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Allison TA, Stephens CE, Kotwal AA. Supporting technology access for older adults through in-home, intergenerational involvement: The case for ethnographic methods and student service-learning courses. J Am Geriatr Soc 2024; 72:1318-1321. [PMID: 38497805 PMCID: PMC11090700 DOI: 10.1111/jgs.18860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 03/19/2024]
Abstract
This editorial comments on the article by Hawley et al. in this issue.
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Affiliation(s)
- Theresa A. Allison
- University of California, San Francisco, Division of
Geriatrics, San Francisco, CA, USA
- San Francisco VA Health Care System, San Francisco, CA,
USA
| | | | - Ashwin A. Kotwal
- University of California, San Francisco, Division of
Geriatrics, San Francisco, CA, USA
- San Francisco VA Health Care System, San Francisco, CA,
USA
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Leung LB, Zhang E, Chu K, Yoo C, Gabrielian S, Der-Martirosian C. Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset. J Gen Intern Med 2024; 39:53-59. [PMID: 38252239 PMCID: PMC10937850 DOI: 10.1007/s11606-023-08462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/06/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness. OBJECTIVE To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic. DESIGN Retrospective cohort study, 3/16/2019-3/15/2022. PARTICIPANTS 394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits. MAIN MEASURES The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing). KEY RESULTS Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42-0.44), women (OR = 1.74, CI: 1.70-1.78), Black (OR = 1.14, CI: 1.12-1.16), Hispanic (OR = 1.34, CI: 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services. CONCLUSIONS Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Division of General Internal Medicine, UCLA David Geffen School of Medicine/Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Eunice Zhang
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Caroline Yoo
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Sonya Gabrielian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Veterans Affairs Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, USA
| | - Claudia Der-Martirosian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
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Schubert CC, Penney LS, Schwartzkopf AL, Damush TM, Preddie A, Flemming S, Myers J, Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits. J Gen Intern Med 2024; 39:36-43. [PMID: 38227169 PMCID: PMC10937878 DOI: 10.1007/s11606-023-08460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/06/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). OBJECTIVES The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. DESIGN Quality improvement project with longitudinal qualitative data collection. PROGRAM DESCRIPTION The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. APPROACH & PARTICIPANTS We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. KEY RESULTS The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. CONCLUSIONS These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.
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Affiliation(s)
- Cathy C Schubert
- Geriatrics and Community Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Alaina Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Soyna Flemming
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
- Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.
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Newmark RL, Allison TA, Smith AK, Perissinotto CM, Tha SH, Kotwal AA. The Role of Digital Technologies in Facilitating Psychosocial Resilience to Sudden Social Isolation Among Older Adults: Lessons Learned from the COVID-19 Pandemic. J Appl Gerontol 2023; 42:2348-2359. [PMID: 37536316 PMCID: PMC11056268 DOI: 10.1177/07334648231190228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
This study investigated how older adults adopted new technologies in response to sudden social isolation caused by the COVID-19 pandemic and how this adoption was related to their long-term psychosocial well-being. The study involved a 6-month longitudinal survey of 151 older adults and two phone-based focus groups, which informed a semi-structured interview guide and purposive sampling of diverse community-dwelling older adults. We then conducted twenty qualitative interviews and thematic analysis and mapped themes to 6-month quantitative trajectories of psychosocial health. Three themes emerged: first, most participants adopted multiple technologies to maintain social connection and psychosocial well-being. Second, participants felt left behind by certain technologies due to complicated systems or ageist societal norms. Third, pandemic-related community resources promoted technology independence among isolated older adults and those wanting to avoid "burdening" family. Results challenge ageist stereotypes and provide a framework for encouraging access and comfort with multiple technologies to adapt to sudden health crises or disruptive events.
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Affiliation(s)
- Rebecca L Newmark
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Department of Humanities and Social Sciences, University of California, San Francisco, CA, USA
- School of Medicine, University of California, San Francisco, CA, USA
| | - Theresa A Allison
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Carla M Perissinotto
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Soe Han Tha
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic. BMC PRIMARY CARE 2022; 23:155. [PMID: 35717159 PMCID: PMC9206131 DOI: 10.1186/s12875-022-01738-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/17/2022] [Indexed: 01/19/2023]
Abstract
Abstract
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.
