Primary Care Team Perspectives on the Suitability of Telehealth Modality (Phone vs Video) at the Veterans Health Administration.

INTRODUCTION: Telehealth has the potential to improve access and timeliness of care, enabling primary care teams to deliver hybrid (virtual/in-person) services that will likely extend beyond the COVID-19 pandemic. To optimize its use and sustainability, it is imperative to understand how primary care teams perceive the suitability of telehealth services, including appropriate choice of mode (telephone or video). However, there is limited research on providers' decision-making processes surrounding telehealth use in primary care, including whether to use telephone or video, which this VA-focused study addresses. We examined how primary care (PC) team members determine whether to use telehealth and the mode of delivery, in the care of patients. METHODS: Qualitative case study that included 15 semi-structured interviews with employees who provided or supported telehealth care at primary care clinics at the Veterans Health Administration. We used a team-based rapid analysis approach to identify experiences using telehealth soon after COVID-19's emergence, consisting of the creation of structured summaries of each transcribed interview. The lead author then identified and compiled themes and sub-themes related to the suitability of telehealth in primary care, as well as associated quotes from transcripts. Resulting themes and quotes were reviewed and validated by 2 members of the project team. RESULTS: Primary care team members considered several factors when assessing both the suitability of telehealth for appointments, and mode of use. They were largely guided by patient-related factors including patient preferences, specific health issues, and access to technology. Additional considerations centered on team members' personal preferences and factors that supported the wellbeing of the team, such as the flexibility to work from home (work-life balance) and protection from infection. Generally, participants viewed the option of both telephone and video telehealth modalities as useful tools in the care of patients although a few respondents emphasized its inferiority to in-person care. CONCLUSIONS: Determining the suitability of telehealth services, including appropriate choice of mode is complex. Its suitability is tied to a variety of factors related to multilevel resources, preferences, and timing. When appropriate, telehealth should be considered a useful tool in the care of patients and for employee well-being.

"The Yo-Yo Effect": U.S. Department of Veterans Affairs Social Workers' Experiences with Job Flexibility during the Pandemic.

Social work turnover from the emotional overload of providing care during the pandemic has created staff shortages and exposed many gaps in service delivery. Those social workers who sustained employment during this pandemic are asked to take on flexible/additional roles to fill in those gaps in services to their most vulnerable clients. This qualitative study (N = 12) of U.S. Department of Veterans Affairs (VA) inpatient social workers at two sites across the country assesses their experiences of taking on additional roles at their respective VA facility. Three research questions were addressed to the participants: (1) Describe your roles and responsibilities during the COVID-19 pandemic? (2) How did those responsibilities change/evolve over time? and (3) Did you receive training for your new roles or tasks? Thematic analysis revealed six themes that would facilitate effectiveness and continuity of care: (1) recognizing insufficient training to handle a pandemic, (2) meeting the demand for care, (3) responding to unexpected aspects of flexibility, (4) adjusting to new roles over time, (5) adaptation and support, and (6) additional resources to simplify efforts. With COVID rates stabilizing across much of the United States, now is the time to implement trainings and education about job flexibility in the future instance of a pandemic.

Pandemic preparedness and response-related content to integrate into the msw curricula: Implications for provider burnout

The COVID-19 pandemic, a first in many generations disaster, has highlighted gaps globally among graduated social work providers. This qualitative study of (N = 12) inpatient social workers who provided care during the pandemic, strives to suggest specific disaster-related content to inform the MSW curricula. Thematic analysis suggested including: 1) self-care in a prolonged disaster;2) responding to nuances of the job;3) expansion and integration of practicum specialties;4) preparing for the effects of another pandemic;5) advocating for yourself;and 6) the public's view of social workers. Findings could potentially inform the content that is taught to MSW students post-pandemic. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

COVID-19 Vaccine Hesitancy among U.S. Veterans Experiencing Homelessness in Transitional Housing.

