Integrating CFIR-ERIC and e-Delphi Methods to Increase Telegeriatrics Uptake

BACKGROUND AND OBJECTIVES

Participatory implementation methods are needed in geriatric health care to improve care and services for a growing population of older adults. We describe an efficient participatory approach to improve uptake of Geriatric Research Education and Clinical Center (GRECC) Connect, a national geriatrics outpatient consultation service using telehealth technology to connect geriatric specialists to rural, older veterans though community-based clinics.

RESEARCH DESIGN AND METHODS

We designed a three-phase participatory method to identify high-priority implementation strategies to support the uptake of GRECC Connect. We used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Strategy Matching Tool to derive expert-recommended implementation strategies informed by qualitative interviews with both GRECC Connect staff and clinicians at community-based clinics. We engaged expert panelists in a participatory two-step modified e-Delphi process using confidential surveys and discussion to prioritize strategies nationally.

RESULTS

Qualitative interviews revealed barriers, facilitators, and recommendations for program uptake. Many strategies recommended by CFIR-ERIC addressed multiple barriers but needed to be tailored to our specific context. In our two-step e-Delphi process, expert panelists shared previous experience with the strategies presented, views on the importance and feasibility of each, and arrived at a consensus about which strategies to prioritize nationally.

DISCUSSION AND IMPLICATIONS

We demonstrate the feasibility and benefits of engaging subject matter experts to identify strategies to be tested on a national level. Future considerations include weighting of survey responses, accounting for regional differences, and sensitivity of Likert scales used in the e-Delphi process.

Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers

OBJECTIVE

Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value.

DATA SOURCES

In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits.

STUDY DESIGN

A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges.

DATA COLLECTION

We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach.

PRINCIPAL FINDINGS

Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity).

CONCLUSIONS

Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.

GEROFIT TELEHEALTH-DELIVERED GROUP EXERCISE IMPACTS SOCIAL SUPPORT AND HEALTH AMONG OLDER VETERANS

Group exercise provides social support, which is especially important among older adults. Gerofit conducted a telephone survey with participants (n=258) from 15 sites to learn about Veterans’ experiences with transition to Gerofit-specific telehealth-delivered group exercise to guide continuous improvement of the program. One, open-ended question was asked at the end, inviting respondents to reflect on any other thoughts they had about the telehealth-delivered exercise sessions. This yielded robust qualitative responses which constitute the data analyzed in this qualitative descriptive study. Key themes that emerged from participant responses included: 1) telehealth-delivered group exercise provides structure, motivation, and accountability; and 2) transitioning from in-person to telehealth-delivered exercise has many beneficial impacts on health such as retaining strength and ability to recover from injury, weight management, and positive impacts on mental health and quality of life. Telehealth-delivered group exercise sessions provide social support and are associated with positive health impacts.

IMPROVING VIDEO DEVICE USAGE AMONG OLDER RURAL VETERANS WITH USER-CENTERED DESIGN

The Veterans Administration (VA) established pathways to provide VA-issued tablets and increased access to internet for Veterans without these resources. Veterans aged above 65, experience barriers with telemedicine such as access and usability. We sought to improve the usability and experience of telemedicine for rural, older Veterans receiving a VA-issued tablet by modifying materials and qualitatively evaluating their experience with set-up and preparing for their first appointment, guided by user-centered design. We conducted a rapid exploratory evaluation, to understand Veteran and care partner experiences setting up VA-issued tablets and logging into their first appointment using standard 9-page instructions. We interviewed telehealth technicians, and providers to better understand patient barriers from their perspective. Using insights from interviews and evidence-informed guidelines on educational materials for older adults, we created a two-page guidance. A group of Veterans and care partners reviewed the materials and provided feedback. Received feedback provided 17 suggestions, 8 of which were utilized, including enlarging graphics, clarifying abbreviations (or wording), consolidating the instructions further and emphasizing pertinent information further. Modified materials reduced standard written instructions from nine pages to two. Feedback suggests that updated materials are helpful, aesthetically pleasing and preferred over current materials. Utilizing user-centered design methods, addressed barriers experienced by older, rural Veterans with initial telemedicine device and appointment set-up. Veterans, care partners, providers, and telehealth technicians perceived materials adapted for older adults as supportive of video device usability, helping to alleviate barriers that prevent Veterans from initiating telemedicine.