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Schubert CC, Perkins AJ, Myers LJ, Damush TM, Penney LS, Zhang Y, Schwartzkopf AL, Preddie AK, Riley S, Menen T, Bravata DM. Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study. J Am Geriatr Soc 2022; 70:3598-3609. [PMID: 36054760 PMCID: PMC10087268 DOI: 10.1111/jgs.18013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/01/2022] [Accepted: 07/29/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction. METHODS This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups. RESULTS VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation. CONCLUSIONS The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.
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Affiliation(s)
- Cathy C. Schubert
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Anthony J. Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsIndiana University School of Medicine, IUPUIIndianapolisIndianaUSA
| | - Laura J. Myers
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Teresa M. Damush
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
| | - Lauren S. Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care SystemSan AntonioTexasUSA
- Department of MedicineUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- Department of BiostatisticsCollege of Public Health, University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Ashley L. Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Alaina K. Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Sam Riley
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Tetla Menen
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
| | - Dawn M. Bravata
- Medicine ServiceRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E‐Health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI)IndianapolisIndianaUSA
- VA HSR&D Center for Health Information and Communication (CHIC); Richard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Regenstrief InstituteIndianapolisIndianaUSA
- Department of NeurologyIndiana University School of MedicineIndianapolisIndianaUSA
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Baum SG, Coan LM, Porter AK. Meeting the needs of rural veterans through rapid implementation of pharmacist-provided telehealth management of diabetes during the COVID-19 pandemic. J Am Pharm Assoc (2003) 2022; 63:623-627. [PMID: 36379866 PMCID: PMC9569929 DOI: 10.1016/j.japh.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The rapid implementation of telehealth care owing to the coronavirus disease 2019 (COVID-19) pandemic allowed clinical pharmacist practitioners (CPPs) within the Veterans Health Administration (VA) to continue to provide diabetes management to veterans with health care disparities, including rural veterans. OBJECTIVES This project aimed to describe the change in hemoglobin A1c (HbA1c) in telehealth-naïve veterans with types 1 or 2 diabetes mellitus (DM) before and after the rapid implementation of CPP-provided telehealth DM management owing to the COVID-19 pandemic. The project also sought to describe potential health care disparities that may be addressed by the increase in telehealth use and the impact of metformin sustained action (SA) recalls. METHODS Analysis included patients receiving face-to-face DM-focused visits with a CPP before the COVID-19 pandemic (June 1, 2019, to December 1, 2019) who transitioned to telehealth care via telephone or VA Video Connect during the COVID-19 pandemic (June 1, 2020, to December 1, 2020). One or more HbA1c readings within each time frame was required for inclusion. Patients were excluded if previously enrolled in VA telehealth DM management. RESULTS The rapidly implemented telehealth management of DM provided by VA CPPs was observed to maintain or improve HbA1c control in 84.2% of patients. During the same time frame, 10.9% of patients were taken off metformin SA secondary to national drug recalls. In total, 76% of patients were from rural communities and > 52% of patients traveled greater than 50 miles round trip to receive face-to-face DM care before the pandemic. CONCLUSION Glycemic control was improved or maintained for most patients who were rapidly converted to pharmacist-provided telehealth DM management during the COVID-19 pandemic. A large majority of rural patients were reached as a result of CPP-provided telehealth care. This provides evidence to support the continued widespread telehealth utilization to effectively manage DM and reach veterans with health care disparities, particularly rural communities.
