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Jacobs J, Ferguson JM, Van Campen J, Yefimova M, Greene L, Heyworth L, Zulman DM. Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemed J E Health 2021; 28:199-211. [PMID: 33887166 DOI: 10.1089/tmj.2020.0530] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.
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Affiliation(s)
- Josephine Jacobs
- Health Economics Resource Center, and Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, California, USA
| | - Jacqueline M Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - James Van Campen
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Maria Yefimova
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Office of Research Patient Care Services, Stanford Health Care, Stanford, California, USA
| | - Liberty Greene
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Leonie Heyworth
- Office of Connected Care/Telehealth, Department of Veterans Affairs Central Office, Washington, District of Columbia, USA.,Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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Day SC, Day G, Keller M, Touchett H, Amspoker AB, Martin L, Lindsay JA. Personalized implementation of video telehealth for rural veterans (PIVOT-R). Mhealth 2021; 7:24. [PMID: 33898593 PMCID: PMC8063014 DOI: 10.21037/mhealth.2020.03.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/09/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND A national shortage of mental health (MH) professionals leaves more than 90% of rural individuals without adequate access to services each year, troubling because 33% of Veterans Health Administration (VHA) enrollees live in rural areas and rural Veterans have a greater risk of suicide than urban Veterans. Additional barriers such as travel distance and cost, stigma and extreme weather or geography add to challenges of rural Veterans seeking treatment. Although the VHA has addressed this disparity by providing telemental health services, provision of services via traditional hub-and-spoke and/or establishment of regional centers has not fully addressed barriers or resource limitations. Video telehealth to home (VTH) has assisted in better addressing geographic, attitudinal and systematic barriers to in-person care; however, its uptake and implementation have been problematic. This article describes the Personalized Implementation of Video Telehealth for Rural Veterans (PIVOT-R) approach, developed in response to the unique needs of rural veterans. METHODS We developed PIVOT, a flexible implementation strategy that is adaptive to site-specific contexts and different digital innovations and relies on a collaborative relationship between external facilitators, internal facilitators and clinical champions. We used formative evaluation (FE) to gather ongoing information about our quality improvement (QI) implementation approach of VTH. Our FE of PIVOT at rural sites provided insight into adaptations to improve rural implementation. This led to development of PIVOT-R, which explicitly focuses on rural implementation. PIVOT-R, developed from provider and patient feedback plus lessons learned during implementation, focuses on rurality as an important diversity factor and addresses relationship building, engaging the site, assessing context and infrastructure and balancing national expectations with site-level goals. During fiscal year 2018 we partnered with a VHA healthcare system in a Western mountain state to pilot the PIVOT-R approach, again using FE which included quantitative and qualitative data collection to evaluate its impact. RESULTS PIVOT-R effectively increased uptake of VTH for MH care at the healthcare system evaluated. In fiscal year 2019 the percentage of Veterans receiving MH care via VTH at the site was 10 times greater than in fiscal year 2018, matching the mean VHA nationwide percentage and increasing by 43.24% by the end of 2019. Veteran feedback supported a positive experience by users. CONCLUSIONS Inclusion of a comprehensive assessment of the rural system, including infrastructure and resources, greatly improves understanding of a system's specific needs and enables a tailored approach targeting relevant barriers. Our FE suggests the potential of PIVOT-R to increase VTH uptake at other rural locations and reinforces the value of telehealth technology as an important resource for rural sites.
