This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive Technology, is properly cited. The complete bibliographic information, a link to the original publication on https://rehab.jmir.org/, as well as this copyright and license information must be included.
Occupational therapy (OT) is a vital service that supports older adults’ ability to age in place. Given the barriers to accessing care, video telehealth is a means of providing OT. Even within Veterans Health Administration (VHA), a pioneer in telehealth, video telehealth by OT practitioners to serve older adults is not well understood.
This study examines VHA OT practice using video telehealth with older veterans using an implementation framework.
A web-based national survey of VHA OT practitioners conducted between September and October 2019 contained a mix of mostly closed questions with some open-text options. The questions were developed using the Promoting Action on Research Implementation in Health Services model with input from subject matter experts. The questions gathered the extent to which VHA OT practitioners use video telehealth with older veterans; are comfortable with video telehealth to deliver specific OT services; and, for those using video telehealth with older veterans, the barriers, facilitators of change, and perceived benefits of video telehealth.
Of approximately 1455 eligible VHA OT practitioners, 305 participated (21.0% response rate). Most were female (196/259, 75.7%) occupational therapists (281/305, 92.1%) with a master’s degree (147/259, 56.8%) and 10 years or fewer (165/305, 54.1%) of VHA OT practice. Less than half (125/305, 41.0%) had used video telehealth with older veterans, and users and nonusers of video telehealth were demographically similar. When asked to rate perceived comfort with video telehealth to deliver OT services, participants using video telehealth expressed greater comfort than nonusers, which was significant for 9 of the 13 interventions: activities of daily living (
Most VHA OT survey respondents had not used video telehealth with older veterans. Users and nonusers were demographically similar. Differences in the percentages of respondents feeling comfortable with video telehealth for specific OT interventions suggest that some OT services may be more amenable to video telehealth. This, coupled with the primacy of respondent beliefs versus organizational factors as facilitators, underscores the need to gather clinicians’ attitudes to understand how they are driving the implementation of video telehealth.
Veterans Health Administration (VHA), the largest integrated health care system in the United States, has been using telehealth since the 1990s to provide care to a broadly dispersed veteran population. VHA provides care to veterans who served in military, naval, or air services. Approximately 60% of US veterans are enrolled in VHA care, including more than 90% of those who incurred a service-related disability. The median age of veterans is 65 years, including a large portion of rural veterans [
Video telehealth for specialty care such as occupational therapy (OT) has historically been underdeveloped; of an estimated 1.5 million total VHA OT encounters in fiscal year 2018, less than 1% were delivered using telehealth [
Lack of evidence for OT video telehealth has resulted in a gap in knowledge about how best to integrate video telehealth into OT practice in response to the COVID-19 pandemic [
To optimize the integration of video telehealth solutions, various contextual factors must be considered, according to the Promoting Action on Research Implementation in Health Services (PARIHS) framework. PARIHS was developed as an evaluative framework to support the systematic integration of research findings and intervention strategies into clinical care, thereby enhancing the quality and efficacy of health services [
Given this knowledge gap, this study sought to gather OT practitioners’ experiences with and perspectives on video telehealth to serve older adults. Specifically, we sought to ascertain the extent to which VHA OT practitioners use video telehealth to serve older veterans; VHA OT practitioners’ comfort with video telehealth to deliver specific OT services; and, for those using video telehealth with older veterans, perceived barriers, facilitators of change, and benefits of video telehealth. The aim of this study is to identify barriers and facilitators related to the successful implementation of video telehealth to ensure equitable distribution of this service to older adults.
To gather data, a survey was conducted with a volunteer sample of OT practitioners enrolled in VHA’s national internal OT email listserv groups from a network of 1243 health care facilities, including 170 VA medical centers and 1063 outpatient sites. Inclusion criteria were being either an occupational therapist or OT assistant and treating older veterans, who were defined as those aged 65 years or older. No other exclusion criteria were included. The survey flow and inclusion criteria are shown in
Survey flow diagram. OT: occupational therapy.
