Study Shows Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic

BACKGROUND:
Patients routinely communicate with primary care teams using telehealth modalities, yet there exists a “Digital Divide” that includes a lack of access to technology (e.g., smartphones, tablets, laptops) or to the internet, which is necessary to participate in telehealth care. The COVID-19 pandemic led to expanded telehealth use across healthcare systems, including VA; however, little is known about how large-scale telehealth rollouts affected access to primary care for patients experiencing homelessness, who suffer most from the Digital Divide. This retrospective cohort study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care—and to characterize users before and after the onset of the pandemic. The study included 394,731 Veterans with a homelessness diagnosis between March 2019 and March 2022, which included both pre- and post-pandemic years. The outcomes measured were Veterans’ use of one or more telehealth visits (video, phone, or secure messaging) for primary care during each year. Investigators also examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care [HPACT], permanent supportive housing).

FINDINGS:

• Despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone.
• High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%).
• Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups.

IMPLICATIONS:

• Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.

LIMITATIONS:

• This study cohort excluded patients with homeless experiences who did not receive diagnostic coding, due to lack of standardized screening and coding of housing status, or in cases where informal supportive services were offered.

AUTHOR/FUNDING INFORMATION:
Dr. Leung is supported by an HSR&D Career Development Award (CDA). All authors are part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP) in Los Angeles, CA.

Leung LB, Zhang E, Chu K, Yoo C, Gabrielian S, and Der-Martirosian C. Characteristics of Veterans Experiencing Homelessness Using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset. Journal of General Internal Medicine. January 22, 2024; online ahead of print.