Cancer Rehabilitation Veterans Affairs Extension for Community Healthcare Outcomes Virtual Education Program

Abstract

Rehabilitation is important in the care of patients with cancer for improving function, pain, and quality of life. However, only a small number of clinicians are formally trained in cancer rehabilitation. Virtual learning environments may play a promising role in cancer rehabilitation education, especially in the coronavirus pandemic era where in-person learning is not readily available. A national, interprofessional cancer rehabilitation education program involving a monthly longitudinal webinar series and a 2-day virtual bootcamp was developed through the US Department of Veterans Affairs Extension for Community Healthcare Outcomes to improve Department of Veterans Affairs clinician understanding of cancer rehabilitation and ultimately increase the availability of cancer rehabilitation services in the Veterans Health Administration. From March 2020 to July 2022, 923 individuals participated with an average of 72 participants per session and 204 participants per session in the bootcamp. Participants’ most common disciplines were physical therapy, occupational therapy, nursing, medicine (physicians), advanced practice providers, speech therapy, and pharmacy. Participants reported improved knowledge of cancer rehabilitation and anticipated that the knowledge would change their practice. Virtual education can be a useful means to educate Department of Veterans Affairs–based healthcare professionals about cancer rehabilitation and improve access to rehabilitation services for veterans with cancer.

The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States (US), caring for more than 9 million Veterans at more than 1200 facilities.¹ Thus, VA serves the largest population of patients with cancer in the US.² Cancer and its subsequent therapies can cause significant impairments in functional status.³ Examples include a large lung mass inhibiting pulmonary function leading to decreased endurance, a metastatic lesion in the lumbosacral plexus impairing lower limb sensation and strength resulting in gait deficits, or an intracranial mass resulting in uncontrolled seizure activity. Many of the systemic treatments used in cancer treatment are known to cause a wide variety of adverse effects, including peripheral neuropathies, fatigue, cognitive dysfunction, cardiotoxicities, and more.^3,4 Rehabilitation is increasingly being recognized as essential to the high-quality care of patients with cancer in reducing pain and improving function and quality of life.^5,6

While cancer rehabilitation services in VA and community settings have dramatically expanded in the past decade, the number of veterans who need these services remain far greater than the clinical services available.⁷ Rehabilitation physicians and healthcare professionals throughout the country who provide rehabilitative care (e.g., physical therapists, occupational therapists, speech language pathologists) are already seeing individuals with cancer in their practice but only a small percentage receive formal training in cancer rehabilitation.⁷ Part of this may be due to the small number of training programs in cancer rehabilitation. Currently, subspecialty training in cancer rehabilitation is available only for physicians and physical therapists through 11 cancer physiatry fellowships in the US and Canada⁸ and the Oncology Physical Therapy Certification through the American Board of Physical Therapy Specialties.⁹ In addition, cancer patients who may benefit from rehabilitation are often underreferred to cancer rehabilitation services in part because oncology providers are unfamiliar with the role of cancer rehabilitation in cancer care.^10,11 There is a need for ongoing cancer rehabilitation education for both rehabilitation based and nonrehabilitation-based providers to fill this gap.

The VA implemented VA-ECHO (also known as Specialty Care Access Network–Extension for Community Healthcare Outcomes) in 2011 to expand specialty care services for veterans, particularly in rural and medically underserved regions. The VA-ECHO, which is based on the internationally recognized telementorship program Project ECHO,¹² initially focused on a range of conditions including chronic kidney disease, hepatitis C, and pain management.¹³

Cancer Rehabilitation VA-ECHO, a nationwide virtual education program for interprofessional VA healthcare providers, was developed in 2019 in response to the gap in cancer rehabilitation education in VA and to fulfill Commission on Accreditation of Rehabilitation Facilities accreditation standards for cancer rehabilitation specialty programs. Coincidentally, the first Cancer Rehabilitation VA-ECHO sessions were offered early in 2020 at the beginning of the coronavirus disease (COVID-19) pandemic. The pandemic significantly disrupted ongoing medical professional development and healthcare delivery, forcing healthcare to use virtual learning strategies more than ever before. Here, we describe the first national VA-based cancer rehabilitation education program including curriculum, participant characteristics, program evaluation results, challenges, successes, and its unique role in the field of cancer rehabilitation education during COVID-19.

