Increasing Use of Video Telehealth Among Veterans Experiencing Homelessness with Substance Use Disorder: Design of A Peer-Led Intervention

Using the Plan-Do-Study-Act Evaluation Framework to Improve the Recruitment of Women Experiencing Homelessness: Lessons Learned

BACKGROUND AND OBJECTIVES

Strategic recruitment is necessary to reach recruiting goals when conducting research with vulnerable and transient populations, such as postpartum women experiencing homelessness. The current study evaluated the recruitment process for a qualitative study using the Plan-Do-Study-Act (PDSA) method.

METHODS

In a study conducting semistructured interviews about reproductive interconception care barriers and facilitators for local women who were recently pregnant and homeless in 2022, PDSA cycles were used to improve community organizations' assistance with identifying participants, facilitate screening and interviewing processes, and ensure participants were safeguarded.

RESULTS

Iterative PDSA cycles were conducted across a 20-week period. Ultimately, 12 women were interviewed, with increasing participant location and organizational assistance over time. Following 4 key lessons were identified: provide in-person and remote options for conducting data collection; include fair compensation that balances time versus study coercion; weigh feasibility versus importance of sample size with eligibility criteria; and support partnerships with organization connections.

CONCLUSIONS

The PDSA method served as a parsimonious framework for evaluation. The lessons learned will help facilitate future recruitment efforts for this difficult-to-recruit and vulnerable population.

Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset

BACKGROUND

The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness.

OBJECTIVE

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 COVID-19 pandemic.

DESIGN

Retrospective cohort study, 3/16/2019-3/15/2022.

PARTICIPANTS

394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits.

MAIN MEASURES

The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we 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).

KEY RESULTS

Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42-0.44), women (OR = 1.74, CI: 1.70-1.78), Black (OR = 1.14, CI: 1.12-1.16), Hispanic (OR = 1.34, CI: 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services.

CONCLUSIONS

Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. 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.

Stakeholder Perceptions of a Web-Based Physical Activity Intervention for COPD: A Mixed-Methods Study

Technology-based physical activity interventions have been shown to be efficacious in chronic obstructive pulmonary disease (COPD), though their potential impact has not been fully realized due to ineffective implementation. We used a convergent, parallel mixed-methods design to identify patient- and provider-facing barriers and facilitators to implementing a rigorously studied web-based physical activity intervention for COPD. Quantitative surveys (based on the unified theory of acceptance and use of technology; range 1 (poor usability)-5 (high usability)) and semi-structured interviews (guided by the practical robust implementation and sustainability model) assessed the perspectives of 15 patients and 15 health care providers. The patients and providers rated the usability of the intervention as high (median = 5.0, IQR = 1.0). For both patients and providers, the main facilitators included: the potential high impact of the intervention on patient health, the usefulness of the intervention for unmet clinical needs, and the perceived ease of use of the intervention. The main barriers identified were digital literacy and its fit with current clinical workflows. Implementation efforts may benefit from supporting patients' use of the website and developing strategies to integrate referrals to the intervention and the monitoring of patients into current clinical infrastructures.