Here, we present survey details in accordance with the Checklist for Reporting Results of Internet E-Surveys checklist [
Items were reviewed for face and content validity by 5 subject matter experts in OT, telehealth, and geriatrics care and revised based on feedback. Before the survey launch, 5 VHA OTs (separate from above) pretested the survey, which involved completing the survey draft via the REDCap (Research Electronic Data Capture) link, followed by cognitive interviews conducted by the first author using predetermined verbal probes [
The final survey included 17 survey items (
The survey was conducted in September and October 2019. Practitioners were invited to participate by emailing a survey link to the VHA OT provider listserv and posting on the VHA’s web-based forum for OTs. An anonymous URL link only available on the VA intranet was used. Survey respondents had to be logged into an active VA network account to respond to the survey. The survey was kept open for 4 weeks, with 3 reminder emails and forum posts sent before the survey closed. The email invitation and survey overview specified that participation was voluntary, anonymous, and confidential and that those who agreed to participate agreed to these conditions. Survey data were collected and managed using the REDCap electronic data capture tools hosted at VHA. REDCap is a secure web-based app designed to support data capture for research studies [
Survey data were exported from REDCap into Excel (Microsoft Corporation) and imported into R for analysis. To statistically examine baseline differences in demographics and differences between perceived comfort for those using video telehealth or not, chi-square or Fisher exact tests (when cell counts were <5) were used for categorical variables and two-tailed
Short open-ended responses to barriers, facilitators, and benefits items were analyzed using conventional content analysis [
Overall, from approximately 1455 eligible VHA OT practitioners, 305 participated (21.0% response rate). The survey flow is shown in
Respondents’ characteristics by use of video telehealth with older veterans.a
Demographic variables | Using video telehealth (n=125) | Not using video telehealth (n=180) | |||
|
|||||
|
Male | 12 (12.9) | 21 (13.2) | ||
|
Female | 70 (75.3) | 119 (74.8) | ||
|
Nonbinary | 1 (1.1) | 2 (1.3) | ||
|
Prefer not to answer | 10 (10.7) | 17 (10.7) | ||
|
|||||
|
<5 | 20 (16.0) | 55 (30.6) | ||
|
5-10 | 40 (32.0) | 50 (27.7) | ||
|
11-20 | 46 (36.8) | 52 (28.9) | ||
|
21-30 | 16 (12.8) | 19 (10.6) | ||
|
>30 | 3 (2.4) | 4 (2.2) | ||
|
|||||
|
Associate’s | 4 (4.2) | 4 (2.6) | ||
|
Bachelor’s | 27 (29.0) | 47 (29.5) | ||
|
Master’s | 50 (53.8) | 93 (58.5) | ||
|
Doctorate | 10 (10.8) | 11 (6.9) | ||
|
Prefer not to answer | 2 (2.2) | 4 (2.5) | ||
|
|||||
|
Mean (SD) | 34.2 (23.1) | 31.5 (21.7) | ||
|
Range | 0-82 | 0-95 |
aNot all questions were required. Percentages reflect the proportion of respondents who answered the questions.
bVHA: Veteran Health Administration.
cVAMC: Veterans Affairs Medical Center.
Less than half (125/305, 41.0%) of survey respondents used video telehealth with older veterans. There were no statistically significant differences between respondents using video telehealth and those not using video telehealth according to demographic characteristics. The sample characteristics using video telehealth are shown in
The 9 interventions showing this statistically significant relationship, with sample sizes for users versus nonusers of video telehealth in parentheses (as this question was not required, respondent totals varied), were ADL (nuser=69; nnonuser=67), IADL (nuser=66; nnonuser=101), home safety (nuser=78; nnonuser=117), home exercise or therapeutic exercise (nuser=75; nnonuser=118), wheelchair clinic or seating and positioning (nuser=53; nnonuser=97), durable medical equipment provision or follow-up (nuser=80; nnonuser=115), veteran and/or caregiver education or training (nuser=85; nnonuser=114), education and work (nuser=55; nnonuser=97), and assistive technology provision or follow-up (nuser=69; nnonuser=101). No significant relationships between comfort and use of video telehealth were found for the interventions of sensory or cognitive strategies (nuser=52; nnonuser=90), social participation (nuser=52; nnonuser=101), leisure (nuser=52; nnonuser=103), and rest and sleep (nuser=51; nnonuser=100).
Responses from occupational therapists using video telehealth to the questions “What, if any, barriers have you encountered in adding video telehealth to your practice?” and “What has helped you to add video telehealth to your practice?” (n=74).a
Question category | Responses, n (%) | |
|
||
|
Inadequate space, physical locations, and related equipment | 37 (50) |
|
Delays in process to set up video telehealth (eg, clinic creation and establishing TSAb) | 35 (47) |
|
Lack of administrative support (eg, assistance with scheduling and setting up clinics) | 26 (35) |
|
Other | 23 (31) |
|
None | 19 (26) |
|
Lack of leadership support | 6 (8) |
|
||
|
Belief that video telehealth with improve veterans’ access to care | 77 (83) |
|
Willingness to try new approaches | 76 (82) |
|
Belief that video telehealth will improve veteran care | 62 (67) |
|
Leadership support | 54 (58) |
|
Administrative support (eg, assistance with scheduling and setting up clinics) | 47 (51) |
|
Adequate space, physical locations, and related equipment | 40 (43) |
|
Other | 2 (2) |
|
None | 1 (1) |
aItems rank ordered by the most frequent barrier or facilitator. Totals may exceed 100%, as respondents could select more than one option. Percentages reflect the number of respondents who selected a given option divided by the number of respondents who answered the question.
bTSA: telehealth service agreement.