METHODS

VA-ECHO

VA-ECHO leverages video-teleconferencing technology to allow VA-based healthcare professionals to participate in virtual learning at no cost to participants. The programming is available to all VA-based healthcare professionals, as well as nonclinical team members, including those based in rural care settings. The VA offers multiple VA-ECHO programs, in a variety of specialties, including diabetes, sleep medicine, and gastroenterology. Previous work has shown that VA-ECHO promotes topic knowledge and is anticipated (by learners) to result in practice change.^14–16 In most VA-ECHO sessions, subject matter experts present didactic material and review clinical cases for 60–90 mins. The sessions promote real-time communication between learners and speakers and facilitate the development of a multidisciplinary community of practice inclusive of providers from all disciplines, all clinical specialties, and all sites of care.

Cancer Rehabilitation VA-ECHO

Program Overview

The Cancer Rehabilitation VA-ECHO program was created by clinicians in the VA Puget Sound Health Care System, which is part of the Northwest VA Health Network (Veterans Integrated Services Network [VISN] 20). It provides two types of educational offerings: (1) a monthly webinar series and (2) an annual bootcamp series which consists of multiple session per day over several days. The sessions are available to all VA healthcare professionals throughout the nation, regardless of specialty or discipline, who are interested in cancer rehabilitation. Nonclinical team members are also welcome to attend. Cancer rehabilitation VA-ECHO diverges slightly from the Project ECHO model as described by Arora et al.¹² in that rather than review of individual clinical cases and patient-specific recommendations, it relies more on structured didactic content and bidirectional communication between learners and speakers. Speakers in Cancer Rehab VA-ECHO include physiatrists, urologists, psychologists, physical therapists, occupational therapists, and speech therapists (Table 1). All sessions are recorded, and recordings and presentation handouts are available via VA intranet online for individuals who are unable to attend the sessions or who would like to review or share with colleagues.

TABLE 1.

Monthly cancer rehabilitation extension for community healthcare outcomes curriculum from March 2020 to July 2022

Month	Topic	Speaker
Mar 2020	The role of rehabilitation in comprehensive cancer care	Physiatrist
Apr 2020	Impairments in head & neck cancer	Physiatrist
May 2020	Prostate and bladder cancer: treatment and survivorship	Urologist
Jun 2020	Precautions in cancer rehabilitation	Physiatrist
Jul 2020	Better communications for better patient outcomes	Psychologist
Aug 2020	Lung cancer rehabilitation	Physiatrist
Sep 2020	Principles of physical therapy in cancer	Physical therapist
Oct 2020	Gastrointestinal (GI) medical oncology—colorectal cancer	Oncologist
Nov 2020	GI cancers, treatment modalities and functional deficits	Physiatrist
Dec 2020	Diagnosis and treatment strategies for cancer cachexia	Geriatrician
Jan 2021	Hematology for the rehabilitation team	Physiatrist
Feb 2021	Why cancer patients can’t do stuff	Physiatrist
Mar 2021	Inpatient cancer rehabilitation	Physiatrist
Apr 2021	Integrating rehabilitation services in cancer care	Physical therapist
May 2021	Telemedicine in cancer rehabilitation	Physiatrist
Jun 2021	Post-operative head and neck cancer treatment	Speech therapist
Jul 2021	Neuropsychology and oncology: cognition in cancer	Psychologist
Aug 2021	Lymphedema treatment overview	Physical and occupational therapist
Sep 2021	Cancer rehab: prehab to survivorship	Physical therapist
Sep 2021	Caring for the older adult with cancer	Geriatric oncologist
Oct 2021	Occupational therapy and the art of functional living	Occupational therapist
Nov 2021	Prehabilitation for veterans with cancer	Physiatrist, physical, occupational, and speech therapist
Jan 2022	Building a cancer rehabilitation program	Physiatrists
Feb 2022	Cumulative effects of radiation treatment on bone health	Physiatrist
Apr 2022	Survivorship and cancer rehabilitation	Physiatrist
May 2022	Cancer rehabilitation 101	Physiatrist
June 2022	Cancer care navigation; addressing psychosocial distress	Social worker
July 2022	Ototoxicity management	Audiologist

