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Published Online: 2 June 2022

Differential Impact of COVID-19 on the Use of Tele–mental Health Among Veterans Living in Urban or Rural Areas

Abstract

Objective:

The authors examined the use of Veterans Affairs Video Connect (VVC) for mental health care by rural and urban veterans and the impact of the COVID-19 pandemic on patterns of VVC use.

Methods:

Data from 557,668 rural and 1,384,093 urban veterans (collected July 2019–October 2020) from the Veterans Health Administration Corporate Data Warehouse were examined with interrupted time-series models to determine rural versus urban VVC use before and during the initial 7 months of the pandemic.

Results:

Before COVID-19, rates of VVC use as percentages of all mental health care were higher among rural veterans. After implementation of pandemic restrictions, rural veteran VVC use continued to increase, but this increase was surpassed by that of urban veterans.

Conclusions:

These findings highlight the need to monitor emerging disparities in telehealth use and to encourage and support use of VVC and access to mental health care for all veterans, particularly those experiencing barriers to care.

HIGHLIGHTS

Restrictions to in-person mental health care during the COVID-19 pandemic led to a rapid overall increase of telehealth.
However, rural veterans received a lower percentage of mental health care via telehealth during the initial 7 months of the pandemic compared with urban veterans.
Technological solutions can allow for rapid transition to new service delivery systems in times of need, but emerging gaps in service delivery need to be identified to provide equitable care.
The U.S. Department of Veterans Affairs (VA) has been a leader in expanding access to high-quality mental health care (1). However, compared with urban veterans, rural veterans experience barriers to receiving high-quality mental health care, including fewer available providers (2), limited information technology infrastructure (3), travel limitations (4), concerns regarding confidentiality in smaller communities (4), logistical concerns (e.g., time off work or child care coverage in smaller communities) (4), and personal factors (e.g., attitudes and beliefs) (5). Additionally, rural veterans tend to be older (≥65 years) with complex medical conditions (6), further complicating care.
Telehealth has been helpful in connecting rural veterans to mental health care services and in improving patient outcomes (7), yet many rural veterans continue to experience disparities in care. Rural providers often may be the only mental health provider in their clinic and are therefore isolated from peers and from educational or supportive resources. For these reasons, rural veterans may receive less care and have access to fewer types of specialty care (8).
Notably, telehealth effectively delivers mental health care, with outcomes comparable to those of in-person care (9). VA resources have been allocated to promote the growth of VA Video Connect (VVC) in rural, underresourced areas and to offer more options for care (9). This effort has resulted in increased use of VVC by rural veterans, suggesting that the VVC has connected them to care they may not have otherwise received. At the onset of the COVID-19 pandemic, many clinics, both urban and rural, swiftly transitioned to virtual care and increased VVC adoption. Despite the increased resource allocation, the impact of rapid VVC expansion on rural veterans’ mental health care is unknown, especially in relation to their urban counterparts. The aim of this study was to examine VVC use by rural and urban veterans and to examine the impact of the COVID-19 pandemic on VVC use.

Methods

Data were obtained between July 2019 and October 2020 through the Corporate Data Warehouse, the Veterans Health Administration’s (VHA’s) national administrative database. A national cohort of patients receiving VHA care was identified by selecting records of veterans receiving at least one outpatient mental health visit during the data-capture period. Mental health clinic stops (500 series), a coding system for determining types of care provided, were used to identify mental health. Demographic data, including rurality (i.e., geocoded patient location generated through a spatial intersection process), were obtained through this database. This process, developed by VHA, designates areas as urban, rural, or highly rural; urbanized areas are defined in accordance with the U.S. Census Bureau’s definition (≥2,500 residents), and highly rural areas are defined as nonurban areas of counties with population density of less than seven people per square mile (10). The final cohort included 557,668 rural veterans (with 5,120,166 encounters across 16 months) and 1,384,093 urban veterans (with 15,681,360 encounters across 16 months). The study was approved by the institutional review boards of the Michael E. DeBakey VA Medical Center and the Baylor College of Medicine.
We began by examining differences between rural veterans (consisting of both rural and highly rural veterans) and urban veterans in demographic characteristics, by using an independent samples t test for age and chi-square tests for gender and race-ethnicity. We then conducted two single interrupted time-series analyses: one for rural veterans and one for urban veterans. For each group, we evaluated a change in the percentage of VVC mental health encounters over time, how the pandemic affected this percentage, and how the pandemic’s impact continued during the first 7 months of the pandemic. For each month, the percentage of VVC mental health encounters was calculated by dividing the number of VVC mental health encounters for that month by the total number of mental health encounters in the same month. We separately evaluated a change in the rate of VVC use at the population level for rural and urban veterans, so that any confounding by individual-level variables would not introduce serious bias (11). Phase was coded as 0 for July 2019 to March 2020 (pre–COVID-19 period) and as 1 for April to October 2020 (COVID-19 period). Because of the structure of the available data (i.e., aggregated monthly, so we were unable to separate days within a given month), March 2020 was included in the pre–COVID-19 period—formal restrictions to in-person care were released in the middle of that month. April 2020 therefore represented the first full month with COVID-19 restrictions. We also coded time sequentially for the 16 months to control for the effect of secular trends, with July 2019 coded as 1 and October 2020 coded as 16. We then sequentially coded the time since the start of the pandemic to capture its continuing effect over successive periods, with April 2020 coded as 1 and October 2020 coded as 7. For each patient group (i.e., rural and urban), we used segmented regression (using PROC AUTOREG in SAS, version 9.4) to measure changes in the percentage of VVC mental health encounters from before the pandemic to during the pandemic, as well as the slope of change during the first 7 full months of the pandemic, with each analysis controlled for the secular effect of time. The percentage of VVC mental health encounters served as the dependent variable; predictors included time (i.e., 1–16), phase (pre–COVID-19 vs. during COVID-19), and time since the COVID-19 pandemic began. Maximum likelihood estimation was used to estimate the population parameters. We calculated effects (i.e., the secular effects of time, phase, and time since the pandemic began) separately for rural and urban veterans and then compared them by calculating 95% confidence intervals (CIs) around each regression estimate. A notable difference between rural and urban veterans was apparent when a given regression coefficient for one group did not fall within the 95% CI for the regression coefficient interval for the other.

