Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized.

OBJECTIVE

This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA).

METHODS

Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use.

RESULTS

Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed.

CONCLUSIONS

This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

Understanding rural-urban differences in veterans' internet access, use and patient preferences for telemedicine

BACKGROUND

The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans.

PURPOSE

To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality.

METHODS

Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported.

FINDINGS

After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1% vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3% vs. 36.8%), just as good (51.1% vs. 53.1%), or better (3.5% vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%).

CONCLUSIONS

Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.

Beyond forced telehealth adoption: A framework to sustain telehealth among allied health services

INTRODUCTION

As COVID-19 restrictions reduce globally, services will determine what components of care will continue via telehealth. We aimed to determine the clinician, service, and system level factors that influence sustained use of telehealth and develop a framework to enhance sustained use where appropriate.

METHODS

This study was conducted across 16 allied health departments over four health service facilities (Brisbane, Australia). It used a multi-method observational study design, involving telehealth service activity data from hospital administrative databases and qualitative interviews with allied health staff (n  =  80). Data were integrated and analysed using Greenhalgh's Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework.

RESULTS

Increased telehealth use during the peak COVID period reverted to in-person activity as restrictions eased. Telehealth is unlikely to be sustained without a clear strategy including determination of roles and responsibilities across the organisation. Clinician resistance due to forced adoption remains a key issue. The main motivator for clinicians to use telehealth was improved consumer-centred care. Benefits beyond this are needed to sustain telehealth and improvements are required to make the telehealth experience seamless for providers and recipients. Data were synthesised into a comprehensive framework that can be used as a blueprint for system-wide improvements and service enhancement or redesign.

DISCUSSION

Sustainability of telehealth activity beyond the peak COVID period is unlikely without implementation strategies to address consumer, clinician, service, and system factors. The framework can inform how these strategies can be enacted. Whilst developed for allied health disciplines, it is likely applicable to other disciplines.

Research Priorities to Expand Virtual Care Access for Patients in the Veterans Affairs Health Care System

The rapid expansion of virtual care is driving demand for equitable, high-quality access to technologies that are required to utilize these services. While the Department of Veterans Affairs (VA) is seen as a national leader in the implementation of telehealth, there remain gaps in evidence about the most promising strategies to expand access to virtual care. To address these gaps, in 2022, the VA's Health Services Research and Development service and Office of Connected Care held a "state-of-the-art" (SOTA) conference to develop research priorities for advancing the science, clinical practice, and implementation of virtual care. One workgroup within the SOTA focused on access to virtual care and addressed three questions: (1) Based on the existing evidence about barriers that impede virtual care access in digitally vulnerable populations, what additional research is needed to understand these factors? (2) Based on the existing evidence about digital inclusion strategies, what additional research is needed to identify the most promising strategies? and (3) What additional research beyond barriers and strategies is needed to address disparities in virtual care access? Here, we report on the workgroup's discussions and recommendations for future research to improve and optimize access to virtual care. Effective implementation of these recommendations will require collaboration among VA operational leadership, researchers, Human Factors Engineering experts and front-line clinicians as they develop, implement, and evaluate the spread of virtual care access strategies.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered.

OBJECTIVE

Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension.

DESIGN

Retrospective cohort study.

PATIENTS

Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years.

MAIN MEASURES

The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering.

KEY RESULTS

Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06).

CONCLUSIONS

Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Importance

Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions.

Objective

To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics.

Design, Setting, and Participants

This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed.

Exposure

Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021).

Main Outcomes and Measures

The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES).

Results

Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03).

Conclusions and Relevance

In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

The impact of COVID-19 on trends in alcohol use disorder treatment in Veterans Health Administration

BACKGROUND AND AIMS

The COVID-19 pandemic disrupted health-care provision in the United States and prompted increases in telehealth-delivery of care. This study measured alcohol use disorder (AUD) treatment trends across visit modalities before and during COVID-19.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

We conducted a national, retrospective cohort study with interrupted time-series models to estimate the impact of COVID-19 on AUD treatment in the Veterans Health Administration (VHA) in the United States during pre-COVID-19 (March 2019 to February 2020) and COVID-19 (March 2020 to February 2021) periods. We analyzed monthly trends in telephone, video and in-person visits for AUD treatment and compared patient and treatment characteristics of patients receiving AUD treatment between the pre-COVID-19 and COVID-19 periods. AUD was defined using International Classification of Diseases, 10th revision (ICD-10) codes for alcohol abuse (F10.1) and alcohol dependence (F10.2), which have previously been used to study AUD in VHA.