Reported facilitators, which included both organizational factors and practitioner beliefs, are given in
Response to the question “As a practitioner, what benefits do you experience from using video telehealth with Veterans?”a
Benefit | Responses, n (%) |
I can see veterans who live a distance from VAb | 87 (94) |
I can see veterans who have difficulty coming to VA | 87 (94) |
I get a view into veterans’ homes | 63 (68) |
I can see more veterans | 39 (42) |
I can see veterans more often | 29 (32) |
Other | 7 (8) |
None | 0 (0) |
aItem rank is ordered by most frequent benefit. Totals may exceed 100%, as respondents could select more than one benefit. Percentages reflect the number of respondents who selected a given benefit divided by the number of respondents who answered the question.
bVA: Veterans Affairs.
Most VHA OTs who responded to the survey had not used video telehealth with older veterans, with those using video telehealth demographically similar to those not using video telehealth. Differences in comfort with video telehealth for specific OT interventions suggest that some OT services may be more amenable to video telehealth. This, coupled with our finding that respondent beliefs were more pronounced than organizational factors as facilitators, suggests the importance of clinicians’ attitudes in the implementation of video telehealth.
This is the first study to provide insights into the state of OT video telehealth with older adults, a population of heightened interest because of changing demographics and their increased risk of complications and infections related to COVID-19 [
Although most respondents were not, at the time of the survey, using video telehealth with older adults, users and nonusers were demographically similar. Given that the highest rated facilitators to and benefits of video telehealth by users included clinicians’ attitudes toward video telehealth, such as the belief that video telehealth would increase access to care, emphasis on perceived benefits could help encourage OT practitioners hesitant to try video telehealth. However, we did not ask those using video telehealth about attitudinal barriers, such as perceived harm or negative impact of video telehealth in terms of decreased privacy or limitations of what can be clinically done in video telehealth. Thus, it is difficult to draw further conclusions about clinicians’ attitudes toward video telehealth from these data.
Regarding respondent comfort using video telehealth for specific areas of OT practice, differences between users and nonusers indicate that using video telehealth may enhance comfort with video telehealth. However, the causal relationship between respondent comfort and use of video telehealth is not clear, that is, Does the use of video telehealth enhance comfort or do those who are more comfortable with the technology opt to use video telehealth? This relationship should be examined in future studies.
Interventions receiving higher ratings of
In addition, lower comfort for leisure and social participation is noteworthy, given the strongly established role of OT in these areas [
The findings suggesting that certain OT interventions may be more amenable to a video telehealth platform than others warrant further investigation as to clinician decision making around video telehealth. Both those using video telehealth and those not yet using it felt comfortable with the idea of using video telehealth to provide veteran or caregiver education and training. This may reflect either increased comfort with the use of video telehealth to support interventions relying primarily on verbal engagement or the ubiquity of educational strategies to accompany OT interventions. Relatedly, high percentages of feeling comfortable in using video telehealth for home safety is an interesting finding, given that video telehealth home safety evaluations are complex and may require a caregiver or the patient to ambulate through the home while carrying a portable computing device [
Given that older adults may have less confidence in operating technology and more mobility limitations, OT interventions delivered through video telehealth, particularly more dynamic interventions such as home safety evaluations, should be optimized to meet older adults’ needs. Identifying strategies to train and prepare veterans to participate in OT-delivered video telehealth (eg, how to take measurements during a home safety evaluation or how to position the camera to allow for a full-body view when observing functional mobility) may facilitate the implementation of video telehealth. In addition, certain populations may have complex care needs, which hamper their ability to participate in video telehealth. Caregiver assistance, particularly for adults who have cognitive impairment or are at risk of falls, may also be needed. Promoting eHealth literacy and co-designing interventions to match technology with older users’ needs will optimize telehealth delivery [
Perceived benefits, which primarily focused on increased access, corroborate VHA’s organizational mission to use video telehealth to increase access to care. Access was partly related to travel distance; however, open-ended responses suggested that access was more broadly conceptualized to include the ability for more timely care and for more care coordination. For example, practitioners noted that video telehealth allowed them to involve different members of the care team. Older adults often manage multiple chronic conditions that require ongoing intervention by several clinicians. Therefore, video telehealth may increase opportunities for interdisciplinary collaboration to address care needs. This may be even more relevant at times such as during the global pandemic when video telehealth is virtually the only option for face-to-face care. Similarly, these findings raise factors relevant to health care systems that aim to integrate video telehealth OT services.
