Increasing Use of Video Telehealth Among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-Led Intervention.

Telehealth offers promising opportunities, but also challenges, for veterans experiencing homelessness - during the COVID-19 pandemic and beyond. Recent research found low utilization of clinical video visits among homeless veterans receiving a VA tablet, and having a substance use disorder (SUD) further reduced visit likelihood. Hence, this study sought to identify unique barriers to telehealth use among veterans experiencing homelessness with a SUD and design an intervention to promote adoption. This qualitative study was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The study's three phases included veteran interviews (N = 28) to identify barriers and facilitators to video telehealth use and propose intervention candidates, a provider expert panel to obtain feedback on interventions, and a focus group with veterans to complete the intervention. Finally, a prototype was designed using the intervention mapping approach. Veteran interviews revealed that barriers to video telehealth included complex physical and mental health issues, lack of digital literacy, and insufficient technical support. Together, veterans and experts proposed five intervention candidates. In the end, a veteran focus group combined two candidates, peer-led digital training and motivational interviewing. Intervention mapping was used to design a "stepped care" intervention that trains and activates veterans at all skill levels. This study demonstrates how inclusion of expert and veteran views led to development of a novel intervention to support and sustain video telehealth use among veterans experiencing homeless with SUD.

Home Low Vision Ocular Rehabilitation Telehealth Expansion Due to COVID-19 Pandemic.

Background: In March 2020, the pandemic added a major barrier resulting in the cancelation of all low vision ocular rehabilitation services. To prevent delay of beginning low vision ocular rehabilitation services, all low vision care was switched to telerehabilitation to home. Methods: Case managers began to cancel all in-person services and offer Veterans Affairs (VA) video connect services to their home. Patients with video access scheduled a home VA video connect telerehabilitation evaluation and therapy assessment. Patients who did not have video access waited to schedule a future in-person low vision appointment (postpandemic). Results: Of the in-person canceled appointments, 54% who scheduled the new home telerehabilitation evaluation were delayed on average 25 calendar days. Patients who waited for in-person low vision care were delayed on average 98, 138, or 153 calendar days. Of the 56 new patients referred for low vision optometry services during this 4-month period (COVID-19), 91% scheduled home low vision ocular telerehabilitation evaluations without delay; 5% waited until in-person clinics were open; and 4% waited until rural VA's and community-based outpatient centers were open. Discussion: Veterans with low vision who live in rural communities have limited access to services unless they are able to travel several miles to a specialty low vision clinic. Low vision ocular rehabilitation telehealth services have been successfully provided at the VA Western New York Healthcare System (Buffalo, NY) low vision clinic. Conclusions: Home low vision ocular rehabilitation telehealth increases access as early as possible once diagnosed with ocular pathology resulting in low vision.

Provider, Staff, and Patient Perspectives on medical Visits Using Clinical Video Telehealth: A Foundation for Educational Initiatives to Improve Medical Care in Telehealth.

Clinical Video Telehealth (CVT) use is increasing and allows geographically separated care; however, this separation may affect participants behaviors. Using semi-structured in-depth interviews, we asked CVT nurse practitioners (NP), staff and patients at a VA Medical Center about perspectives on how CVT effects communication and identified three themes. They remarked on the complexity of scheduling appointments, local barriers to care, and acutely ill patients. NPs discussed how CVT altered sensory collection during the physical exam and differences in building provider-patient relationships. Patients perceptions mirrored these themes. NPs identified how CVT requires different workflow, behaviors, and use of their senses. Patients expressed similar concerns with CVT.

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.

Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP) via Video Telehealth: A Case Example During the COVID-19 Outbreak.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.