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Affiliation(s)
- Stephanie C. Day
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Giselle Day
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | - Michele Keller
- Veterans Affairs Medical Center-Fort Harrison, Fort Harrison, MT, USA
| | - Hilary Touchett
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Amber B. Amspoker
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Lindsey Martin
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Jan A. Lindsay
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
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Hensel JM, Yang R, Vigod SN, Desveaux L. Videoconferencing at home for psychotherapy in the postpartum period: Identifying drivers of successful engagement and important therapeutic conditions for meaningful use. COUNSELLING & PSYCHOTHERAPY RESEARCH 2020. [DOI: 10.1002/capr.12372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Rebecca Yang
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care Toronto ON Canada
| | - Simone N. Vigod
- Department of Psychiatry University of Toronto Toronto ON Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care Toronto ON Canada
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Recent trends in the rural–urban suicide disparity among veterans using VA health care. J Behav Med 2020; 44:492-506. [DOI: 10.1007/s10865-020-00176-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/21/2020] [Indexed: 02/08/2023]
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Giese KK. Coronavirus Disease 2019's Shake-up of Telehealth Policy: Application of Kingdon's Multiple Streams Framework. J Nurse Pract 2020; 16:768-770. [PMID: 32837405 PMCID: PMC7430271 DOI: 10.1016/j.nurpra.2020.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Providing care by telehealth has been an aspiration for many health care practices. However, regulatory barriers often prevented its implementation. The emergence of the COVID-19 virus provided a window of opportunity for federal policy change in telehealth during a national state of emergency. Telehealth policy is examined using Kingdon’s multiple streams (policy) framework. Evidence suggests the effectiveness of telehealth for the delivery of health care. Before coronavirus disease 2019 (COVID-19), widespread use of telehealth lagged related to reimbursement. The COVID-19 pandemic provided a window of opportunity for federal policy change in telehealth reimbursement.
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Slightam C, Gregory AJ, Hu J, Jacobs J, Gurmessa T, Kimerling R, Blonigen D, Zulman DM. Patient Perceptions of Video Visits Using Veterans Affairs Telehealth Tablets: Survey Study. J Med Internet Res 2020; 22:e15682. [PMID: 32293573 PMCID: PMC7191342 DOI: 10.2196/15682] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/05/2019] [Accepted: 12/19/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Video-based health care can help address access gaps for patients and is rapidly being offered by health care organizations. However, patients who lack access to technology may be left behind in these initiatives. In 2016, the US Department of Veterans Affairs (VA) began distributing video-enabled tablets to provide video visits to veterans with health care access barriers. OBJECTIVE This study aimed to evaluate veterans' experiences with VA-issued tablets and identify patient characteristics associated with preferences for video visits vs in-person care. METHODS A baseline survey was sent to the tablet recipients, and a follow-up survey was sent to the respondents 3 to 6 months later. Multivariate logistic regression was used to identify patient characteristics associated with preferences for care, and we examined qualitative themes around care preferences using standard content analysis methods for coding the data collected in the open-ended questions. RESULTS Patient-reported access barriers centered around transportation and health-related challenges, outside commitments, and feeling uncomfortable or uneasy at the VA. Satisfaction with the tablet program was high, and in the follow-up survey, approximately two-thirds of tablet recipients preferred care via a tablet (194/604, 32.1%) or expressed that video-based and in-person care were "about the same" (216/604, 35.7%), whereas one-third (192/604, 31.7%) indicated a preference for in-person care. Patients were significantly more likely to report a preference for video visits (vs a preference for in-person visits or rating them "about the same") if they felt uncomfortable in a VA setting, reported a collaborative communication style with their doctor, had a substance use disorder diagnosis, or lived in a place with better broadband coverage. Patients were less likely to report a preference for video visits if they had more chronic conditions. Qualitative analyses identified four themes related to preferences for video-based care: perceived improvements in access to care, perceived differential quality of care, feasibility of obtaining necessary care, and technology-related challenges. CONCLUSIONS Many recipients of VA-issued tablets report that video care is equivalent to or preferred to in-person care. Results may inform efforts to identify good candidates for virtual care and interventions to support individuals who experience technical challenges.
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Affiliation(s)
- Cindie Slightam
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
| | - Amy J Gregory
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
| | - Jiaqi Hu
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, United States
| | - Josephine Jacobs
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
| | - Tolessa Gurmessa
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
- Program Evaluation and Resource Center, Veterans Health Administration, Menlo Park, CA, United States
| | - Rachel Kimerling
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
- National Center for Post-Traumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
| | - Daniel Blonigen
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, United States
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