Results

Compared with urban veterans, rural veterans were older and more likely to be male and non-Hispanic White; however, effect sizes were small (see Table S1 in an online supplement to this report). Figure 1 shows the unadjusted percentage of VVC mental health encounters by month and by rural or urban location. As shown in the figure, between July 2019 and February 2020, rates of VVC use were between 1.5% (i.e., urban veterans in July 2019) and 3.8% (i.e., rural veterans in February 2020) and were consistently higher for rural than for urban veterans. For example, in February 2020, the percentage of VVC mental health encounters was 3.8% for rural veterans and 2.2% for urban veterans. At the start of and during the COVID-19 pandemic, rates of VVC quickly increased among both rural and urban veterans. In March and April 2020, percentages of VVC mental health encounters were 7.9% and 18.5% (respectively) for rural veterans and 6.8% and 18.4% (respectively) for urban veterans. By May 2020, the percentage of VVC mental health encounters was greater among urban veterans than among rural veterans (22.3% for urban vs. 22.2% for rural); this difference increased each month through October 2020, when the percentage of VVC mental health care was 31.9% for urban veterans and 28.5% for rural veterans.
FIGURE 1. Mean percentage of mental health encounters of veterans through U.S. Department of Veterans Affairs’ Video Connect (VVC) over time, by rural or urban location
We observed a significant effect of time during the 16 months for both rural and urban veterans. (See Table S2 in the online supplement for results of segmented regression analyses for urban and rural veterans.) On average, the percentage of mental health visits that were held via VVC increased by 0.4% each month. Importantly, we noted significant effects of phase and time since the pandemic started for both urban veterans (phase: percentage of mental health encounters via VVC [b]=13.5, 95% CI=10.8–16.2, p<0.001; time since the pandemic started: b=1.8, 95% CI=1.3–2.4, p<0.001) and rural veterans (phase: b=12.9, 95% CI=10.5–15.3, p<0.001; time since the pandemic started: b=1.2, 95% CI=0.6–1.7, p=0.005). The results indicated that the percentage of VVC mental health encounters significantly increased during the first 7 months of the pandemic for both urban and rural veterans. The increase over the first 7 months of the pandemic was greater for urban than for rural veterans: the CIs for the 1.2% monthly increase for rural veterans did not contain 1.8, and the CIs for the 1.8% monthly increase for urban veterans did not contain 1.2.

Discussion

The VVC program is key for reaching underserved rural veterans. VVC has been deployed throughout the VA health care system, but particular attention has been paid to using VVC to reach rural veterans, who, even in typical times, experience unique barriers to care (4). Before the COVID-19 pandemic, rural veterans received a larger proportion of their mental health care via VVC than did their urban counterparts. However, after widespread changes throughout the VA system provoked by the pandemic, urban veterans received a greater proportion of their care by VVC than did rural veterans. VVC use grew in both groups during the pandemic. Taken together, these findings suggest that, although both groups increased the percentage of VVC care received, barriers to a rapid transition to telehealth delivery may have affected rural areas more than urban areas.
The barriers affecting rural mental health care, and tele–mental health care in general, may have also influenced transitions to telehealth in rural areas during the pandemic. First, characteristics of rural areas may have played a role. Rural individuals have less access to broadband Internet and, when it is available, it is often unaffordable (12). Thus, rural veterans may not have been able to quickly shift their modality of mental health care delivery during the pandemic to the same degree as urban veterans did.
Second, fewer rural and older veterans report owning a smartphone or tablet (13), possibly limiting their access to tele–mental health. VA programs provide devices and Internet access for mental health care and support veterans in getting set up on both personal and VA-loaned devices; these programs have had great success in connecting veterans to care (14). However, longer time frames associated with requesting, receiving, and learning how to use such devices may dampen rapid transition to primarily telehealth delivery in rural areas. Interestingly, even though staffing of VA programs and training of veterans were barriers to full utilization of these tablet programs, older veterans were more likely to use VA-supplied tablets than were younger veterans (14). Moreover, rural veterans have shown more negative attitudes toward using smartphones and applications than urban veterans, possibly further exacerbating the rural-urban service divide (13).
Several limitations of this study must be considered. We used national VA data, and regional and local guidance regarding telehealth and in-person appointments varied. Additionally, our data could not capture variations in community spread of the COVID-19 virus, for example, differences in VVC uptake caused by early surges of COVID-19 in urban areas (15). It is possible that urban areas saw a larger increase in VVC use because of differential community infection rates. Thus, our conclusions may not apply to all rural or urban sites. Future work would benefit from examining how the contexts of different sites influenced VVC use during the COVID-19 pandemic. Furthermore, our data were aggregated monthly and so could not be used to explore the impact of specific dates (i.e., when COVID-19–related restrictions were issued). The outcome variable, percentage of VVC mental health encounters as a proportion of total mental health services, was especially useful for understanding VVC uptake in the context of other modalities of mental health delivery; however, our variable could not be used to consider other modalities whose use may have increased or decreased during the pandemic, depending on a site’s response to COVID-19 restrictions (e.g., telephone-based sessions, in-person sessions, or use of other video platforms).

