Abstract Background Food insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices. Methods We conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes. Results Participants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were “very important” for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming. Conclusions Rural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI.
Rural communities need access to effective interventions that can prevent functional decline among a growing population of older adults. We describe the conceptual framework and rationale for a multicomponent intervention (“Mind, Mood, Mobility”) delivered by Area Agency on Aging staff for rural older adults at risk for functional decline due to early impairments in cognition, mood, or mobility. Our proposed model utilizes primary care to identify at-risk older adults, combines evidence-based interventions that address multiple risk factors simultaneously, and leverages a community-based aging services workforce for intervention delivery.
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.In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits.A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges.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.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).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.
Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.
To facilitate access to telehealth services among Veterans enrolled in Veterans Health Administration (VHA) care during the COVID-19 pandemic, in August 2020 VHA implemented a national Digital Divide (DD) Consult. Through this consult, Veterans without reliable internet access or video-capable devices can receive a loaned internet-connected device and/or assistance applying for federal internet subsidies. VHA lacks a way, however, to systematically identify Veterans who would benefit from a DD Consult.
Objective:
To develop and integrate digital needs screening questions into an existing VHA social risk screening and referral program, “Assessing Circumstances & Offering Resources for Needs” (ACORN).
Study Design:
Cross-sectional pilot.
Setting:
Two rural VA primary care clinics.
Population Studied:
Veterans seen by primary care social work between July-September 2021.
Intervention:
Digital needs screening questions were developed with input from an interprofessional group of clinicians and subject matter experts, and refined through cognitive testing with Veterans. Questions assessed access to a phone, tablet, and/or computer; access to reliable and affordable internet; running out of phone minutes and/or data before the end of the month; interest in assistance setting up a telehealth visit; and need for help learning to use a device for a telehealth visit. Social workers routinely administered the expanded ACORN screening tool to Veterans as part of an intake assessment.
Outcome Measures:
1) prevalence of reported digital needs and 2) DD Consult placed in the prior 12 months (y/n).
Results:
Of 156 Veterans screened, 45% reported >=1 digital need. Twenty-two percent reported not having access to a device, 13% lacked reliable and affordable internet, and 3% reported often or sometimes running out of phone minutes and/or data. Thirteen percent of Veterans were interested in help setting up a telehealth visit; of those, 55% needed help learning to use a device. Among Veterans with a digital need, only 4% had a DD Consult placed in the prior 12 months.
Conclusions:
Nearly half of rural Veterans in our pilot screened positive for >=1 digital need. The vast majority of Veterans identified as having a digital need had not previously had a DD Consult placed. Routine screening for digital needs is a critical step towards connecting Veterans with needed technology resources and informing future resource allocation in VHA.
Importance Telehealth can expand access to care, but digital needs present barriers for some patients. Objective To investigate sociodemographic and clinical associations of digital needs among veterans. Design, Setting, and Participants This quality improvement study used data collected between July 2021 and September 2023 from Assessing Circumstances and Offering Resources for Needs (ACORN), a Department of Veterans Affairs (VA) initiative to systematically screen for, comprehensively assess, and address social risks and social needs. Eligible participants were veterans screened for social risks and social needs during routine care at 12 outpatient clinics, 3 emergency departments, and 1 inpatient unit across 14 VA medical centers. Data analysis occurred between October 2023 and January 2024. Exposure The ACORN screening tool was administered by clinical staff. Main Outcomes and Measures Veterans were considered positive for a digital need if they reported no smartphone or computer, no access to affordable and reliable internet, running out of minutes and/or data before the end of the month, and/or requested help setting up a video telehealth visit. Results Among 6419 veterans screened (mean [SD] age, 67.6 [15.9] years; 716 female [11.2%]; 1740 Black or African American [27.1%]; 202 Hispanic or Latino [3.1%]; 4125 White [64.3%]), 2740 (42.7%) reported 1 or more digital needs. Adjusting for sociodemographic and clinical characteristics, the adjusted prevalence (AP) of lacking a device among veterans aged 80 years or older was 30.8% (95% CI, 27.9%-33.7%), 17.9% (95% CI, 16.5%-19.2%) among veterans aged 65 to 79 years, 9.9% (95% CI, 8.2%-11.6%) among veterans aged 50 to 64 years, 3.4% (95% CI, 2.1%-4.6%) among veterans aged 18 to 49 years, 17.6% (95% CI, 16.7%-18.6%) for males, and 7.9% (95% CI, 5.5%-10.3%) for females. AP of lacking affordable or reliable internet was 25.3% (95% CI, 22.6%-27.9%) among veterans aged 80 years or older, 15.0% (95% CI, 12.1%-18.0%) among veterans aged 18 to 49 years, 31.1% (95% CI, 28.9%-33.4%) for Black or African American veterans, 32.1% (95% CI, 25.2%-39.0%) for veterans belonging to other racial groups (ie, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, as well as those with more than 1 race captured in their medical record), and 19.4% (95% CI, 18.2%-20.6%) for White veterans. Veterans with dementia were at higher risk of lacking a device (adjusted relative risk [aRR], 1.21; 95% CI, 1.00-1.48). Veterans with high medical complexity were at higher risk of lacking internet (aRR, 1.26; 95% CI, 1.11-1.42). Veterans with dementia (aRR, 1.58; 95% CI, 1.24-2.01) or substance use disorder (aRR, 1.22; 95% CI, 1.00-1.49) were more likely to want help scheduling a telehealth visit than those without. Conclusions and Relevance In this quality improvement study of veterans screened for social risks and social needs, there were substantial disparities in digital needs. These findings suggest that routine screening is important to understand patients’ digital access barriers and connect patients with telehealth resources to address inequities in health care.
