ABSTRACT
Older Veterans at high-risk for institutionalization often require home- and community-based services (HCBS). Yet, current HCBS delivery often fails to meet the needs of high-risk Veterans due to decreased veteran engagement in outpatient programs and limited HCBS capacity. A promising approach to address these gaps is the use of Veteran-Peers to make home-visits. Peer-2-PACT is a peer-led needs-assessment intervention for high-risk older veterans. Two trained peers conducted a checklist-guided virtual and/or in-person home-assessment to identify unmet needs and home-safety concerns. Veterans with access, acceptance and ability for video-capable technology were offered video-visits. We report on the feasibility of video home-visits in this high-risk group, and the experience of the video-visits using the visit-data and interviews with peers.Eight of 27 Peer-2-PACT Veterans successfully completed initial video-visit to home. The video-visit participants (n=8) were age 74±9;Non-Hispanic Black (50%);males (100%), compared to initial in-person home-visit participants (n=19), age 75.3±10.8;Non-Hispanic Black (47%);males (89%). The commonest needs identified during video-home-visits were home-safety devices 5(62.5%), housing assistance 4(50%), and medication refills 2(25%). Peers report that identifying veterans suitable for video-visits was challenging. During video-visits, depth-perception by peers is limited and sometimes needed in-person follow-up. Main advantages of video-visits was ability to identify unmet needs, engage veterans, provide care during COVID, and tele-present to remote clinicians. Preliminary data suggest that peer-conducted video home-visits is a feasible way to identify unmet needs in some high-risk older adults. This is particularly important improve care of Veterans who live at a distance from the facility.
ABSTRACT
The reach of home-based clinical programs for medically complex, older adults can be limited by geographic scope. Implementing telehealth versions can expand reach but create constraints for comprehensive assessments and technological barriers for users. We describe challenges and lessons learned during the pre-implementation period for the randomized trial of a hybrid video -modality of the Geriatrics Resources for Assessment and Care for Elders (GRACE) Program at the Indianapolis Veterans Health Care System. In TeleGRACE, a health technician makes home visits to facilitate clinical activities (e.g., medication reconciliation) using telehealth technology for a clinical team (social worker, nurse practitioner) who conduct the visits remotely. Data used in this one-year pre-implementation evaluation included: periodic reflections with the clinical and evaluation staff, planning and interdisciplinary team meeting fieldnotes, and interviews with clinical team members. Data were summarized by selected constructs from the Consolidated Framework for Implementation Research;implementation challenges and problem solving were identified. Pre-implementation challenges occurred in: assuring assessment devices worked correctly for and were trusted by staff (e.g., connectivity, virtual stethoscope), technician fit with existing GRACE team, ensuring technician welfare (e.g., COVID-19 exposure, guns in the home), caseload balance amid staffing shortages, travel logistics, and sampling to adequately power the trial. Building on an existing strong team dynamic and a culture of feedback for quality improvement, challenges were addressed through pilot-testing, monitoring for barriers and impacts, and group reflecting conversations. Adaptations to the initial plan resulted in a more focused and targeted implementation effort to test the model and its effectiveness.
ABSTRACT
Informal caregivers face challenges in supporting older or medically-complex Veterans, which could be exacerbated by the COVID-19 pandemic. Our mixed methods observational study explored Veteran caregivers' supports, challenges, and self-identified impacts during the pandemic. Caregivers whose veterans needed help with at least one activity of daily living for the last year and received care at one of five Veterans Health Administration (VA) study sites were eligible. Survey participants (n=46) were 96% female, 32-83 years old (median 59);most (83%) cared for a spouse. A majority (67%, n=31) reported increased stress since the start of the pandemic. Top sources of increased stress included worry about COVID-19 infection, increased caregiving responsibility, delayed access to care, concerns about vaccine safety, and employment or financial concerns. Caregiver interviews (n=26) qualitatively analyzed using a rapid, templated approach identified the following themes: (1) the benefits and challenges of VA COVID precautions to Veteran care access (e.g. telehealth, getting care for new problems), (2) supports afforded by and limits of the expansion of the VA Caregiver Support Program, (3) declines in Veteran physical and cognitive functioning, (4) increased caregiver role in Veterans' support and care, (5) changes in work and living situations to address increased caregiving needs and/or reduce risk of exposure, and (6) loss of and then return to more usual routines and social outlets amid ongoing COVID-related uncertainties. Recommendations include targeted, personalized outreach to engage caregivers in existing supports, removing barriers and streamlining processes for obtaining services, and creating durable caregiver-to-caregiver, peer support opportunities.