FINDINGS

The predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the beginning of the pre-COVID period was 13.8% (n = 49 494). The predicted percentage decreased by 4.3% (P = 0.001) immediately at the start of the COVID-19 period due to a decline in AUD psychotherapy. Despite an increase of 0.3% per month (P = 0.026) following the start of COVID-19, the predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the end of the study period remained below the pre-COVID-19 period. In February 2021, AUD psychotherapy visits were primarily delivered by video (50%, 58 748), followed by in-person (36.6%, 43 251) and telephone (13.8%, 16 299), while AUD pharmacotherapy visits were delivered by telephone (38.9%, 3623) followed by in-person (34.3%, 3193) and video (26.8%, 2498) modalities. Characteristics of VHA patients receiving AUD treatment were largely similar between pre-COVID-19 and COVID-19 periods.

CONCLUSIONS

Despite increased telehealth use, the percentage of United States Veterans Health Administration patients with an alcohol use disorder (AUD) diagnosis receiving AUD treatment declined during COVID-19 (March 2020 to February 2021) mainly due to a decrease in psychotherapy.

Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties

BACKGROUND

Increasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care.

OBJECTIVE

This study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting.

METHODS

We conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA.

RESULTS

Interviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers' perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption.

CONCLUSIONS

This work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation.

Variation in initial and continued use of primary, mental health, and specialty video care among Veterans

OBJECTIVE

To identify which Veteran populations are routinely accessing video-based care.

DATA SOURCES AND STUDY SETTING

National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021.

STUDY DESIGN

This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021.

DATA COLLECTION

Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study.

PRINCIPAL FINDINGS

Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations.

CONCLUSIONS

Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

Rates of Primary Care and Integrated Mental Health Telemedicine Visits Between Rural and Urban Veterans Affairs Beneficiaries Before and After the Onset of the COVID-19 Pandemic

IMPORTANCE

Telemedicine can increase access to care, but uptake has been low among people living in rural areas. The Veterans Health Administration initially encouraged telemedicine uptake in rural areas, but telemedicine expansion efforts have broadened since the COVID-19 pandemic.

OBJECTIVE

To examine changes over time in rural-urban differences in telemedicine use for primary care and for mental health integration services among Veterans Affairs (VA) beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined 63.5 million primary care and 3.6 million mental health integration visits across 138 VA health care systems nationally from March 16, 2019, to December 15, 2021. Statistical analysis took place from December 2021 to January 2023.

EXPOSURES

Health care systems with most clinic locations designated as rural.

MAIN OUTCOMES AND MEASURES

For every system, monthly visit counts for primary care and mental health integration specialties were aggregated from 12 months before to 21 months after pandemic onset. Visits were categorized as in person or telemedicine, including video. A difference-in-difference approach was used to examine associations in visit modality by health care system rurality and pandemic onset. Regression models also adjusted for health care system size as well as relevant patient characteristics (eg, demographic characteristics, comorbidities, broadband internet access, and tablet access).

RESULTS

The study included 63 541 577 primary care visits (6 313 349 unique patients) and 3 621 653 mental health integration visits (972 578 unique patients) (6 329 124 unique patients among the cohort; mean [SD] age, 61.4 [17.1] years; 5 730 747 men [90.5%]; 1 091 241 non-Hispanic Black patients [17.2%]; and 4 198 777 non-Hispanic White patients [66.3%]). In fully adjusted models for primary care services before the pandemic, rural VA health care systems had higher proportions of telemedicine use than urban ones (34% [95% CI, 30%-38%] vs 29% [95% CI, 27%-32%]) but lower proportions of telemedicine use than urban health care systems after pandemic onset (55% [95% CI, 50%-59%] vs 60% [95% CI, 58%-62%]), signifying a 36% reduction in the odds of telemedicine use (odds ratio [OR], 0.64; 95% CI, 0.54-0.76). The rural-urban telemedicine gap was even larger for mental health integration (OR, 0.49; 95% CI, 0.35-0.67) than for primary care services. Few video visits occurred across rural and urban health care systems (unadjusted percentages: before the pandemic, 2% vs 1%; after the pandemic, 4% vs 8%). Nonetheless, there were rural-urban divides for video visits in both primary care (OR, 0.28; 95% CI, 0.19-0.40) and mental health integration services (OR, 0.34; 95% CI, 0.21-0.56).