Little is known about COVID-19 vaccine hesitancy and acceptance among individuals experiencing homelessness, despite their higher risk for morbidity and mortality from SARS-CoV-2. This study examines COVID-19 vaccination attitudes and uptake among U.S. military Veterans experiencing homelessness enrolled in transitional housing programs funded by the U.S. Department of Veterans Affairs (VA). Telephone interviews were conducted with 20 Veterans in California, Florida, Iowa, Kentucky, and Massachusetts, USA (January-April 2021). A rapid analysis approach was used to identify and enumerate commonly occurring themes. Although 60% of interviewed Veterans either received the COVID-19 vaccine or were willing to do so, one-third expressed hesitancy to get vaccinated. COVID-19 vaccination attitudes (e.g., belief that the vaccines were inadequately tested), military experience, beliefs about influenza and other vaccines, and sources of information emerged as influential factors for COVID-19 vaccination uptake or hesitancy. Veterans in VA-funded homeless transitional housing programs are generally willing to be vaccinated. However, a substantial minority is reluctant to take the vaccine due to concerns about the COVID-19 vaccine and distrust of authority. Recommendations for increasing uptake include utilizing Veteran peers, homeless service providers, and healthcare providers as trusted messengers to improve confidence in the vaccine.

Military Culture and Cultural Competence in Public Health: U.S. Veterans and SARS-CoV-2 Vaccine Uptake

As part of the U.S. effort to encourage vaccination for SARS-CoV-2, scholars have emphasized the importance of culture and identity in vaccine uptake decisions. The culture and identity of military service are poorly understood in the context of understanding Veterans' acceptance of COVID-19 vaccines. In analyzing data from semi-structured interviews with Veterans in homeless transitional housing, this article examines their willingness to get vaccinated for COVID-19. Themes invoking military culture included (a) mandatory vaccinations in the military;(b) cynicism and mistrust toward the government;and (c) trust of and reliance on Veteran peers with shared military culture in decision-making. To further understand how military culture influences vaccine uptake and explore avenues for building culturally competent, trust-based health care interventions with Veterans, a previously published case study of Veterans volunteering in Team Rubicon (TR) disaster relief is examined. Veteran participants in TR described the experience of being in a Veteran-centric organization as an empathetic context wherein they were able to: (a) address their reintegration struggles;(b) gain a new appreciation of their Veteran status;and (c) connect with trusted peers. Given TR's credibility, Veteran-serving health care organizations could collaborate with Veteran-led organizations to expand shared efforts to address Veterans' distrust of government-promoted vaccines.

Household Preparedness and Perceptions of Workforce Preparedness During Pandemics: A Health Care Employee Survey at the US Department of Veterans Affairs.

OBJECTIVE: To examine the effects of household preparedness on perceptions of workplace preparedness during a pandemic among all employees at the US Department of Veterans Affairs (VA) medical facilities. METHODS: The VA Preparedness Survey (October-December 2018, Los Angeles, CA) used a stratified simple random, web-based survey. Multivariate statistical analyses examined the effect of household preparedness on perceptions of workforce preparedness during a pandemic: institutional readiness; desire for additional training; and understanding their role and its importance. RESULTS: VA employees totaling 4026 participated. For a pandemic, 55% were confident in their VA medical facility's ability to respond, 63% would like additional training, 49% understood their role during a response, and 68% reported their role as important. Only 23% reported being "well prepared" at home during major disasters. After controlling for study-relevant factors, household preparedness was positively associated with perceptions of workforce preparedness during a pandemic. CONCLUSIONS: Efforts to increase household preparedness for health care employees could bolster workforce preparedness during pandemics. Organizations should consider robust policies and strategies, such as flexible work arrangements, in order to mitigate factors that may serve as barriers to household preparedness.

Association of the COVID-19 Pandemic on VA Resident and Fellow Training Satisfaction and Future VA Employment: A Mixed Methods Study.