One continuing education (CE) credit was offered per session. Most Cancer Rehabilitation VA-ECHO sessions offer the following accreditations: Joint Accreditation for Interprofessional Continuing Education (JA IPCE); Accreditation Council for Continuing Medical Education (ACCME); ACCME nonphysician certificate option (ACCME-NP); Accreditation Council for Pharmacy Education (ACPE); American Nurses Credentialing Center (ANCC); American Psychological Association (APA); Association of Social Work Boards (ASWB); New York State Education Department (NYSED) Social Work Board; American Physical Therapy Association (APTA); American Occupational Therapy Association (AOTA); American Speech-Language-Hearing Association (ASHA, the only one not offered if the content did not fit the accreditation criteria for speech language pathologists).

This operational analysis was reviewed jointly by the Human Research Protection Program and Quality, Safety & Value service line at the VA Puget Sound Health Care System and determined to not constitute human subjects research.

Monthly Webinar

The goal of the monthly webinar is to provide a longitudinal, flexible learning cancer rehabilitation program for healthcare professionals in the VA system. The program started March 2020 and offers monthly 60-min sessions on the fourth Tuesday of the month.

The curriculum (Table 1) was developed by an interdisciplinary planning committee. The committee developed a curriculum based on cancer diagnoses with the highest incidence in the VA population (e.g., prostate, lung, and colon cancer),² consultation with national subject matter experts, and participants’ recommendations on postsession evaluations.

Bootcamp

The Cancer Rehabilitation VA-ECHO bootcamps are learning programs with aggregated content occurring over a short period. The bootcamps occur annually and are developed and offered to provide an accelerated, intensive program on high-yield cancer rehabilitation topics. The bootcamp is a 2-day program with each day lasting approximately 4.5 hrs (4.5 CE per day). The first bootcamp, offered in March 2022, included 8 modules per day, each lasting 30–45 mins.

The initial bootcamp curriculum was based on the longitudinal series. The course directors created a comprehensive, accelerated curriculum focusing on how to build a cancer rehabilitation program within the VA and on key impairments associated with various cancer treatments (Table 2).

TABLE 2.

Two-day bootcamp curriculum in March 2022

	Topic	Speaker
Day 1	Welcome/building a case for cancer rehabilitation in the VA	Physiatrist
	The role of rehabilitation in comprehensive cancer care	Physiatrist
	Common medical treatments and key impairments associated with treatments	Physical therapist
	Commonly diagnosed cancers and treatment-related impairment considerations: lung, prostate, colon	Physiatrists
	Building a cancer rehabilitation program at your VA	Physiatrist
	Commonly diagnosed cancers and treatment-related impairment considerations: head and neck, hematologic, breast	Physiatrists
	A systems-based approach to cancer treatment-related impairments: musculoskeletal	Physical therapist
	A systems-based approach to cancer treatment-related impairments: neuromuscular	Physiatrist
Day 2	A systems-based approach to cancer treatment-related impairments: integumentary	Physiatrist
	A systems-based approach to cancer treatment-related impairments: cancer cachexia	Physiatrist, psychologist
	Exercise prescription	Physical therapist
	Cancer prehabilitation	Physiatrist
	Enhanced recovery programs in 2022: opportunities and challenges	Anesthesiologist, physiatrist
	Survivorship screening across all cancers	Physical therapist
	Palliative care in cancer rehab	Physiatrist
	Best practices across VA	Physical therapist
	Course wrap up

One continuing education (CE) credit was offered per 1-hr session. The following accreditations were offered: Joint Accreditation for Interprofessional Continuing Education (JA IPCE); Accreditation Council for Continuing Medical Education (ACCME); ACCME nonphysician certificate option (ACCME-NP); Accreditation Council for Pharmacy Education (ACPE); American Nurses Credentialing Center (ANCC); American Psychological Association (APA); Association of Social Work Boards (ASWB); New York State Education Department (NYSED) Social Work Board; American Physical Therapy Association (APTA); American Occupational Therapy Association (AOTA); American Speech-Language-Hearing Association (ASHA, the only one not offered if the content did not fit the accreditation criteria for Speech Language Pathologists).