CONCLUSIONS AND RELEVANCE

This study suggests that, despite initial telemedicine gains at rural VA health care sites, the pandemic was associated with an increase in the rural-urban telemedicine divide across the VA health care system. To ensure equitable access to care, the VA health care system's coordinated telemedicine response may benefit from addressing rural disparities in structural capacity (eg, internet bandwidth) and from tailoring technology to encourage adoption among rural users.

Informing Use of Telehealth for Managing Chronic Conditions: Mixed-Methods Evaluation of Telehealth Use to Manage Heart Failure During COVID-19

Background The COVID-19 pandemic forced Veterans Health Administration facilities to rapidly adopt and deploy telehealth alternatives to provide continuity of care to veterans while minimizing physical contact. The impact of moving to virtual visits on patients with congestive heart failure (HF) is unknown. The goal of this study was to understand how patients with HF and their providers experienced the shift to telehealth for managing a chronic condition, and to inform best practices for continued telehealth use. Methods and Results We identified Veterans Health Administration Medical Centers with high telehealth use before COVID-19 and sites that were forced to adopt telehealth in response to COVID-19, and interviewed cardiology providers and veterans with HF about their experiences using telehealth. Interviews were recorded, transcribed, and analyzed using team-based rapid content analysis. We identified 3 trajectory patterns for cardiology telehealth use before and during COVID-19. They were the low-use class (low to low), high-use class (relatively high to higher), and increased-use class (low to high). The high-use and increased-use classes fit the criteria for sites that had high telehealth use before COVID-19 and sites that rapidly adopted telehealth in response to COVID-19. There were 12 sites in the high-use class and 4 sites in the increased-use class. To match with the number of sites in the increased-use class, we selected the top 4 sites by looking at the months before COVID-19. We identified 3 themes related to telehealth use among patients with HF and cardiology providers: (1) technology was the primary barrier for both patients and providers; (2) infrastructural support was the primary facilitator for providers; and (3) both patients and providers had largely neutral opinions on how telehealth compares to in-person care but described situations in which telehealth is not appropriate. Conclusions Only 12 sites fit the criteria of high telehealth use in cardiology before COVID-19, and 4 fit the criteria of low use that increased in response to COVID-19. Patients and providers at both site types were largely satisfied using telehealth to manage HF. Understanding best practices for managing ambulatory care-sensitive conditions through virtual visits can help the Veterans Health Administration prepare for long-term impacts of COVID-19 on in-person visits, as well as improve access to care for veterans who live remotely or who have difficulty traveling to in-person appointments.

The role of gender and veteran status in healthcare access among a national sample of U.S. adults with unhealthy alcohol use

Background: Routine healthcare access is critical to reduce drinking and its effects, yet little is known about Veteran and gender differences in routine healthcare access among unhealthy drinkers. The current study examined differences in routine healthcare access, stratified by Veteran status and gender, among a national sample of adults endorsing unhealthy drinking. Method: Using data from the Centers for Disease Control and Prevention's 2019 Behavioral Risk Factor Surveillance System National Survey, we identified adults who endorsed unhealthy drinking over the past month (N = 58,816; 41.4% female; 2.7% female Veterans). Bivariate and multivariable analyses modeled associations between gender, Veteran status, and their interaction in predicting routine healthcare access. All multivariable models adjusted for sociodemographic characteristics. Results: Veterans with unhealthy alcohol use reported high rates of routine healthcare access (e.g., >86% sought care in the past 2 years) and were less likely to experience a cost barrier to care (aOR = 0.75, 95% CI = 0.62-0.92). Females were more likely than males to report better access to care but also to experience a cost barrier (aOR = 1.2, 95% CI = 1.10-1.37). The interaction between Veteran status and gender was non-significant. Conclusions: Overall, healthcare access was better for Veterans and females with unhealthy alcohol use compared to civilians and males with unhealthy alcohol use. However, given that females were more likely to report a cost barrier, future implementation research aiming to improve equity in care may want to explore reasons for cost barriers and develop strategies to help reduce these barriers in order to eliminate gender disparities in primary care-based alcohol-related care.

Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic

Background

At the onset of COVID-19, there was a rapid expansion of telehealth (video/telephone) visits to maintain delivery of primary care (PC) services at the Veterans Health Administration (VA). This study examines patient, provider, and site-level characteristics of any virtual and video-based care in PC.

Methods

Interrupted time series (ITS) design was conducted using VA administrative/clinical, electronic healthcare data, 12-months before and 12-months after COVID-19 onset (set at March 2020) at the VA Greater Los Angeles Healthcare System (GLA), between 2019 and 2021. Patients with at least one visit to a VA PC clinic at GLA (n = 547,730 visits) were included in the analysis. The two main outcomes for this study were 1) any telehealth (versus in-person), as well as 2) video-based care (versus telephone). For the ITS analysis, segmented logistic regression on repeated monthly observations of any telehealth and video-based care was used.

Results

Percent telehealth and video use increased from 13.9 to 63.1%, and 0.3 to 11.3%, respectively, before to after COVID-19 onset. According to adjusted percentages, GLA community-based clinics (37.7%, versus 29.8% in hospital-based clinics, p < .001), social workers/pharmacists/dietitians (53.7%, versus 34.0% for PC clinicians, p < .001), and minority groups, non-Hispanic African Americans (36.3%) and Hispanics (34.4%, versus 35.3% for Whites, p < .001) were more likely to use telephone than video. Conversely, mental health providers (43.3%) compared to PC clinicians (15.3%), and women (for all age groups, except 75+) compared to men, were more likely to use video than telephone (all p’s < .001).

Conclusions

Since telehealth care provision is likely to continue after COVID-19, additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) versus video-based care (e.g., integrated mental health visits). Additionally, it is important to understand how all clinics can systematically increase access to both telephone- and video-based PC services, while ensuring equitable care for all patient populations.

Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians

Social support is bidirectionally linked to symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that family involvement in veterans' mental health treatment is desired by both veterans and family members, and that such involvement has the potential to improve treatment outcomes. However, rates of family involvement are low in the Veterans Health Administration (VHA). We sought to understand VHA clinicians' perspectives on family involvement in PTSD treatment by conducting qualitative interviews with 31 providers at 10 VHA facilities across the U.S. The i-PARIHS framework was used to guide the interviews and analysis, and several major themes were identified. All clinicians reported that they at least occasionally offered family-inclusive sessions, and they frequently referenced both the influence of family behaviors or attitudes on veterans' functioning, and also how veterans' symptoms could cause tremendous disruption in the family. Clinicians' past experience with supervised family- or couple-based work strongly influenced their current comfort with family-inclusive sessions. Multiple potential avenues exist to support increased family involvement in PTSD treatment in VHA.

Factors influencing uptake of telemental health via videoconferencing at high and low adoption sites within the Department of Veterans Affairs during COVID-19: a qualitative study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the use of telemental health via videoconferencing (TMH-V). While TMH-V has been found to be effective and satisfactory to both patients and providers, little is known regarding factors that influence site-level uptake. We examined facilitators and barriers to TMH-V uptake at higher and lower adoption sites within the US Department of Veterans Affairs (VA).

METHODS

We conducted twenty-four semi-structured qualitative interviews at four northeastern VA medical centers (two with higher TMH-V adoption and two with lower adoption). Six interviews were conducted per site (one member of mental health leadership, one facility telehealth coordinator/technician, and four mental health providers per site). We performed directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), followed by a matrix rating process to rank the degree of influence of each of the 19 included CFIR constructs at the four sites. Positive overall influences, negative overall influences, and differentiators were then identified based on patterns in ratings across sites.

RESULTS

Five CFIR constructs had positive overall influences across sites: Relative advantage, Patient needs and resources, Relative priority, Knowledge and beliefs, and Self-efficacy. Complexity had a negative overall influence across sites. Four constructs significantly differentiated between higher and lower adoption sites with regards to TMH-V use: Quality, Compatibility, Leadership engagement, and Champions.