Given the dynamic nature of many OT interventions, an important organizational consideration is the inclusion of technical support for both OTs and older adults. Technical support as an organizational component of video telehealth may be more critical for OT than other, more stationary video telehealth encounters. Mental health video telehealth, for example, consists of mostly verbal exchange, whereas OT interventions may involve veterans working on a cooking task in the kitchen or transferring in and out of the bathtub. This raises potential problems around bandwidth and lost visual or audio that may require the involvement of technical support, in addition to the aforementioned safety concerns.
Barriers and facilitators reveal additional organizational considerations in the delivery of OT services using video telehealth, beyond the aforementioned need for technical support. Lack of physical space (the most frequent barrier and least reported facilitator) may reflect the fact that OTs are often treating in shared spaces such as rehabilitation gyms, unlike mental health clinicians who usually have private offices. This highlights the need to consider infrastructure and privacy in the implementation of video telehealth for OT services; however, allowing practitioners to deliver video telehealth from home would lessen space demands. This study also has implications for clinician education and training to ensure that interprofessional trainees are prepared to offer telehealth to older adults [
This study had several limitations. Regarding survey design, we did not ask practitioners using video telehealth to reflect on barriers such as potential harm, safety risks, disruptions related to video telehealth, increasing workload, or necessary time and training to familiarize themselves with technology, which limits the scope of our findings. As we cannot demonstrate causality between comfort and use of video telehealth, more in-depth surveys or qualitative interviews with OTs may elucidate perceived primary causal issues for comfort as well as perceived barriers and facilitators. The lack of description for certain OT interventions listed in the survey (eg, sensory or cognitive strategies) results in difficulty interpreting some comfort ratings. Nonrespondent bias may also constrain generalizability, as practitioners may have felt pressured to participate or those with a strong interest may have been more likely to participate in the survey. We did not collect data on age, and although years of practice is informative, it is not a proxy for age. Finally, we did not ask whether video telehealth was conducted into the home or between major medical centers and satellite clinics, thereby limiting what conclusions can be drawn regarding video to home, a main telehealth strategy in the post-COVID-19 landscape.
On the basis of our findings, the following are some key implications for implementation of video telehealth in delivering OT services to older adults. Implications reflect the myriad contextual factors vital to ensuring that video telehealth meets the needs of both OT clinicians and patients:
Perspectives of early OT adopters of video telehealth, including perceived facilitators, may inform those not yet using video telehealth.
The benefit of video telehealth in increasing access to care may encourage increased use of video.
Gathering practitioner decision making around the use of video telehealth for specific OT interventions will optimize delivery to clients who face access barriers, increasing the reach of extant providers while potentially saving resources such as clinic space.
OT practitioners may have unique infrastructure needs, including dedicated private spaces and need for technical support, in the provision of services using video telehealth.
Video telehealth with older adults as a service delivery model is rapidly expanding, with VHA at the forefront. Early adoption of video telehealth by VHA OT practitioners appears to be driven, in some measure, by clinician experiences and attitudes; however, institutional barriers remain. As the pandemic offered a model of veterans and some clinicians participating in video telehealth from their own homes, institutional barriers such as limited space may be less of a concern in the post-COVID era. Expansion of video telehealth to deliver services to older adults will involve identifying ways to maximize the video telehealth platform through adaptation and tailoring of interventions to provide client-centered care. There is a need for more evidence on video telehealth OT strategies for older adults, which COVID-19 and resulting OT rapid practice change may expedite.
Survey questions.
Comfort with video telehealth for occupational therapy services for video users and nonusers.
Comfort ratings by use of video telehealth.
activities of daily living
instrumental activities of daily living
Maintaining Internal Systems and Strengthening Integrated Outside Networks
occupational therapy
Promoting Action on Research Implementation in Health Services
Research Electronic Data Capture
Veterans Affairs
Veterans Health Administration
This material is the result of work supported with resources and the use of facilities at the VA Bedford Health Care Center and New England Geriatric Research Education and Clinical Center. The contents do not represent the views of the US Department of Veterans Affairs or the US Government. This work was also supported by a Virginia Auty Nedved-Cook BSOT 52 Endowed Student Research Award. The authors would like to thank Dr Scott Slotnick for his statistical assistance.
None declared.