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2023 HSR&D/QUERI National Conference Abstract

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4091 — Digital Divide Magnified for Rural, Older Veterans Living “Off the Grid”

Lead/Presenter: Kathryn Nearing,  VA Eastern Colorado Geriatric Research Education and Clinical Center
All Authors: Nearing KA (VA Eastern Colorado Geriatric Research Education and Clinical Center), Pimentel C (Center for Healthcare Organization and Implementation Research and New England Geriatric Research Education and Clinical Center, Bedford VA Medical Center) Dryden E (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Kernan L (formerly with the Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Kennedy M (VA New England Geriatric Research, Education, and Clinical Center, VA Bedford Healthcare System) Moo L (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System) Hung W (Geriatric Research, Education and Clinical Center, James J Peters VA Medical Center, Bronx, NY)

Objectives:
Geriatric Research Education and Clinical Center (GRECC) Connect is an enterprise-wide dissemination project funded by the VA Office of Rural Health. GRECC Connect hub sites (n = 18) increase access to geriatric specialty care through telemedicine for rural, older Veterans with multiple chronic conditions/complex care needs. GRECC Connect hubs, based at VA medical facilities in urban centers, partner with VA community-based outpatient clinics (CBOCs) to connect rural Veterans with geriatric specialty care. To support strategic planning, our national qualitative evaluation study explored facilitators and barriers to uptake of GRECC Connect services among CBOC providers most likely to refer Veterans.

Methods:
Between February-May 2020, the qualitative evaluation core conducted 50 key informant interviews with providers in rural, VA-affiliated CBOCs that were part of the GRECC Connect network in diverse regions (Northeast, South, Midwest and Northwest). Providers ranged from primary care physicians, social workers and psychologists to nurse clinic managers and telehealth technicians. One-on-one semi-structured interviews required 45 minutes to 1 hour; were recorded with permission, professionally transcribed, and checked for accuracy; and, analyzed using a framework analysis approach.

Results:
Rural providers consistently described rural Veteran patients as older (60-90% aged ?65 years), lacking access to adequate primary and specialty care and, consequently, lacking support to manage chronic conditions or address a complex array of care needs. The paucity of VA or community-based services for addressing the social determinants of health often meant rural, older Veterans were less able to remain independent at home. Providers often described rural Veteran patients as isolated, without financial resources or social supports (i.e., no caregiver). Transportation, technology/internet connectivity, and food insecurity topped the list of service gaps/needs. Providers also described highly rural Veterans who were “off the grid.” These Veterans, by choice and/or circumstance, were described as not having access to reliable internet, associated devices or computer knowledge/skills. Providers described the difficulties of connecting with these Veterans even by phone. Providers described isolation as a “meta-influencer,” constraining choice, perspective, hope and influencing self-neglect.

Implications:
Compared to urban Veterans, rural Veterans are more likely to be older (55-74), unemployed, have less education, more service-related disabilities and unmet healthcare needs. The shift to telemedicine in response to COVID-19 may have exacerbated the digital divide as a social determinant of health for these Veterans. For “off-the-grid” Veterans, past experiences and present-day circumstances converge to perpetuate and exacerbate inequities in access to healthcare. Their situation underscores that telehealth is not a panacea for increasing access to care and reaching those with whom it may be most difficult to connect to span social, geographic and digital divides.

Impacts:
This national evaluation surfaced two key tensions with policy, program and practice implications: 1) VA’s mission to serve all Veterans and the difficulty of reaching highly rural, older Veterans who are socially, economically and technologically isolated; and 2) promoting telemedicine to expand access to care and the difficulties with accessing, or encouraging use of, telemedicine due to the intersectionality of geography, age, socioeconomic status, education and untreated physical, cognitive and mental health conditions.