Increasing Telehealth Visits for Older Veterans Associated with Decreased No-Show Rate in a Geriatrics Consultation Clinic.

INTRODUCTION

Older veterans face many challenges when accessing needed healthcare. Frailty, cognitive impairment, mobility limitations, and financial constraints all increase the likelihood of a “no-show” visit.[1] The rapid shift to telemedicine during the COVID-19 pandemic highlighted the potential for telehealth visits, including both video- and telephone-based assessments, to surmount these barriers to clinic attendance. Although telehealth visits pose their own unique challenges for some older adults, including overcoming limitations posed by sensory and cognitive impairment,[2] older veterans report high satisfaction with telehealth.[3] Here, we report a dramatic decrease in no-show rates for an urban Veterans Affairs (VA) Geriatrics Consultation Clinic (GCC) when the pandemic forced a rapid shift from in-person to virtual care.[4] The GCC provides consultative interprofessional care for veterans 65 and older, typically referred from primary care, through team-based geriatrics assessments focused primarily on the 4Ms of an Age Friendly Health Systems Initiative: Mobility, Mentation, Medication and What Matters.[5] Veterans served by the GCC during this time period were 99% urban and 96% male, and had an average age of 82.5 years. Prior to the pandemic, the GCC offered Telehealth Video visits from VA to VA (known as Clinical Video Telehealth, CVT), and had trialed video to home visits, but starting in March 2020, nearly all geriatrics consultations were offered by telephone or video to home due to the pandemic.

METHODS

The GCC consists of two part-time physicians, one part-time nurse practitioner, one full-time pharmacist, and one full-time social worker along with their respective interprofessional trainees. In March of 2020, high community transmission of SARS-CoV-2 forced the rapid implementation of telephone and video telehealth visits in the GCC in lieu of in-person assessments. Telephone and video geriatrics assessments were conducted by the interprofessional team using the VA’s Veteran’s Video Connect (VVC) platform for video visits. Veterans or caregivers without access to a video-capable device were offered a VA-issued tablet device through the VA’s national Digital Divide program,[6] which offers internet-connected devices as well as phone-based technical assistance (Fig. 1). Encounter information was drawn from VA’s electronic health record encounter data and confirmed with manual clinic data review. The principal outcome measure was the annual no-show rate, defined as the percentage of visits in which patients failed to appear on the day appointments were scheduled. We excluded visits that were cancelled by the clinic and then rescheduled to another modality the same day (for example, a VVC visit that was changed to a telephone visit), and also excluded visits from March 2020 when the telehealth transition occured. No-show rates from before and during the pandemic were compared using X2, and statistical significance was defined as P < .05 Fig. 2.

Figure 1.

Process of scheduling a video visit with an older veteran in the Geriatrics Consult Clinic (GCC). *Veterans served by the GCC may live in facilities including independent and assisted living, and State Run Veterans and Soldier's Homes, but generally not Skilled Nursing Facilities.

Figure 2.

Percentage of monthly no shows and modality distribution in a Geriatrics Consult Clinic(GCC), in the 12 months before and after the COVID-19 pandemic led to a Telehealth Transition.

RESULTS

From March 2019 to February 2020, the GCC performed 857 interprofessional geriatric assessments through 801 in-person visits (93.5%), 50 video visits from VA to VA (CVT, 5.8%), and 6 video to home visits (0.7%), with no scheduled telephone assessments. From April 2020 to March 2021, 1038 visits were completed, including 10 in-person visits (1.0%), 291 video visits (28.0%), 737 telephone assessments (71.0%), and no scheduled CVT visits. The no-show rate decreased from 12.6% in the year prior to the pandemic to 7.8% during the first year of the pandemic, a decrease of 38% (P < .001). The no-show rate for VVC visits (4.3%) was lower than that for telephone assessments (7.4%, P = .06). Digital Divide consults were placed for 48 patients by the GCC (17% of VVC visits), though additional patients in the clinic likely received Digital Divide consults placed by other services. Information was not available as to how many patients had their own devices or required tests calls or technical assistance to conduct a video appointment.

DISCUSSION

A rapid transition from in-person to virtual care led to a dramatic 38% reduction in no-show rates, suggesting that virtual care increased access for older veterans who had difficulty attending in-person appointments. The no-show rate for video visits of 4.3%, though not statistically significant, was consistently lower than that for phone assessments, suggesting that veterans who are able to conduct a video visit may have higher levels of support or motivation. The transition to virtual care was facilitated by the availability of VA-provided tablets and technical assistance. Further study is needed to understand the feasibility and acceptability of video visits among older adults and those living with dementia.[2] The telehealth format also facilitated simultaneous engagement of multiple professions with patients and enabled caregivers to easily participate even if not co-located, which had been more challenging to achieve during in-person visits.[7] More research is required to determine the impact of telehealth on patient and caregiver satisfaction and clinical outcomes, as well as the importance of caregiver and technical team involvement for successful telehealth visits. At the very least, the clinic was able to serve a higher number of veterans because telehealth visits eliminated some of the barriers to in-person care which contributed to no shows. The principal limitation of this study is that observations were derived from a small urban GCC at a single institution with mostly male veteran patients and may not generalize to other clinical settings. The national availability of the VA’s VVC platform and Digital Divide program suggests that a video-based approach is a way of increasing access to interprofessional geriatric care that is both sustainable and scalable nationwide.