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Stephens CE, Allison TA, Flint LA, David D, Wertz V, Halifax E, Barrientos P, Ritchie CS. Assessing Technical Feasibility and Acceptability of Telehealth Palliative Care in Nursing Homes. Palliat Med Rep 2022; 3:181-185. [PMID: 36059909 PMCID: PMC9438441 DOI: 10.1089/pmr.2022.0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Over two-thirds of nursing home (NH) residents are eligible for palliative care (PC), yet few receive it, particularly outside of hospice. Little is known about the technical feasibility and acceptability of using telehealth for PC consultations in NHs. Objective To determine the technical feasibility and acceptability of PC telehealth for NH residents seen by a PC team in the hospital in the previous 30 days. Design Mixed methods study including data collection from field observations, focus groups about the telehealth experience with content analysis, and a web-based survey about technical feasibility and acceptability. Sample and Approach Eighteen participants (six PC-eligible NH residents, one PC physician, five family members, six NH nurses) were recruited in 2016 to participate in one of six PC video visits followed by a video-based focus group and web-based survey. Results All participants were comfortable with the PC video visit format, believed it could improve communication and care coordination, and reported they could see themselves using telehealth in the near future. For technical feasibility, audio quality was rated mostly good/very good (71%) and visual quality was rated fair (50%). Conclusions PC video visits are technically feasible and acceptable to NH residents, families, and staff, representing an innovative and relatively low-cost opportunity to improve access to needed NH-based PC services. Assessing stakeholder perspectives on the use of this technology can help inform the selection of the proper telehealth platform to meet the clinical and infrastructure needs, as well as protocol modifications required before testing in a larger trial.
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Affiliation(s)
- Caroline E. Stephens
- Division of Health Systems and Community Based Care, University of Utah College of Nursing, Salt Lake City, Utah, USA
| | - Theresa A. Allison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Lynn A. Flint
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Daniel David
- NYU Rory Meyers College of Nursing, New York City, New York, USA
| | - Victoria Wertz
- Infusion Treatment Area, Stanford Health Care, Stanford, California, USA
| | - Elizabeth Halifax
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Pamela Barrientos
- Division of Health Systems and Community Based Care, University of Utah College of Nursing, Salt Lake City, Utah, USA
| | - Christine S. Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, Massachusetts, USA
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Aliberti GM, Bhatia R, Desrochers LB, Gilliam EA, Schonberg MA. Perspectives of Primary Care Clinicians in Massachusetts on use of Telemedicine with Adults aged 65 and Older during the COVID-19 Pandemic. Prev Med Rep 2022; 26:101729. [PMID: 35155085 PMCID: PMC8824169 DOI: 10.1016/j.pmedr.2022.101729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 02/06/2023] Open
Abstract
PCPs have disparate attitudes towards telemedicine primary care for adults >65. Multilevel interventions are needed to optimize telemedicine care for older adults. PCPs find telemedicine most effective for chronic disease management. PCPs appreciate telemedicine’s convenience but worry about the lack of touch.
To learn how to improve telemedicine for adults >65, we asked primary care clinicians (“PCPs”) affiliated with one large Boston-area health system their views on using telemedicine (which included phone-only or video visits) with adults >65 during the COVID-19 pandemic. In open-ended questions, we asked PCPs to describe any challenges or useful experiences with telemedicine and suggestions for improving telemedicine as part of a larger web-based survey conducted between September 2020 and February 2021. Overall, 163/383 (42%) PCPs responded to the survey. Of these, 114 (70%) completed at least one open-ended question, 85% were non-Hispanic white, 59% were female, 75% were community-based, and 75% were in practice >20 years. We identified three major themes in participants’ comments including the need to optimize telemedicine; integrate telemedicine within primary care; and that PCPs had disparate attitudes towards telemedicine for older adults. To optimize telemedicine, PCPs recommended more effective digital platforms, increased utilization of home medical equipment (e.g., blood pressure cuffs), and better coordination with caregivers. For integration, PCPs recommended targeting telemedicine for certain types of visits (e.g., chronic disease management), enabling video access, and reducing administrative burdens on PCPs. As for PCP attitudes, some felt telemedicine enhanced the doctor-patient relationship, improved the patient experience, and improved show rates. Others felt that telemedicine visits were incomplete without a physical exam, were less rewarding, and could be frustrating. Overall, PCPs saw a role for telemedicine in older adults’ care but felt that more support is needed for these visits than currently offered.
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Affiliation(s)
| | | | | | | | - Mara A. Schonberg
- Corresponding author at: 1309 Beacon Street, 2 Fl, Brookline, MA 02446.