The Integral Role of CBOCs in Rural Healthcare: Promises and Challenges

Community-based outpatient clinics are critical to extending the geographic reach of VA’s healthcare delivery system. Nationwide, 733 CBOCs provide outpatient care to nearly half of the VA’s patient population. The 13 rural CBOCs in the study sample provide outpatient primary care, mental health care, and a limited number of specialty care services. Located 1–3.5 hours away from their closest VA Medical Center, these CBOCs have a wide—sometimes interstate—service catchment area. To effectively serve increasingly older and medically complex patient populations, they rely heavily on partnerships with larger VA Medical Centers and local community providers for inpatient, residential, and additional outpatient services. CBOCs experience myriad staffing challenges, including staff turnover, “access providers” working at multiple CBOCs, and highly variable training in rural health and geriatrics. While some CBOCs have robust telehealth offerings, others cannot currently grow their telehealth capacity owing to constraints in clinic space and provider schedules.

A Strategy Matching Tool for Boosting Implementation of Geriatric Telehealth Services in Rural CBOCs

Fifteen Veterans Administration Medical Centers (VAMCs) offer geriatric specialty care telehealth services through a hub and spoke model to patients at affiliated community-based outpatient clinics (CBOCs). These services are not used to the extent they could be. Through interviews with 50 staff and providers at rural CBOCs we identified several implementation facilitators and barriers. CBOC-level barriers included space constraints, low staffing, internet connection issues, and limited knowledge of services available and referral processes. Patient-level barriers included discomfort with technology, cognitive decline, and inability to travel to the CBOC. We found that champions within the CBOC and iterative, targeted outreach from the hub helped facilitate uptake of services. We entered the identified barriers into the CFIR-ERIC (Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change) Implementation Strategy Matching Tool to help generate targeted strategies that will be used to refine each hub’s implementation approach.

Digital Divide Magnified for Older Veterans Living Off the Grid

Compared to urban Veterans, rural Veterans are more likely to be older (55-74), not employed, have less education, more service-related disabilities and unmet healthcare needs. Interviews with a national sample of community-based outpatient clinic providers described highly-rural Veterans who are “off the grid.” These Veterans, by choice and/or circumstance, do not have access to reliable internet, associated devices or knowledge/skills. Providers described the difficulties of connecting with these Veterans even by phone. The healthcare shift to virtual telehealth modalities in response to COVID-19 highlights the digital divide as a social determinant of health. For “off-the-grid” Veterans, past experiences and present-day circumstances converge to perpetuate and exacerbate inequalities in accessing healthcare. Their situation underscores that telehealth is not a panacea for increasing access to care and confronts us with the moral imperative to reach those with whom it may be most difficult to connect to span social, geographic and digital divides.

Another Set of Eyes: Recipients’ Views of the Benefits of Geriatric Specialty Telehealth Services

The aim of GRECC Connect is to increase access to specialty care for medically complex, older, rural patients through e-consultations and telehealth visits. We interviewed 50 outpatient clinic staff and providers as well as 30 patients and caregivers about these services. Overall, the services were considered beneficial. For patients and caregivers, services alleviated the stress and cost of travel, they improved quality of life by increasing their understanding of the progression of an illness and providing treatment and guidance to increase patient functioning and reduce disruptive behaviors, and they eased anxiety associated with not receiving needed care. Having ‘another set of eyes’ on the patients reduced stress and anxiety for providers. Concerns included alignment of telehealth modality with the capabilities of older patients with cognitive problems, hearing loss and/or limited technological abilities and, for some providers, that the referral for and recommendations resulting from the service added to their workload.