Background: The COVID-19 pandemic altered learning experiences of residents and fellows worldwide, including at the US Department of Veterans Affairs (VA). Because the VA is the largest training provider in the United States, understanding VA trainee experiences is vital to understanding the pandemic's impact on graduate medical education nationwide. Additionally, understanding the pandemic's potential impacts on future employment allows for a better understanding of any future disruptions in the supply of physicians. Objective: To examine whether COVID-19 affected the satisfaction with VA training experiences and likelihood to consider future VA employment among residents and fellows. Methods: Responses from the VA Trainee Satisfaction Survey were collected for 3 academic years (2018-2021). Quantitative analysis (bivariate logistic regression) and qualitative content analysis were conducted to determine COVID-19's impact on satisfaction and likelihood of future VA employment. Results: Across 3 academic years, 17 900 responses from a total of 140 933 physician trainees were analyzed (12.7%). Following COVID-19, respondents expressed decreased satisfaction (84.58% vs 86.01%, P=.008) and decreased likelihood to consider future VA employment compared to prior to the pandemic (53.42% vs 55.32%, P=.013). COVID-19-related causes of dissatisfaction included the onboarding process, which slowed due to the pandemic, limited workspace that precluded social distancing, and reduced learning opportunities. Conclusions: Since the pandemic, physician trainees expressed decreased training satisfaction and decreased likelihood to seek future VA employment. Causes of dissatisfaction included increased difficulties with onboarding, further limitations to accessible workspaces, and the direct obstruction of learning opportunities including decreased patient volume or case mix.

COVID-19 vaccine adoption and hesitancy among older Veterans.

BACKGROUND: Older adults are particularly at risk for severe illness or death from COVID-19. Accordingly, the Veterans Health Administration (VA) has prioritized this population group in its COVID-19 vaccination strategy. This study examines the receptivity of Veterans enrolled in the VA's Geriatric Patient Aligned Care Team (GeriPACT) to receiving the COVID-19 vaccine. GeriPACT is an outpatient primary care program that utilizes multi-disciplinary teams to provide health services to older Veterans. METHODS: We conducted semistructured interviews with 42 GeriPACT-enrolled Veterans from five states. Participants were asked to identify barriers to vaccine acceptance. We gathered data from January-March 2021 and analyzed them using qualitative methods. RESULTS: Both White and African American GeriPACT Veterans had minimal vaccine hesitancy towards the COVID-19 vaccine. On-line registration and ineligibility of a spouse/caregiver for vaccination were primary barriers to early vaccination. CONCLUSIONS: As the first wave of early adopters of the COVID-19 vaccination effort nears completion, targeted strategies are needed to understand and respond to vaccine hesitancy to lower the risk of subsequent waves of infections. The 2021 SAVE LIVES Act, begins to address identified vaccination barriers by permitting vaccination of Veteran spouses and caregivers, but consideration must be given to creating alternatives to on-line registration and allowing spouses and caregivers to register for appointments together.

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.

Responding to COVID-19 While Serving Veterans Experiencing Homelessness: The Pandemic Experiences of Healthcare and Housing Providers.

The U.S. Department of Veterans Affairs (VA) provides essential care through transitional housing and healthcare for Veterans experiencing homelessness through the Grant and Per Diem (GPD) program and the Homeless Patient Aligned Care Team (HPACT), respectively. At the onset of the SARS-CoV-2 pandemic, GPD organizations and HPACT clinics faced the challenge of being essential providers tasked with ensuring the well-being of Veterans under their care. Through semi-structured interviews with 13 providers (6 HPACT health care providers representing 2 HPACT programs, and 7 GPD staff members) across the U.S., this study explored their experiences navigating the tasks of keeping Veterans safe and providing ongoing care from the start of the pandemic up to the 2021 interview dates. Both GPD and HPACT providers reported amplified safety concerns about COVID-19 infection among staff at the start of the pandemic, which diminished to a lower, stable level after a few months as adaptations made for safety became embedded in their routines. However, ongoing challenges included isolation and mental health challenges among Veterans, inherent limitations of telehealth as a care delivery avenue, provider frustration and burnout due to increased workload and frequent change, and the logistics of administering testing for Veterans to enter GPD housing. Enhanced pandemic preparedness planning for GPD organizations, funding for personal protective equipment (PPE) and providing technology to facilitate Veterans' telehealth access, and strategies for preventing provider burnout are critical to both sustaining homeless providers' capabilities during this pandemic and enhancing readiness to respond to the next public health emergency.