Participant Recruitment

Individuals participate at no cost in both the monthly webinar and bootcamp sessions. Program announcements for the webinar and bootcamp are emailed to national discipline–specific listservs and regional VA clinical leaders and are cross-advertised at other VA-ECHO sessions. Incentives for participation include the ability to earn continuing education credits from more than 10 different accrediting bodies through VA Institute for Leadership, Education, and Development (ILEAD).

Program Evaluation

Individual Session Evaluation

After each longitudinal session, participants are automatically directed to a four-item evaluation via an intranet-based SharePoint in which they respond on a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree, 9 = not applicable). The same four-item evaluation are provided to participants at the end of the bootcamp for each individual session. The questions include the following:

• -The content in this session was relevant to my practice.
• -My level of knowledge surrounding today’s topic has improved.
• -I anticipate changing my clinical practice based on the content of this session.
• -I would like to hear from the faculty speaker(s) again.

Participants also receive a single email after each session with reminder to complete the evaluation, a link to the evaluation as well as handouts, recordings, and other material or resources mentioned in the session.

Data Collection

Program data were collected and managed by using research electronic data capture (REDCap) tools¹⁷ at VA Puget Sound. A custom REDCap project, developed and maintained by the VISN 20 VA-ECHO team members, captured participant attendance and characteristics when they joined a session for the first time. Information was self-reported or, when necessary, collected through official online sources (academic affiliate faculty directories and the National Provider Identifier Database). Demographic information collected included participant specialty (using choices based on the Centers for Medicare and Medicaid Services specialty codes),¹⁸ clinical discipline (based on the National Uniform Claim Committee provider taxonomy¹⁹), clinical site of care (including specific site, city, state, and VISN).²⁰ Site of care rurality was determined based on the rural-urban commuting area designation.²¹ When evaluating whether the participant was from a rural or urban setting, metropolitan areas (i.e., primary rural-urban commuting area codes 1–3) were classified as urban. Healthcare trainees, program medical director, cancer rehabilitation VA-ECHO faculty, and VA-ECHO coordinators were excluded from the data set.

Statistical Analysis

Descriptive analysis was performed for participant characteristics and program evaluation results. The primary outcomes were self-reported relevance of topics to professional practice, change in the level of knowledge surrounding specific cancer rehabilitation topics, and prospective report of change in practice. Statistical process control charts for the data were made to assist in measuring variability and to help determine the success of the initiative.

RESULTS

Between March 2020 and July 2022, 27 cancer rehabilitation sessions were offered in the monthly longitudinal program, and one 2-day bootcamp was conducted in March 2022 that included 8 sessions per day. A total of 923 unique individuals participated throughout this period (Table 3), 682 in the webinar series only, 104 in the bootcamp only, and 161 in both the webinar series and bootcamp.

TABLE 3.

Participant demographics

	Rural	Rural %	Urban or Unknowna	Urban or Unknown %	Total	Total %
Discipline
Physical therapist	10	18%	195	22%	205	22.20%
Occupational therapist	4	7%	139	16%	143	15.50%
Nurse	6	11%	118	14%	124	13.40%
Other	13	24%	101	12%	114	12.40%
Speech therapist	7	13%	83	10%	90	9.80%
Physician	3	5%	54	6%	57	6.20%
Pharmacist	4	7%	44	5%	48	5.20%
Advanced practice provider	1	2%	42	5%	43	4.70%
Social worker	4	7%	33	4%	37	4.00%
Psychologist	2	4%	30	3%	32	3.50%
Dietician	1	2%	29	3%	30	3.30%
Attendance (no. sessions)
1	31	54.5%	397	45.80%	428	46.40%
2–4	14	24.6%	184	21.20%	198	21.50%
5–7	2	3.50%	39	4.50%	41	4.40%
8–10	3	5.30%	63	7.30%	66	7.20%
>10	7	12.30%	183	21.10%	190	20.60%
Session attendance
Webinar only	47	82.5	634	73.2	681	73.8
Bootcamp only	4	7.0	103	11.9	107	11.6
Both webinar and bootcamp	6	10.5	129	14.9	135	14.6

^a Rurality based on rural-urban commuting area. Two participants did not have any location listed.