Qualitative Evaluation: GRECC Connect as a Method of Delivering Health Care to Rural Older Veterans

The VA Office of Rural Health-funded GRECC Connect program uses telehealth modalities to provide geriatric specialty care to rural older veterans and education to clinicians in VA Community-based outpatient clinics (CBOCs). Qualitative evaluation of GRECC Connect has included interviews with three stakeholder groups: geriatrics specialty teams at 15 hub medical centers, rural CBOC staff, and patients/family caregivers. CBOC staff interviews included 50 individuals from 13 different CBOCs. Staff roles included clinic managers, social workers, psychologists, physicians, nurses, and telehealth technicians. Older veterans who had recently been involved in a GRECC Connect video visit were also invited to share their views on the visit. By including multiple perspectives on the program, we are better positioned to increase reach, access, and improve care for older rural veterans.

"Firearm access in dementia: legal and logistic challenges for caregivers"

The prevalence of Alzheimer's disease and related dementias (ADRD) is increasing. In the United States, older adults are among those most likely to have firearms in the home. Addressing firearm access among persons with ADRD can be confusing and stressful for family caregivers, healthcare providers, firearm industry representatives and law enforcement. This study sought to examine key stakeholder perspectives concerning legal and logistic considerations for temporary firearm transfers when a person with ADRD owned firearms. A secondary analysis of 24 qualitative interviews conducted to inform the development of a firearm safety tool for ADRD caregivers revealed four types of barriers. These barriers were each associated with logistical challenges and legal ambiguities that hampered ADRD-related firearm transfers: (1) legal questions on firearm ownership and permitted transferees; (2) transfer logistics and duration; (3) issues of engaging law enforcement or retailers for transfers; and, (4) lack of information resources and guidance. Siloes between stakeholder groups persist and limit information sharing. Broad initiatives engaging caregivers, older adults, clinicians, aging service providers, law enforcement, and firearm outlets could inform the development of policies, programs, and practices to enhance the safety and well-being of people with ADRD and their caregivers.

Feasibility and Acceptability of a Web-Based Caregiver Decision Aid (Safety in Dementia) for Firearm Access: Pilot Randomized Controlled Trial

Background

Firearms are common in the households of persons with Alzheimer disease and related dementias (ADRD). Safety in Dementia (SiD) is a free web-based decision aid that was developed to support ADRD caregivers in addressing firearm access.

Objective

We aimed to evaluate the feasibility and acceptability of SiD among a web-based sample of ADRD caregivers.

Methods

SiD was tested in 2 phases by using participants who were recruited from a web-based convenience sample (Amazon Mechanical Turk participants). In phase 1, caregivers were randomized to view either the intervention (SiD) or the control (Alzheimer’s Association materials), and the blinding of participants to the study arms was conducted. In phase 2, caregivers of individuals with ADRD and firearm access were recruited; all of these participants viewed the firearm section of SiD. In both phases, participants viewed SiD independently for as long as they wanted. Measures for evaluating decision-making and SiD acceptability were used, and these were assessed via a self-administered web-based questionnaire.

Results

Participants were recruited for phases 1 (n=203) and 2 (n=54). Although it was feasible to collect the study outcome data in a web-based format, in phase 1, there were no significant differences between SiD and the control in terms of decision-making and self-efficacy. The majority (137/203, 67.5%) of phase 1 participants spent between 5 and 10 minutes reviewing the resources. In phase 2, 61% (33/54) of participants spent 5 to 10 minutes viewing the firearm section, and 31% (17/54) spent 10 to 20 minutes viewing this section. Usability and acceptability were high across the phases.

Conclusions

SiD represents a new resource for promoting safety among people with dementia, and high acceptability was achieved in a pilot trial. In this sample, SiD performed similarly to Alzheimer’s Association materials in supporting decision-making and self-efficacy.

