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

Abstract

Abstract 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.

Topics & Concepts