Conclusions

The COVID-19 pandemic drastically changed the landscape of mental health care provision throughout the VA and the country. Telehealth grew strongly as restrictions on in-person care became widespread. Despite this rapid increase, rural veterans—a group that previously had high use of VVC—received a lower percentage of care via VVC after the pandemic’s onset than did urban veterans, and this gap widened. Although the gap was modest, continued attention to VVC growth is warranted to ensure that all service user groups have equal access to care. Rapid transition to new technologies and delivery systems has been an important development, and it remains an important goal of health care systems to be able to implement such solutions equitably.

Supplementary Material

File (appi.ps.202100363.ds001.pdf)

References

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Karlin BE, Cross G: From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. Am Psychol 2014; 69:19
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Holder KA: Veterans in Rural America: 2011–2015. Washington, DC, US Department of Commerce, Economics and Statistics Administration, US Census Bureau, 2017
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Cheney AM, Koenig CJ, Miller CJ, et al: Veteran-centered barriers to VA mental healthcare services use. BMC Health Serv Res 2018; 18:1–14
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Fischer EP, McSweeney JC, Wright P, et al: Overcoming barriers to sustained engagement in mental health care: perspectives of rural veterans and providers. J Rural Health 2016; 32:429–438
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Hicken B, Seaman AT, Moo L: Gaps and opportunities to improve access to healthcare for older rural veterans. Innov Aging 2019; 3:S388
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Cully JA, Jameson JP, Phillips LL, et al: Use of psychotherapy by rural and urban veterans. J Rural Health 2010; 26:225–233
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McClellan MJ, Osbaldiston R, Wu R, et al: The effectiveness of telepsychology with veterans: a meta-analysis of services delivered by videoconference and phone. Psychol Serv (Epub ahead of print, Feb 4, 2021). doi: 10.1037/ser0000522
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Defining “Rural” Areas. Suitland, MD, US Department of Commerce, Economics and Statistics Administration, US Census Bureau, 2020. https://www.census.gov/content/dam/Census/library/publications/2020/acs/acs_rural_handbook_2020_ch01.pdf
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Connolly SL, Miller CJ, Koenig CJ, et al: Veterans’ attitudes toward smartphone app use for mental health care: qualitative study of rurality and age differences. JMIR Mhealth Uhealth 2018; 6:e10748
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Zulman DM, Wong EP, Slightam C, et al: Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans. JAMIA Open 2019; 2:323–329
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Rural Death Rates From COVID-19 Surpassed Urban Death Rates in Early September 2020. Washington, DC, US Department of Agriculture Economic Research Service, 2021. www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=100740. Accessed March 11, 2022

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 1393 - 1396
PubMed: 35652189

History

Received: 15 June 2021
Revision received: 1 September 2021
Revision received: 17 November 2021
Revision received: 25 March 2022
Accepted: 31 March 2022
Published online: 2 June 2022
Published in print: December 01, 2022

Keywords

  1. Veterans issues
  2. Telehealth
  3. Service disparity
  4. Telecommunications

Authors

Details

Julianna Hogan, Ph.D. [email protected]
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).
Amber B. Amspoker, Ph.D.
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).
Annette Walder, M.S.
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).
Joshua Hamer, Ph.D.
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).
Jan A. Lindsay, Ph.D.
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).
Anthony H. Ecker, Ph.D.
U.S. Department of Veterans Affairs (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston (all authors); VA South Central Mental Illness Research, Education and Clinical Center, Houston (Hogan, Amspoker, Walder, Lindsay, Ecker).

Notes

Send correspondence to Dr. Hogan ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Funding Information

This work was supported by the VA Office of Rural Health; the South Central Mental Illness Research, Education and Clinical Center; and the Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (CIN13-413).The views in this report represent the opinions of the authors and not necessarily those of the VA or the U.S. government.

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