Crossing the Starting Line: A Qualitative Study of Needs for Successful Engagement in Telemedicine among Rural Older Adults and their Caregivers (Preprint)

Abstract

Telemedicine is an important option for rural, older adults who often must either travel far distances to clinics or forgo essential medical care. In 2014, the Veterans Health Administration (VA) established a national telemedicine network, GRECC Connect, to increase access to geriatric specialty care for the 1.4 million rural, service-connected Veterans ages 65 or older. Use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened care systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would otherwise not use telemedicine if in-person care were available.

In Spring 2021, we interviewed Veterans and their informal caregivers to 1) elicit their experiences attempting to participate in a video visit with a GRECC Connect geriatric specialist, and 2) explore facilitators and barriers to successful engagement in a telemedicine visit.

We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least one GRECC Connect telemedicine visit in the three months prior. Thirty participants from six geographically diverse GRECC Connect hub sites agreed to participate. Per participant preference, semi-structured interviews were conducted via telephone or via VA’s videoconference platform for home telemedicine visits (VA Video Connect). We observed challenges and, when needed, provided real-time technical support to facilitate connecting to VA Video Connect (VVC) for interviews. All interviews were recorded with permission and professionally transcribed. A team of five researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis.

We identified four main categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: 1) presence of a caregiver to facilitate technology setup and communication; 2) flexibility in visit modality (e.g., video from home or a clinic; telephone); 3) technology support (e.g., determining device compatibility, providing instruction and on-demand assistance); and 4) assurance of comfort with virtual communication, including orientation to features like closed captioning. Supports were needed at multiple points prior to the visit yet were not one-size-fits-all: participants stressed the importance of eliciting the needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to continue using telemedicine for other types of healthcare visits.

To close gaps in telemedicine use among rural, older adults, supports must be tailored to individuals, accounting for technology availability and comfort, and availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.