The role of Department of Veterans Affairs community-based outpatient clinics in enhancing rural access to geriatrics telemedicine specialty care.

BACKGROUND: Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under-resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff. METHODS: From February-April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi-structured interviews addressed patient population characteristics; CBOC location, staffing, and in-house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data. RESULTS: Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in-person visits. CONCLUSIONS: Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource-poor settings, and are largely unaware of VA telemedicine programs designed to support them.

Integrating CFIR-ERIC and e-Delphi Methods to Increase Telegeriatrics Uptake.

BACKGROUND AND OBJECTIVES: Participatory implementation methods are needed in geriatric health care to improve care and services for a growing population of older adults. We describe an efficient participatory approach to improve uptake of Geriatric Research Education and Clinical Center (GRECC) Connect, a national geriatrics outpatient consultation service using telehealth technology to connect geriatric specialists to rural, older veterans though community-based clinics. RESEARCH DESIGN AND METHODS: We designed a three-phase participatory method to identify high-priority implementation strategies to support the uptake of GRECC Connect. We used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Strategy Matching Tool to derive expert-recommended implementation strategies informed by qualitative interviews with both GRECC Connect staff and clinicians at community-based clinics. We engaged expert panelists in a participatory two-step modified e-Delphi process using confidential surveys and discussion to prioritize strategies nationally. RESULTS: Qualitative interviews revealed barriers, facilitators, and recommendations for program uptake. Many strategies recommended by CFIR-ERIC addressed multiple barriers but needed to be tailored to our specific context. In our two-step e-Delphi process, expert panelists shared previous experience with the strategies presented, views on the importance and feasibility of each, and arrived at a consensus about which strategies to prioritize nationally. DISCUSSION AND IMPLICATIONS: We demonstrate the feasibility and benefits of engaging subject matter experts to identify strategies to be tested on a national level. Future considerations include weighting of survey responses, accounting for regional differences, and sensitivity of Likert scales used in the e-Delphi process.