Vaccinating Veterans Experiencing Homelessness for COVID-19: Healthcare and Housing Service Providers' Perspectives.

This study examines challenges experienced during COVID-19 vaccination efforts, facilitating factors that increased vaccination, and lessons learned from healthcare providers and housing program staff who delivered healthcare and services to Veterans experiencing homelessness during the SARS-CoV-2 pandemic. Qualitative, semi-structured interviews were conducted with seven transitional housing program staff in northern California, southern California, Florida, Iowa, Kentucky, Massachusetts, and New Jersey (January-April 2021) and six primary care providers serving Veterans experiencing homelessness, four from clinics in California and two from a clinic in North Dakota (July-August 2021). Interviews were transcribed and analyzed using a rapid analysis approach. COVID-19 vaccination rates were between 40 and 60% among Veterans who received care from the primary care providers and between 20 and 90% among Veterans who were enrolled in the transitional housing programs. Barriers that providers and housing staff encountered when getting Veterans vaccinated for COVID-19 included lack of eligibility, the vaccine appointment scheduling process, transportation and communication challenges, Veterans' distrust in the government, vaccine mandates, and vaccine hesitancy among organization staff. Recommendations to increase COVID-19 vaccine uptake included making vaccination more convenient, using trusted sources such as homeless program staff or Veteran peers to provide educational information about the safety and efficacy of COVID-19 vaccines, and encouraging rather than mandating vaccination. These lessons will enable entities providing care to people experiencing homelessness to develop more effective policies and educational campaigns to improve vaccine acceptance and uptake among this vulnerable population.

Implementation of Telehealth Services at the US Department of Veterans Affairs During the COVID-19 Pandemic: Mixed Methods Study.

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.

Association Between Virtual Care Use and Same-Day Primary Care Access in VA Primary Care-Mental Health Integration.

INTRODUCTION: Same-day referrals from primary care to mental health increase subsequent mental health treatment engagement. VA Primary Care-Mental Health Integration (PC-MHI) clinics offer integrated mental health services embedded in primary care clinics, providing a key entry point to mental health care. Although telehealth use expanded rapidly after the onset of COVID-19, the impact of telehealth on same-day primary care access among new PC-MHI mental health patients is unknown. To address this knowledge gap, we examined associations between telehealth use and same-day primary care access in VA PC-MHI. METHODS: We examined electronic health record data to identify same-day primary care appointments among PC-MHI patients who initiated care during 3/1/2018 to 10/29/2021. We used logistic regression analyses to evaluate the effect of telehealth on same-day primary care access. Time, demographic characteristics, mental health diagnoses (PTSD and depression), and substance use disorder diagnosis were evaluated as covariates. RESULTS: New PC-MHI patients who were seen via telehealth were less likely to receive same-day primary care access than patients seen in person (OR: 0.54; 95% CI: 0.41-0.71; P < .001). CONCLUSIONS: Despite the potential advantages of using telehealth to increase access, VA patients with an initial PC-MHI visit via telehealth were less likely than patients seen in person to be referred from primary care. Telehealth may adversely affect primary care referrals to mental health services, an outcome that could ultimately reduce specialty mental health care continuity. There is an urgent need to identify strategies to facilitate PC-MHI care coordination in the telehealth context.

COVID-19 Vaccination in VA Home Based Primary Care: Experience of Interdisciplinary Team Members.