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10
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Weiskittle R, Tsang W, Schwabenbauer A, Andrew N, Mlinac M. Feasibility of a COVID-19 Rapid Response Telehealth Group Addressing Older Adult Worry and Social Isolation. Clin Gerontol 2022; 45:129-143. [PMID: 33870881 PMCID: PMC8522175 DOI: 10.1080/07317115.2021.1906812] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES During the early months of the COVID-19 pandemic, virtual and telephone visits rapidly replaced most in-person care within the Veterans Health Administration (VA) to reduce the virus spread. To address the emerging mental health needs of older Veterans (e.g., social isolation) in the context of chronic underlying mental health needs (e.g., trauma), we developed an 8-week virtual group treatment manual. This article describes the results from a survey of geriatric mental health clinicians who used the COVID group manual to determine its acceptability and feasibility in these settings. METHODS Clinicians across three VA integrated care settings (home-based primary care, community living centers, and geriatric primary care) were surveyed about their experiences implementing this treatment (n = 21). RESULTS Clinicians found this intervention to be effective with their patients and useful and adaptable beyond the early pandemic period. CONCLUSIONS This group teletherapy intervention was feasible and acceptable when treating Veterans in integrated geriatric healthcare settings. Despite technical challenges experienced by older Veterans, clinicians found this manual to be effective in addressing COVID-related worry and social isolation. CLINICAL IMPLICATIONS This rapid response manual has remained clinically useful in geriatric mental health care settings beyond the initial weeks of the pandemic.
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Affiliation(s)
- Rachel Weiskittle
- VA New England Geriatric Research Education and Clinical Center (GRECC)
- VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - William Tsang
- VDepartment of Psychology, William Paterson University, Wayne, NJ
| | | | | | - Michelle Mlinac
- VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
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11
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Der-Martirosian C, Wyte-Lake T, Balut M, Chu K, Heyworth L, Leung L, Ziaeian B, Tubbesing S, Mullur R, Dobalian A. Implementation of Telehealth Services at the US Department of Veterans Affairs During the COVID-19 Pandemic: Mixed Methods Study. JMIR Form Res 2021; 5:e29429. [PMID: 34477554 PMCID: PMC8462492 DOI: 10.2196/29429] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
Background At the onset of the COVID-19 pandemic, there was a rapid increase in the use of telehealth services at the US Department of Veterans Affairs (VA), which was accelerated by state and local policies mandating stay-at-home orders and restricting nonurgent in-person appointments. Even though the VA was an early adopter of telehealth in the late 1990s, the vast majority of VA outpatient care continued to be face-to-face visits through February 2020. Objective We compared telehealth service use at a VA Medical Center, Greater Los Angeles across 3 clinics (primary care [PC], cardiology, and home-based primary care [HBPC]) 12 months before and 12 months after the onset of COVID-19 (March 2020). Methods We used a parallel mixed methods approach including simultaneous quantitative and qualitative approaches. The distribution of monthly outpatient and telehealth visits, as well as telephone and VA Video Connect encounters were examined for each clinic. Semistructured telephone interviews were conducted with 34 staff involved in telehealth services within PC, cardiology, and HBPC during COVID-19. All audiotaped interviews were transcribed and analyzed by identifying key themes. Results Prior to COVID-19, telehealth use was minimal at all 3 clinics, but at the onset of COVID-19, telehealth use increased substantially at all 3 clinics. Telephone was the main modality of patient choice. Compared with PC and cardiology, video-based care had the greatest increase in HBPC. Several important barriers (multiple steps for videoconferencing, creation of new scheduling grids, and limited access to the internet and internet-connected devices) and facilitators (flexibility in using different video-capable platforms, technical support for patients, identification of staff telehealth champions, and development of workflows to help incorporate telehealth into treatment plans) were noted. Conclusions Technological issues must be addressed at the forefront of telehealth evolution to achieve access for all patient populations with different socioeconomic backgrounds, living situations and locations, and health conditions. The unprecedented expansion of telehealth during COVID-19 provides opportunities to create lasting telehealth solutions to improve access to care beyond the pandemic.
