead GERI-VET ICT for her unfailing dedication to our older Veterans and Jill Huded for pioneering geriatric emergency medicine care at the VA.

Sponsor’s Role

There were no external sponsors.

The GERI-VET program received support in part by Veterans Health Administration (VHA) grants through the VA Innovators Network, MyVA Access Improvement program, VA Office of Veterans Access to Care and VA Office of Rural Health for development of GERI-VET educational materials and GERI-VET Bootcamp participant travel. The Cleveland VAMC Specialty Care Center of Innovation provided financial support for implementation of the GERI-VET program and program analysts’ time in collaboration with the Cleveland Institute for Computational Biology.

The Intermediate Care Technician (ICT) Supporting Community, Outpatient, Urgent Care and Telehealth Services (SCOUTS) pilot program described in the main text as a future direction received support in part by Veterans Health Administration (VHA) finance through Congressional COVID/Care Act Relief funding. VHA finance supports the ICT SCOUTS pilot implementation, program analysts’ time, field coordinators’ time, the pilot medical director, and medical direction at 10 participating VA Medical Centers. ICT SCOUTS program is a VA collaborative pilot through Office of Primary Care, Office of Emergency Medicine and Office of Geriatrics and Extended Care.

References

Watts B, Lawrence RH, Schaub K, et al. Transitioning former military medics to civilian health care jobs: a novel pilot program to integrate medics into ambulatory care teams for high-risk patients. Mil Med 2016;181(11):e1464–9. https://doi.org/10.7205/MILMED-D-15-00586.
Jackson, L. Veterans benefit from Intermediate Care Technician program. VAntage Point 2018.Available at: Veterans benefit from Intermediate Care Technician program – VAntage Point. Accessed April 16, 2021.
VA Clinical Strong Practice (CSP) Intermediate Care Technician. Diffusion of Excellence VA.gov (online). Available at: CSP_Intermediate_Care_Technician_final.pdf (va.gov). Accessed April 16, 2021.
Huded JM, Lee A, Mcquown CM, et al. Implementation of a geriatric emergency department program using a novel workforce. Am J Emerg Med. Epub 2020. PMID: 33129647: https://doi.org/10.1016/j.ajem.2020.10.039
Models of Nurse-Led Geriatric Case Management 2020. GEDC Webinar (online). Available at: Webinar – Models of Nurse Led Geriatric Case Management – GEDC (gedcollaborative.com) . Accessed April 16, 2021.