CONCLUSIONS

Several positive overall influences on TMH-V uptake were identified across sites; respondents acknowledged multiple advantages of TMH-V (e.g., convenience), and providers' attitudes towards TMH-V improved as they gained experience. In contrast, complexity was a negative overall influence; TMH-V platforms and processes must be simple and user friendly to promote use. The emergence of Quality, Leadership engagement, and Champions as differentiators speaks to the importance of educating frontline staff and leadership at lower adoption sites about the evidence base demonstrating that TMH-V is high-quality care. Compatibility also emerged as a differentiator; if TMH-V is not easily integrated into provider workflows, uptake will falter. Future work should draw from these findings to develop implementation strategies aiming to increase TMH-V uptake at lower adoption sites, thereby increasing access to high-quality mental health care.

Telehealth perceptions and utilization for the delivery of headache care before and during the COVID-19 pandemic: A mixed-methods study

OBJECTIVE

The objective of this study was to evaluate the utilization of telehealth for headache services within the Veterans Health Administration's facilities housing a Headache Centers of Excellence and multiple stakeholder's perspectives to inform future telehealth delivery.

BACKGROUND

Telehealth delivery of headache treatment may enhance patient access to headache care, yet little is known about the utilization or patient and provider perceptions of telehealth for veterans with headache.

METHODS

This mixed-methods study analyzed multiple data sources: (1) administrative data, which included 58,798 patients with medically diagnosed headache disorders, documented in at least one outpatient visit, from August 2019 through September 2020 from the 12 Veterans Health Administration's facilities with a Headache Center of Excellence and (2) qualitative semistructured interviews with 20 patients and 43 providers 6 months before the coronavirus disease 2019 (COVID-19) pandemic, and 10 patients and 20 providers 6 months during the beginning of the pandemic.

RESULTS

During the pandemic, in-person visits declined from 12,794 to 6099 (52.0%), whereas video (incidence rate ratio [IRR] = 2.05, 95% confidence interval [CI] = 1.66, 2.52), and telephone visits (IRR = 15.2, 95% CI = 10.7, 21.6) significantly increased. Utilization differed based on patient age, race/ethnicity, and rurality. Patients and providers perceived value in using telehealth, yet had limited experience with this modality pre-pandemic. Providers preferred in-person appointments for initial encounters and telehealth for follow-up visits. Providers and patients identified benefits and challenges of telehealth delivery, often relying on multiple delivery methods for telehealth to enhance patient engagement.

CONCLUSIONS

The uptake of telehealth delivery of headache-related care rapidly expanded in response to the pandemic. Patients and providers were amenable to utilizing telehealth, yet also experienced technological barriers. To encourage equitable access to telehealth and direct resources to those in need, it is crucial to understand patient preferences regarding in-person versus telehealth visits and identify patient groups who face barriers to access.

Health Care Disparities and Access to Video Visits Before and After the COVID-19 Pandemic: Findings from a Patient Survey in Primary Care

Background: In 2020, the Centers for Medicare & Medicaid Services reimbursement structure was relaxed to aid in the rapid adoption nationally of telemedicine during the COVID-19 pandemic. Due to limited access to internet service, cellular phone data, and appropriate devices, many patients may be excluded from telemedicine services. Methods: In this study, we present the findings of a survey of patients at an urban primary care clinic regarding their access to the tools needed for telemedicine before and after the COVID-19 pandemic. Patients provided information about their access to internet services, phone and data plans, and their perceived access to and interest in telemedicine. The survey was conducted in 2019 and then again in September of 2020 after expansion of telemedicine services. Results: In 2019, 168 patients were surveyed; and in 2020, 99 patients participated. In both surveys, 30% of respondents had limited phone data, no data, or no phone at all. In 2019, the patient responses showed a statistically significant difference in phone plan types between patients with different insurance plans (p < 0.10), with a higher proportion (39%) of patients with Medicaid or Medicaid waiver having a prepaid phone or no phone at all compared with patients with commercial insurance (26%). The overall awareness rate increased from 17% to 43% in the 2020 survey. Conclusions: This survey illustrated that not all patients had access to devices, cellular data, and internet service, which are all needed to conduct telemedicine. In this survey, patients with Medicaid or Medicaid waiver insurance were less likely to have these tools than those with a commercial payor. Finally, patients' access to these telemedicine tools correlated with their interest in using telemedicine visits. Providing equitable telemedicine care requires attention to and mitigation strategies for these gaps in access.