1131 — Necessary But Not Sufficient: Implementation and Effectiveness of VA’s Tablet Initiative and Digital Divide Consult During the COVID-19 Pandemic

Lead/Presenter: Donna Zulman,  COIN - Palo Alto
All Authors: Zulman DM (Center for Innovation to Implementation (Ci2i), VA Palo Alto), Van Campen J (Ci2i, VA Palo Alto), Ferguson JM (Ci2i, VA Palo Alto), Dhanani Z (Ci2i, VA Palo Alto), Greene AL (Ci2i, VA Palo Alto), Soohoo S (Ci2i, VA Palo Alto), Kimerling RE (Ci2i, VA Palo Alto), Slightam CA (Ci2i, VA Palo Alto)

Objectives:
Evaluate the implementation and effectiveness of VA’s national initiative to distribute video-enabled tablets to Veterans with access barriers during the COVID-19 pandemic.

Methods:
The VA began distributing a limited number of video-enabled tablets to Veterans in 2016, but demand for this resource increased dramatically in 2020 with the onset of the COVID-19 pandemic. In response, VA’s Office of Connected Care (OCC) implemented a Digital Divide consult template in the EHR in order to: 1) scale up and standardize tablet distribution, and 2) direct tablets and subsidized data plans to Veterans with documented access barriers and video-based care needs. We evaluated the implementation and effectiveness of the Digital Divide consult and tablet distribution efforts between 2020-2022. Guided by the RE-AIM Framework, we assessed Reach (i.e., number and characteristics of tablet recipients), Adoption (i.e., rates and volume of video-based service use among tablet recipients), and Effectiveness (i.e., patient-reported experiences with tablets, based on a mailed and phone survey of 3,399 tablet recipients with subsequent video visits). We assessed Implementation by examining reasons for tablet referral from the consult and changes over time in the percentage of Veterans who had a video visit within 90 days of tablet receipt.

Results:
Between 2020-2022, >130,000 Veterans received VA-issued video-enabled tablets, one-third of whom resided in rural locations. Tablet recipients (compared to the general VA population) were more likely to be younger than 65 years (53% vs 47%), non-white (34% vs 28%), and have >5 chronic conditions (45% vs 18%), a mental health condition (70% vs 33%), priority status for high disability (52% vs 41%), and a history of homelessness (19% vs 4%). The most common criteria cited in tablet referrals were a mental health diagnosis (64%), social isolation (24%), and distance from VA >30 miles (23%). Following implementation of the Digital Divide consult, the percentage of tablet recipients who had a video visit within 90 days of tablet receipt rose from 57% in October 2020 to 74% in April of 2022. After consult implementation, we observed that many high-need patient populations had high rates of video visit engagement (i.e. ?4 video visits in six months after tablet receipt) including 51%, 40%, and 42% of Veterans at high-risk for suicide, with substance use disorder, and with a hospitalization in the 90 days prior to tablet receipt, respectively. However, a moderate proportion (22-30%) did not have any video visits in the six months after tablet receipt. Among 1,000 survey respondents (response rate 35.7%), 91% reported that video visits helped them get care in a timely manner and 80% reported that they received the same quality of care during video-based and in-person visits.

Implications:
VA’s distribution of video-enabled tablets supported virtual care adoption and engagement during the COVID-19 pandemic, especially among Veterans with complex medical and social needs.

Impacts:
Although VA’s tablet initiative successfully targeted Veterans with high clinical and access needs during the pandemic, video visit rates remained low for many recipients. Future implementation strategies should focus on facilitating tablet adoption and use for high-value virtual care services.