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2023 HSR&D/QUERI National Conference Abstract

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1139 — Characteristics of homeless-experienced Veterans using telehealth for primary care before and after COVID-19 onset

Lead/Presenter: Eunice Zhang,  COIN - Los Angeles
All Authors: Zhang E (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA), Der-Martirosian C (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA); Chu K (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA); Gabrielian S (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA); Yoo CK (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, US); Hou CG (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA); Leung LB (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA)

Objectives:
The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Yet, little is known about the impact of telehealth expansion on vulnerable patients with preexisting access challenges who are affected by a “digital divide,” such as Veterans experiencing homelessness. While some research on telehealth mental health services for individuals experiencing homelessness exists, there is a knowledge gap on the extent to which primary care services are delivered via telehealth. There is also limited information on patient characteristics of telehealth users among individuals experiencing homelessness. This study aims to characterize homeless-experienced Veterans who utilized telehealth primary care services before and after pandemic onset.

Methods:
In this retrospective cohort study, we identified 392,870 homeless-experienced Veterans nationally using ICD-10 codes in VA administrative data. This study cohort had 1,665,680 primary care visits in the year before (March 16, 2019–March 15, 2020) and 3,537,418 visits since the onset of the COVID-19 pandemic (March 16, 2020–December 15, 2021). Our study examined their use of various telehealth modalities (e.g., phone, video, secure messaging). We also described patient users by age, gender, race/ethnicity, and Charlson Comorbidity Index.

Results:
Among homeless-experienced Veterans, the average monthly telehealth primary care visits increased from 41,975 to 87,894, before to after pandemic onset. Most telehealth visits were delivered via phone (n = 40,115 to 76,225); video visits, specifically, increased the most (n = 443 to 9,699), before to after COVID-19 onset. Compared to video non-users, high video users (i.e., completed 2+ video visits in one year) were consistently younger (18-44 years old; 21.4% vs 32.0%), female (9.8% vs 21.0%), and had more comorbidities (2+ on the Charlson Comorbidity Index; 36.1% vs 39.4%) after pandemic onset. Additionally, among high video users, video uptake disproportionately increased for Black (24.5% vs 38.1%) and Hispanic (6.8% vs 9.1%) Veterans compared to White Veterans (59.8% vs 44.8%) before to after COVID-19 onset.

Implications:
Despite the “digital divide” and low rates of pre-pandemic telehealth use, homeless patients still had significant uptake of telehealth primary care after pandemic onset. Female patients and racial-ethnic minorities had higher uptake proportionately with video modalities, suggesting that telehealth may help to address some disparities in primary care access among vulnerable populations. Higher video use among patients with greater comorbidities may partly be attributed to an ongoing VA national initiative to distribute tablets to high-risk patients.

Impacts:
Healthcare delivery should consider how best to incorporate telehealth services into primary care for all Veterans experiencing homelessness. Telehealth services for this vulnerable patient population might help to reduce racial disparities in access to care. Future research is needed to identify system-level characteristics that predict telehealth primary care use among homeless-experienced Veterans to further increase the adoption in telehealth modalities in this group.