Expanding Workforce Capacity to Care for Older Veterans: The VA GRECC Interprofessional Training Experience

The Veterans Health Administration (VHA) contributes more to training healthcare professionals in geriatrics/gerontology than any other entity nationally, with the Geriatric Research Education and Clinical Center (GRECC) network serving as a leader in geriatric-/gerontology-specific interprofessional education. The Associated Health Training (AHT) Program is supported by all GRECCs, training ~427 trainees annually (FY17). Each AHT program brings together a diverse array of trainees – the specific constellation of disciplines unique to each GRECC based on local capacity/expertise. Common to all programs is intentional interprofessional training, aligned with Interprofessional Education Collaborative (IPEC) competencies. In 2016, the VA Office of Academic Affiliations (OAA) administered a 22-item survey to characterize the depth and breadth of geriatric-/gerontologic-specific interprofessional education across GRECCs. Questions explored how AHT programs addressed each of the four IPEC competency domains. Responses were de-identified; at least 2 coders independently applied directed coding to responses. Across GRECCs (n=18), 323 interprofessional training activities were coded, of which 9% were didactic; 27%, clinical; and, 63%, combination. Interprofessional education activities were integrated with profession-specific curricula (65.3%) or featured as part of GRECC-specific core curricula (5.4%). GRECC AHT interprofessional programs involved an average of 11 disciplines. GRECC AHT programs provide a vital infrastructure for building workforce capacity through robust, interprofessional training that engages diverse disciplines across a variety of care settings representing the continuum of care for older Veterans. GRECC and OAA efforts are critical to enhancing the quality, and expanding the capacity, of this workforce to meet increasing needs for patient-directed, team-based care for older adults.

GRECC Connect Increases Access to Geriatric Specialty Care for Rural, Older Veterans With Complex Care Needs

A higher percentage of Veterans in rural areas are older, have multiple chronic conditions and select the VA for healthcare. To address the needs of rural older Veterans with complex needs, GRECC Connect hubs use case finding approaches combined with regular outreach and education to VA community-based outpatient clinic (CBOC) providers serving rural Veterans and caregivers. Alignment of GRECC Connect services with needs of providers and patients promotes establishment of therapeutic alliances in caring for medically complex older Veterans. After identifying high risk, high need patients, hubs use the following strategies to increase access to geriatric specialty care through telehealth modalities: 1) Co-management of patients through e-consultation and telehuddles (GRECC Connect interprofessional geriatric specialty care teams extend support to CBOC providers); 2) Clinical video telehealth to CBOCs and Video on Demand to Veteran homes (to reduce travel burden); and, 3) Tele-group visits (especially for behavioral health and caregiver support).

Spreading Telehealth for Older Adults in Rural Areas Through Network of Geriatric Interprofessional Teams

Older adults living in rural areas have limited access to geriatrics interprofessional team care. In the Veteran healthcare system, geriatric teams such as geriatricians, nursing professionals, social workers, pharmacists and psychologists, located in urban areas link up with rural clinics to provide geriatric consultation remotely through clinical video telehealth and other means in the project GRECC Connect. Since its inception in 2014, the service has now grown to 16 geriatric teams offering consultation to over 100 clinic sites serving older rural Veterans. GRECC Connect delivered over 2,000 consultations in 2019, meeting complex care needs by identifying and linking geriatric services and management to patients with geriatric syndromes. The network of established geriatric teams, local champions and a shared Electronic Health Record facilitated the spread, while ongoing effort to build and maintain relationships between consultants and local rural provider teams and other community based services are important for ongoing success.

