Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset.

ABSTRACT

BACKGROUND: The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness. OBJECTIVE: To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic. DESIGN: Retrospective cohort study, 3/16/2019-3/15/2022. PARTICIPANTS: 394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits. MAIN MEASURES: The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing). KEY RESULTS: Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video 1.37% versus 20.56%, phone 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years OR = 0.43, CI 0.42-0.44), women (OR = 1.74, CI 1.70-1.78), Black (OR = 1.14, CI 1.12-1.16), Hispanic (OR = 1.34, CI 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services. CONCLUSIONS: Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.