Thirty-five disciplines were represented (Fig. 1) with rehabilitation and restorative care therapists making up most of the participants (47.5% total [22.2% physical therapists, 15.5% occupational therapists, and 9.8% speech-language pathologists]). Physicians comprised 6.2% of participants and APPs (advanced practice nurses and physician assistants) were 4.7%. The most common specialty groups represented among physicians were physiatry (47.4%), internal medicine and family medicine (15.8%), geriatrics (14.0%), oncology (5.3%), and perioperative care (surgery and anesthesiology, 5.3%).

FIGURE 1.

Participant disciplines represented with physician specialties further detailed.

Participants represented 222 unique sites of care (Fig. 2) representing 48 states (all except Maine and Vermont), the District of Columbia, and 1 US territory (Puerto Rico). The highest percentage of participants came from Florida (11.4%) and Washington (9.0%). The VISNs most represented were VISN 20 (13.8%) in the Pacific Northwest and VISN 10 (12.9%), which serves Ohio, Indiana, and Michigan. Only 6.0% of participants worked in rural settings.

FIGURE 2.

Participant practice locations throughout the United States between March 2020 and July 2022.

An average of 71 participants attended each session in the webinar series between 2020 and 2022, and an average of 203 participants attended the 2-day March 2022 bootcamp (Fig. 3). Approximately one third of participants (33.8%) demonstrated “high participation,” attending five or more of the 43 sessions. Twenty-one percent attended two to four sessions (“intermediate participation”), and 44.9% attended a single session (“low participation”).

FIGURE 3.

Participants per month between March 2020 and July 2022.

On average, the sessions received evaluation scores of 4.6/5 (5 being strongly agree) for topic relevance, 4.3/5 for being a topic that would change practice, and 4.5/5 for improving knowledge on the topic (Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/PHM/C36). The response rate averaged 54.4% for the monthly sessions and 51.0% for the bootcamp.

DISCUSSION

The virtual Cancer Rehabilitation VA-ECHO program addresses the national gap in education on cancer rehabilitation among interprofessional healthcare team members working in the VA system. It focuses on topics relevant to healthcare professionals treating veterans with cancer. The program provides education in two ways: a longitudinal lecture series over 2 yrs with a total of 27 lectures and a 2-day bootcamp with 16 lectures. A total of 923 unique participants attended the program in the 2 yrs, with an average of 71 participants per monthly session and almost triple the number of participants (average of 203 participants) attending each bootcamp session. More than half of the participants attended more than one session, which is similar to the attendance patterns reported with the other VA-ECHO programs.¹⁵ A previous evaluation of a VA-ECHO program found that time of day/day of the week was the most common reason for limited participation among those receiving invitations to attend,¹⁴ which may be similar with this program because it occurs at the same time and date each month.

Each educational format has specific goals and benefits. The longitudinal monthly lecture series provide regular exposure to cancer rehabilitation content through a high-frequency, low-dose strategy. In comparison, the bootcamp is designed with a high-dose, low-frequency strategy to help participants focus intensely on cancer rehabilitation to acquire new knowledge on the topic over a shorter period. There are observations that longer duration engagement (≥1 yr) in VA-ECHO–based virtual programming improves healthcare professional self-reported knowledge, and competency and access to specialty care when compared with shorter duration engagement.²² Future evaluations will be needed to determine whether this is similar for cancer rehabilitation education. The boot camp curriculum appeals to a diverse audience with certain sessions focusing on physician learning needs (e.g., inpatient cancer rehabilitation) and other sessions focusing on therapists (e.g., principles of physical therapy in cancer). As a result, the speakers and participants are diverse from the perspective of discipline and geography. The overall benefits of the VA-ECHO program include the ability for healthcare professionals to obtain continuing education remotely during a busy workday along with the opportunity for community building and collaboration within the field.