OBJECTIVES: Describe how Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) team members discussed the COVID-19 vaccine with Veteran patients and their caregivers; describe HBPC team members' experiences providing care during the pandemic; identify facilitators and barriers to vaccinating HBPC Veterans during the COVID-19 pandemic. DESIGN: Online survey that included 3 open-ended COVID-19 vaccine-related questions. SETTING AND PARTICIPANTS: HBPC Program Directors from 145 VA Medical Centers were invited to participate and share the survey invitation with team members. The survey was open from March to May 2021. We collected N = 573 surveys from 73 sites. METHODS: We analyzed demographic data using descriptive frequencies and open-ended questions using thematic analysis. RESULTS: Respondents from all HBPC roles were included in the study: Registered Nurses, Psychologists, Advanced Registered Nurse Practitioners, Social Workers, Dieticians, Occupational Therapists, Pharmacists, Physical Therapists, HBPC Program Directors, HBPC Medical Directors, MDs, Physician Assistants, Other. Qualitative thematic analysis revealed 3 themes describing VA HBPC team members' experiences discussing and administering the COVID-19 vaccine: communication and education, advocating for prioritization of HBPC Veterans to receive the vaccine, and logistics of delivering and administering the vaccine. CONCLUSIONS AND IMPLICATIONS: Our study findings highlight the multifaceted experiences of VA HBPC team members discussing and administering initial doses of the COVID-19 vaccine to primarily homebound Veterans. Although the VA's HBPC program offers an example of a singular health care system, insights from more than 70 sites from across the United States reveal key lessons around the internal and external structures required to successfully support programs and their staff in providing these key activities. These lessons include proactively addressing the needs of homebound populations in national vaccine rollouts and developing vaccine education and training programs for HBPC team members specifically aligned to HBPC program needs. These lessons can extend to non-VA organizations who care for similar homebound populations.

Nurse Executive Experiences With COVID-19: Now We Know-We Are Not Going Back.

We conducted semistructured telephone interviews with 2 hospital-based nurse leaders who supervised nurses during the initial phases of the COVID-19 pandemic in northeastern region of the United States. These interviews are a subset of a larger study with 11 nurse executives who supervised nurses during both natural and human-made disasters in different regions of the United States. Qualitative data were analyzed using a grounded theory approach, followed by a content analysis of emerging themes. Participants shared several key concepts: deep commitment of nurses in an extensive range of roles and responsibilities during tragic events; an emphasis on educational needs to best prepare nurses for disaster response; the importance of organizational strategies and definitive policies for supporting nurses' response and recovery; and mental/emotional health support as essential for nurses to cope with the events. The nurse executive participants reported many opportunities to enhance nurses' knowledge and skill set to augment care in the hospital. A team-based approach that leverages the expertise of team members to strengthen the health care team is implemented and demonstrates positive patient outcomes.

Disparities in Excess, All-Cause Mortality among Black, Hispanic, and White Veterans at the U.S. Department of Veterans Affairs during the COVID-19 Pandemic.

BACKGROUND: From 2019 to 2020, all-cause mortality in the U.S. increased, with most of the rise attributed to COVID-19. No studies have examined the racial disparities in all-cause mortality among U.S. veterans receiving medical care (VA users) at the U.S. Department of Veterans Affairs (VA) during the pandemic. METHODS: In the present paper, we conduct a longitudinal study examining the differences in mortality among White, Black, and Hispanic veterans, aged 45 years and older, during the first, full year of the pandemic (March 2020-February 2021). We calculated the Standardized Mortality Rates (SMRs) per 100,000 VA users for each racial and ethnic group by age and gender. RESULTS: The highest percentage increase between the number of deaths occurred between pre- and post-pandemic years (March 2020-February 2021 vs. March 2019-February 2020). For Hispanics, the all-cause mortality increased by 34%, while for Blacks, it increased by 32%. At the same time, we observed that an 18% increase in all-cause mortality occurred among Whites. CONCLUSION: Blacks and Hispanics were disproportionately affected by the COVID-19 pandemic, leading both directly and indirectly to higher all-cause mortality among these groups compared to Whites. Disparities in the all-cause mortality rates varied over time and across groups. Additional research is needed to examine which factors may account for the observed changes over time. Understanding those factors will permit the development of strategies to mitigate these disparities.