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.

VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs.

IMPORTANCE: United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. OBJECTIVE: To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. METHODS: VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. MEASURES: Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). RESULTS: 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. CONCLUSION: VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.

Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic.

Objective: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic. Materials and Methods: Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model. Results: 416 587 Veterans with 1 689 595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92). Conclusion: The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology 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.

Crossing the digital divide: a veteran affairs program to distribute video-enabled devices to patients in a supportive housing program

Objective Evaluate an initiative to distribute video-enabled tablets and cell phones to individuals enrolled in Veterans Health Affairs supportive housing program during the COVID-19 pandemic. Materials and Methods In September 2020, individuals in the Veteran Health Affairs (VA) Housing and Urban Development-VA Supportive Housing (HUD-VASH) program were offered either a video-enabled tablet or cellphone to support their communication and health care engagement needs. We examined sociodemographic and clinical characteristics of device recipients, and compared engagement in in-person, telephone, and video-based visits (categorized as primary care, specialty care, rehabilitation, HUD-VASH, mental health care, and other) for 6 months prior to (March 1, 2020–August 31, 2020) and following (September 1, 2020–July 30, 2021) device receipt. Results In total, 5127 Veterans received either a tablet (n = 4454) or a cellphone (n = 673). Compared to the 6 months prior to device receipt, in the 6 months following receipt, in-person and video engagement increased by an average of 1.4 visits (8%) and 3.4 visits (125%), respectively, while telephone engagement decreased (−5.2 visits;−27%). Both tablet and cellphone recipients had increased in-person visits (+1.3 visits [8%] and +2.1 visits [13%], respectively);while tablet users had a substantially larger increase in video-based engagement (+3.2 visits [+110%] vs. +0.9 [+64%]). Similar trends were noted across all assessed types of care. Discussion Providing video-enabled devices to Veterans in a supportive housing program may facilitate engagement in health care. Conclusions and Relevance VA’s device distribution program offers a model for expanding access to health-related technology and telemedicine to individuals in supportive housing programs.

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.

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.