Specialized cancer rehabilitation services remain limited throughout the nation inside and outside VA settings, with only approximately 10% of National Cancer Institute–accredited hospitals having a link to cancer rehabilitation services on their Websites.²³ Project ECHO helps bridge knowledge gaps between specialists at academic health centers and frontline healthcare professionals in underserved areas.¹⁶ Furthermore, a systematic review of Project ECHO based programs found preliminary evidence that Project ECHO is an effective cost-saving model to improve access to high-quality medical education.²⁴ Although we did not address costs associated with running this ECHO program specifically, it is clear that this virtual education format delivers a high number of education hours across a wide geographical region for a fixed investment of person-hours, including ECHO coordination, medical leadership, and speaker time. Cost savings for virtual education compared with traditional education formats in terms of travel for participants and speakers, as well as clinical time lost, is another factor worth considering in evaluating the cost-effectiveness of this format.

While many VA-ECHO programs were demonstrating steadily increased engagement over time¹⁵ before 2020, the COVID-19 pandemic resulted in significantly increased interest and participation in virtual education overall.^25–28 This program provides national access to cancer rehabilitation education, allowing for multidisciplinary VA attendance. This program demonstrates that virtual education plays a valuable role in cancer rehabilitation education, especially in the COVID-19 era where virtual education has risen to supplement in-person events. It shifts cancer rehabilitation education away from the traditional teaching paradigm of single institutional silos of knowledge to a shared national community of learning with national subject matter experts from a range of disciplines. This program creates enduring resources for education in cancer rehabilitation that may be used to improve individual practices and allows learners to teach others based on the materials provided. Disadvantages of virtual teaching include reduced learner engagement and technical challenges of using a virtual platform.²⁵ For live educational programs such as this one, the sessions’ date and/or time may not work for all individuals.

The need for cancer rehabilitation care will continue to grow as advancements are made in cancer treatments to help patients achieve maximal physical, social, psychological, and vocational function.⁷ Cancer rehabilitation is an emerging specialty with a limited number of experts. Virtual learning can connect experts in the field to remote learners in a variety of specialties and settings, especially those healthcare professionals in regions without access to cancer rehabilitation services. It provides flexible access, increased access to resources, and improved efficiency in educational delivery. Virtual educational programming is an option for advancing cancer rehabilitation education as the field expands further.

Additional work on the program needs to be done to facilitate increased participation and completion of the educational sessions. Data from the sessions (e.g., chat conversations, questions asked) could help identify topic areas of importance and content that may have been challenging to understand. Furthermore, the inclusion of patient and caregiver input in curriculum building would be beneficial to allow opportunities for patients to address the learners. Most significantly, future assessments of this educational program should include the application of evidence-based practice assessment tools supported by the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework²⁹ (e.g., Fresno Test³⁰ and Berlin Questionnaire³¹) to measure learner knowledge and how the knowledge impacts one’s clinical practice.

Limitations

This program evaluation has some limitations. It evaluates a VA-specific educational program, making it less generalizable to the wider population of providers that care for veterans with cancer. Attendees voluntarily participated in sessions, which likely resulted in selection bias of healthcare professionals more motivated to improve their knowledge base on cancer rehabilitation, and thus affected evaluation responses. Evaluation responses were identifiable and not required, and respondents were informed of this, which may have influenced responses and response rate. In addition, this program was developed exclusively for remote learning and was not designed to be compared with live, in-person training. Therefore, we are unable to comment on the comparative effectiveness of virtual versus in-person learning for this content area. Finally, based on the evaluation data from this series alone, we are unable to determine whether the overarching goal of increasing availability and access to cancer rehabilitation has been met. Future study may be helpful to establish a baseline and well as trends in rehabilitation referrals as well as clinical encounters for persons with cancer over time.

CONCLUSIONS

We describe a model for a virtual interprofessional cancer rehabilitation education program, which successfully and rapidly expanded cancer rehabilitation education across the nation. Overall, participants reported the increased knowledge would likely change their clinical practice. This model may serve as an example for dissemination of relatively scarce cancer rehabilitation knowledge to frontline clinicians delivering care closer to the patient’s home. Future studies are needed to assess the impact this education might have on access to rehabilitation services for veterans with cancer.