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Affiliation(s)
- Claudia Der-Martirosian
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States.,Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States
| | - Michelle Balut
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States
| | - Karen Chu
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States
| | - Leonie Heyworth
- Office of Connected Care/Telehealth Services, Veterans Health Administration, Washington, DC, United States.,Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, United States
| | - Lucinda Leung
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Boback Ziaeian
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Sarah Tubbesing
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Rashmi Mullur
- Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States.,Division of Diabetes, Endocrinology & Metabolism, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, United States.,Division of Health Systems Management and Policy, School of Public Health, University of Memphis, Memphis, TN, United States
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12
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Bowling CB, Berkowitz TSZ, Smith B, Whitson HE, DePasquale N, Wang V, Maciejewski ML, Olsen M. Unintended consequences of COVID-19 social distancing among older adults with kidney disease. J Gerontol A Biol Sci Med Sci 2021; 77:e133-e137. [PMID: 34286836 PMCID: PMC8344603 DOI: 10.1093/gerona/glab211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While social distancing policies protect older adults with advanced chronic kidney disease (CKD) from exposure to COVID-19, reduced social interaction may also have unintended consequences. METHODS To identify subgroups of patients at risk for unintended health consequences of social distancing, we conducted a cross-sectional analysis of data from a national cohort study of older Veterans with advanced CKD (n=223). Characteristics included activities of daily living (ADLs), instrumental ADLs (IADLs), cognition score, depression score, social support, financial stress, symptom burden, and number of chronic conditions. Unintended consequences of social distancing included restricted Life Space mobility, low willingness for video telehealth, reduced in-person contact with caregivers, and food insecurity. We identified subgroups of patients at risk of unintended consequences using model-based recursive partitioning (MoB). RESULTS Participants had a mean age of 77.9 years, 64.6% were white, and 96.9% were male. Overall, 22.4% of participants had restricted Life Space, 33.9% reported low willingness for video telehealth, 19.0% reported reduced caregiver contact, and 3.2% reported food insecurity. For Life Space restriction, four subgroups partitioned (i.e., split) by IADL difficulty, cognition score, and ADL difficulty were identified. The highest rate of restricted Life Space was 54.7% in the subgroup of participants with >3 IADL difficulties For low willingness for telehealth and reduced caregiver contact, separate models identified two subgroups split by cognition score and depression score, respectively. CONCLUSIONS Measures of function, cognition, and depressive symptoms may identify older adults with advanced CKD who are at higher risk for unintended health consequences of social distancing.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Health Care System (VAHCS), Durham, NC.,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC.,Center for the Study of Aging and Human Development (the Aging Center), Duke University, Durham, NC.,Department of Medicine, Duke University, Durham, NC
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Battista Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Heather E Whitson
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Health Care System (VAHCS), Durham, NC.,Center for the Study of Aging and Human Development (the Aging Center), Duke University, Durham, NC.,Department of Medicine, Duke University, Durham, NC
| | | | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Medicine, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Medicine, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC
| | - Maren Olsen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Medicine, Duke University, Durham, NC
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13
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Kalicki AV, Moody KA, Franzosa E, Gliatto PM, Ornstein KA. Barriers to telehealth access among homebound older adults. J Am Geriatr Soc 2021; 69:2404-2411. [PMID: 33848360 PMCID: PMC8250614 DOI: 10.1111/jgs.17163] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/16/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background/Objectives To identify major barriers to video‐based telehealth use among homebound older adults. Design Cross‐sectional survey. Setting A large home‐based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community. Participants Sixteen primary care physicians. Measurements An 11‐item assessment of provider perceptions of patients' experience with and barriers to telehealth. Results According to physicians in the HBPC program, more than one‐third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first‐time video‐based telehealth encounters between April and June 2020 during the first COVID‐19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) “unable to interact over video” for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video‐capable device access. Conclusion The COVID‐19 pandemic resulted in a large and dramatic shift to video‐based telehealth use in home‐based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video‐based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video‐based telehealth use.
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Affiliation(s)
- Alexander V Kalicki
- Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kate A Moody
- Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Franzosa
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter M Gliatto
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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