Telehealth Competencies for Interprofessional Teams Caring for Older Adults and Care Partners

Providing interprofessional geriatric care via telehealth is a unique clinical skillset that differs from providing face-to-face care. The lack of clear guidance on telehealth best practices for providing care to older adults and their care partners has created a systems-based practice educational gap. For several years, GRECC Connect has provided interprofessional telehealth visits to older adults, frequently training interprofessional learners in the process. Using our interprofessional telehealth expertise, the GRECC Connect Education Workgroup created telehealth competencies for the delivery of care to older adults and care partners for interprofessional learners. Competencies incorporate key telehealth, interprofessional and geriatric domains, and were informed by diverse stakeholders within the Veterans Health Administration. During this symposium, comments will be solicited from attendees. Once finalized, these competencies will drive the development of robust curricula and evaluation measures aimed at training the next generation of interprofessional providers to expertly care for older adults via telehealth.

Lessons learned from community-based participatory research: establishing a partnership to support lesbian, gay, bisexual and transgender ageing in place

Background

Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population.

Objective

To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN).

Methods

A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAIN's partners.

Results

Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors.

Conclusion

Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

Researching together: a CTSA partnership of academicians and communities for translation

BACKGROUND

The Colorado Clinical and Translational Sciences Institute (CCTSI) aims to translate discovery into clinical practice. The Partnership of Academicians and Communities for Translation (PACT) represents a robust campus-community partnership.

METHODS

The CCTSI collected data on all PACT activities including meeting notes, staff activity logs, stakeholder surveys and interviews, and several key component in-depth evaluations. Data analysis by Evaluation and Community Engagement Core and PACT Council members identified critical shifts that changed the trajectory of community engagement efforts.

RESULTS

Ten "critical shifts" in six broad rubrics created change in the PACT. Critical shifts were decision points in the development of the PACT that represented quantitative and qualitative changes in the work and trajectory. Critical shifts occurred in PACT management and leadership, financial control and resource allocation, and membership and voice.

DISCUSSION

The development of a campus-community partnership is not a smooth linear path. Incremental changes lead to major decision points that represent an opportunity for critical shifts in developmental trajectory. We provide an enlightening, yet cautionary, tale to others considering a campus-community partnership so they may prepare for crucial decisions and critical shifts. The PACT serves as a genuine foundational platform for dynamic research efforts aimed at eliminating health disparities.

A community translational research pilot grants program to facilitate community--academic partnerships: lessons from Colorado's clinical translational science awards

BACKGROUND

National growth in translational research has increased the need for practical tools to improve how academic institutions engage communities in research.

METHODS

One used by the Colorado Clinical and Translational Sciences Institute (CCTSI) to target investments in community-based translational research on health disparities is a Community Engagement (CE) Pilot Grants program. Innovative in design, the program accepts proposals from either community or academic applicants, requires that at least half of requested grant funds go to the community partner, and offers two funding tracks: One to develop new community-academic partnerships (up to $10,000), the other to strengthen existing partnerships through community translational research projects (up to $30,000).

RESULTS AND CONCLUSION

We have seen early success in both traditional and capacity building metrics: the initial investment of $272,742 in our first cycle led to over $2.8 million dollars in additional grant funding, with grantees reporting strengthening capacity of their community- academic partnerships and the rigor and relevance of their research.

Interdisciplinary rural immersion week

INTRODUCTION

Health professions students interested in future rural practice locations spend a week learning about and investigating all aspects of small town personal, professional and community life. This augments the mainly clinical experience provided by clinical rotations they complete as part of their professional academic training program.

METHODS

Students from professional programs in medicine, physician assistant, pharmacy, nursing, public health and psychology travel to a small community, receive an orientation and in small interprofessional groups investigate health care, education, government, law enforcement, public health, economy and natural resources.

RESULTS

Participants report that the experience raises their interest in future rural practice, answers questions they have about rural life and enhances their understanding of the issues they must learn more about before making a career location choice.

CONCLUSIONS

The interdisciplinary rural immersion program provides students with the time, structure and permission to move out of their clinical 'comfort zone' and think about the cultural, economic and environmental aspects of rural life and work.