Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic.

BACKGROUND: Telehealth has the potential to improve health care access for patients but it has been underused and understudied for examining patients with substance use disorders (SUD). VA began distributing video-enabled tablets to veterans with access barriers in 2016 to facilitate participation in home-based telehealth and expanded this program in 2020 due to the coronavirus COVID-19 pandemic. OBJECTIVE: Examine the impact of VA's video-enabled telehealth tablets on mental health services for patients diagnosed with SUD. METHODS: This study included VA patients who had ≥1 mental health visit in the calendar year 2019 and a documented diagnosis of SUD. Using difference-in-differences and event study designs, we compared outcomes for SUD-diagnosed patients who received a video-enabled tablet from VA between March 15th, 2020 and December 31st, 2021 and SUD-diagnosed patients who never received VA tablets, 10 months before and after tablet-issuance. Outcomes included monthly frequency of SUD psychotherapy visits, SUD specialty group therapy visits and SUD specialty individual outpatient visits. We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person). Regression models adjusted for several covariates such as age, sex, rurality, race, ethnicity, physical and mental health chronic conditions, and broadband coverage in patients' residential zip-code. RESULTS: The cohort included 21,684 SUD-diagnosed tablet-recipients and 267,873 SUD-diagnosed non-recipients. VA's video-enabled tablets were associated with increases in video visits for SUD psychotherapy (+3.5 visits/year), SUD group therapy (+2.1 visits/year) and SUD individual outpatient visits (+1 visit/year), translating to increases in visits across all modalities (in-person, phone and video): increase of 18 % for SUD psychotherapy (+1.9 visits/year), 10 % for SUD specialty group therapy (+0.5 visit/year), and 4 % for SUD specialty individual outpatient treatment (+0.5 visit/year). CONCLUSIONS: VA's distribution of video-enabled tablets during the COVID-19 pandemic were associated with higher engagement with video-based services for SUD care among patients diagnosed with SUD, translating to modest increases in total visits across in-person, phone and video modalities. Distribution of video-enabled devices can offer patients critical continuity of SUD therapy, particularly in scenarios where they have heightened barriers to in-person care.

Overcoming Access Barriers for Veterans: Cohort Study of the Distribution and Use of Veterans Affairs' Video-Enabled Tablets Before and During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, as health care services shifted to video- and phone-based modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for veterans with limited video care access. OBJECTIVE: This study aimed to characterize veterans who received and used US Department of VA-issued video-enabled tablets before versus during the COVID-19 pandemic. METHODS: We compared sociodemographic and clinical characteristics of veterans who received VA-issued tablets during 6-month prepandemic and pandemic periods (ie, from March 11, 2019, to September 10, 2019, and from March 11, 2020, to September 10, 2020). Then, we examined characteristics associated with video visit use for primary and mental health care within 6 months after tablet shipment, stratifying models by timing of tablet receipt. RESULTS: There was a nearly 6-fold increase in the number of veterans who received tablets in the pandemic versus prepandemic study periods (n=36,107 vs n=6784, respectively). Compared to the prepandemic period, tablet recipients during the pandemic were more likely to be older (mean age 64 vs 59 years), urban-dwelling (24,504/36,107, 67.9% vs 3766/6784, 55.5%), and have a history of housing instability (8633/36,107, 23.9% vs 1022/6784, 15.1%). Pandemic recipients were more likely to use video care (21,090/36,107, 58.4% vs 2995/6784, 44.2%) and did so more frequently (5.6 vs 2.3 average encounters) within 6 months of tablet receipt. In adjusted models, pandemic and prepandemic video care users were significantly more likely to be younger, stably housed, and have a mental health condition than nonusers. CONCLUSIONS: Although the COVID-19 pandemic led to increased distribution of VA-issued tablets to veterans with complex clinical and social needs, tablet recipients who were older or unstably housed remained less likely to have a video visit. The VA's tablet distribution program expanded access to video-enabled devices, but interventions are needed to bridge disparities in video visit use among device recipients.

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.

Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic.

Importance: Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown. Objective: To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes. Design, Setting, and Participants: This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022. Exposure: Receipt of a video-enabled tablet. Main Outcomes and Measures: Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs). Results: The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide. Conclusions and Relevance: This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

Caregiving Intensity and Psychosocial Impact of COVID-19 in Dementia and Non-Dementia Caregivers

COVID-19 has adversely impacted the well-being of informal caregivers (CG) due to infection risk, changes to the home environment, and changes to resource availability. CG of persons living with dementia (PLWD) may be especially vulnerable due to the intensity of care provided. We compared CG activities and well-being among CG who did and did not care for PLWD during COVID-19. We conducted an anonymous online survey from April 2020-present. Respondents self-identified as 18+ years and CG to a child or adult with mental health or medical conditions. CG answered questions regarding hours of care provision and caregiving activities, and completed measures of CG burden (Zarit Burden Inventory-4), loneliness (UCLA Loneliness Scale), depressive symptoms (Patient Health Questionnaire), and anxiety (Generalized Anxiety Disorder-2). Of the 258 respondents within the United States, 86 cared for PLWD (33%;88% female;56±12 years) while 172 did not (66%;87% female;49±14 years). Compared to non-dementia CGs, more CGs of PLWD provided 40+ hours of caregiving/week (36% vs. 49%, p<.05), performed more caregiving activities (8.5 vs. 10.5, p<.01), and assisted with more activities of daily living (55% vs. 73%, p<.01). Compared to non-dementia CG, more dementia CG reported CG burden (53% vs. 67%;p<.05) and loneliness (7.3 vs. 9.1, p<.05). No differences in depressive symptoms or anxiety were found. Results suggest that existing needs of CG of PLWD may be exacerbated by the stressors and concerns of the pandemic, necessitating higher levels of support.

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

Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.

Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization.

OBJECTIVES: To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care. MATERIALS AND METHODS: Outpatient encounters (N = 42 916 349) were categorized by care type (eg, primary, mental health, etc) and delivery method (eg, in-person, video). For 5 400 878 Veterans, we used generalized linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care between March 11, 2020 and June 6, 2020. RESULTS: By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45-64 and 65+ were less likely to use video care compared to those aged 18-44 (aRR 0.80 [95% confidence interval (CI) 0.79, 0.82] and 0.50 [95% CI 0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [95% CI 0.86, 0.90]) and nonhomeless Veterans (0.89 [95% CI 0.86, 0.92]). DISCUSSION: Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic; however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers. CONCLUSIONS AND RELEVANCE: While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.