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Health Services Research & Development

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2023 HSR&D/QUERI National Conference Abstract

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1063 — Increasing Use of Video Telehealth among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-led Intervention

Lead/Presenter: Lynn Garvin
All Authors: Garvin LA (Center for Healthcare Organization and Implementation Research, Boston; Boston University School of Public Health), Greenan MA (Center for Healthcare Organization and Implementation Research, Boston) Edelman EJ (Yale University School of Medicine) Slightam C (Center for Innovation to Implementation, Palo Alto) McInnes DK (Center for Healthcare Organization and Implementation Research, Bedford; Boston University School of Public Health) Zulman DM (Center for Innovation to Implementation, Palo Alto; Stanford University School of Medicine)

Objectives:
The Veterans Affairs (VA) Healthcare System faces unique challenges in caring for the over 37,000 Veterans experiencing homelessness and an additional 1.4 million Veterans at risk of homelessness. Video telehealth, specifically through the VA Video Connect (VVC) app, presents opportunities and challenges for Veterans experiencing homelessness, particularly those with substance use disorder (SUD) who are less likely to utilize video visits. This study sought to identify unique barriers to telehealth use among Veterans experiencing homelessness with a SUD and design an intervention to promote telehealth adoption.

Methods:
This qualitative study was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The study’s three phases included: (1) one-hour, semi-structured veteran interviews (N = 28) to identify barriers and facilitators to video telehealth use and identify intervention candidates, (2) a provider expert panel to obtain feedback on intervention candidates, and a focus group with Veterans to select one intervention to develop, and (3) development of a prototype of the selected intervention using intervention mapping, a theory- and evidence-based planning approach.

Results:
In Phase 1, Veteran interviews revealed that barriers to video telehealth included: complex physical and mental health issues and lack of digital literacy. Despite receiving VA phone calls to guide video visit set-up, Veterans reported requiring more hands-on technical support. Veterans proposed three intervention candidates: digital training and support from VA Peer Specialists; an automated tutorial text from the VA Annie Text Messaging app; and a mobile app to guide video telehealth log-on. In Phase 2, an expert panel was convened with four VA clinical leaders with research experience among homeless Veterans with SUD. The expert panel added two interventions involving therapeutic techniques used in addiction treatment: motivational interviewing based on intrinsic personal goals, and contingency management based on extrinsic monetary rewards. A Veteran focus group then considered the five interventions, and combined two candidates: peer-led digital training and motivational interviewing. In Phase 3, intervention mapping was used to design a stepped care intervention that included peer-led digital training and motivational interviewing that trains and activates Veterans at all skill levels to use telehealth.

Implications:
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. This intervention offers flexible stepped care that can provide increasing support based on the needs of individual Veterans, and can flexibly accommodate both individual and group training modalities.

Impacts:
The intervention developed in this study will help increase access to video telehealth through the combination of motivational interviewing and peer-led training and support. The intervention will strengthen Veterans’ digital skills to enable their telehealth adoption and build Veterans’ confidence in those skills to sustain telehealth use. This intervention supports VA’s broader commitment to health access and health equity through the expansion of digital literacy.