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2023 HSR&D/QUERI National Conference Abstract

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4096 — Challenges Rural Community-Based Outpatient Clinics Face Delivering Geriatrics Care

Lead/Presenter: Lauren Moo,  COIN - Bedford/Boston
All Authors: Moo LR (Center for Healthcare Organization and Implementation Research, New England Geriatric Research Education and Clinical Center, Harvard Medical School), Pimentel CB (Center for Healthcare Organization and Implementation Research, New England Geriatric Research Education and Clinical Center, University of Massachusetts Lowell) Nearing KA (Eastern Colorado Geriatric Research Education and Clinical Center, University of Colorado Anschutz Medical Campus) Kernan LM (Dartmouth-Hitchcock Medical Center) Dryden EM (Center for Healthcare Organization and Implementation Research) Hung WW (Bronx Geriatric Research Education and Clinical Center, Icahn School of Medicine)

Veterans aged 65+ years comprise half of the 2.9 million VA enrollees in rural communities. They have higher rates of military service-related disability and chronic conditions than urban Veterans. Their rurality presents unique challenges, e.g., lack of public transportation options and a dearth of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs), which care for half of VA’s patient population, are critical to extending VA’s geographic reach. To establish a CBOC, a VA Medical Center (VAMC) must first determine non-VA or “community care” programs cannot meet identified demand. Consequently, CBOCs are typically located in under-resourced settings. In this challenging context, telemedicine offers a solution to increase access to care. Little is known, however, about CBOCs’ capacity to leverage telemedicine to meet older patients’ needs. This study identified barriers and facilitators to increasing access to geriatric telehealth specialty care from the perspective of rural CBOC clinicians and staff.

We purposively selected geographically diverse CBOC “spokes” (N = 13) affiliated with four VA Geriatric Research Education and Clinical Center (GRECC) “hubs.” We interviewed CBOC clinicians and staff (N = 50) from February-April 2020. Semi-structured interviews addressed patient population characteristics, including met and unmet needs; CBOC location, staffing, and in-house resources; use of VA specialty services; and barriers and facilitators of telemedicine use. We developed a codebook using an iterative process and Ritchie and Spencer’s Framework Method (1994) to thematically organize and analyze data. We summarized findings by CBOC and by hub and spoke clusters.

Participating CBOCs serve a majority older patient population. They are located 1-3.5 hours from their VAMC and serve catchment areas spanning multiple states. Many patients are eligible for non-VA resources through the MISSION Act; however, access to these resources may be county- or state-specific, and home care and visiting nurses are limited or do not reach highly rural populations. Four key organizational characteristics enabled CBOCs to offer geriatric telehealth specialty care: (1) partnerships with VAMCs/interprofessional teams; (2) social workers and telehealth technicians as champions; (3) periodic outreach and education from geriatric specialists; and (4) robust telehealth capacity and routine use of other telehealth services. Barriers to use of geriatric telehealth specialty care included: (1) constraints on clinic space and unstable Internet for telehealth visits; (2) staffing challenges (e.g., turnover); (3) limited staff familiarity with telehealth resources and navigating complex patient referral processes; and (4) staff perceptions that older Veterans prefer in-person visits with specialists.

Telehealth is an important modality to care for an increasingly older and medically complex patient population. Rural CBOCs provide a large portion of care to VA’s growing geriatric population but are understaffed, undertrained in geriatrics, working in resource-poor settings, and largely unaware of VA telemedicine programs designed to support them.

CBOCs, by design, operate in underserved areas. VA is thus invested in connecting CBOCs with geriatrics specialists at urban VAMCs. Findings suggest that to successfully reach aging rural Veterans, VA will need to increase CBOC support in terms of staffing, telemedicine capability, CBOC clinician education, and geriatric specialist telemedicine capacity.