To the Editor
The COVID-19 pandemic has facilitated increased use of telehealth for primary and specialty care encounters, and recently there have been calls to expand its use in post-acute and long-term care settings.
1
,2
Telehealth expansion is particularly important for rural and underserved populations as it represents a medium to increase access and reduce disparities in health care delivery.3
However, despite the increase in availability, relatively little is known about whether rural older adults are open to using telehealth.Methods
Sample
Participants were adults aged ≥65 years from one clinic affiliated with a network of rural southeastern federally qualified health centers. These clinics serve more than 22,000 primarily rural patients, of which approximately 3000 are aged ≥65 years. Approximately 38% of patients are racial or ethnic minorities: 27% are black and 11% Hispanic/Latino. As part of a larger quality improvement (QI) initiative, older adults who were active patients (n = 357) were contacted for participation in a brief survey. Sixty-five (18.2%) completed the survey (50 by e-mail, 15 by mail). Because this project was deemed QI, institutional review board approval was not required.
Measures
Included in a survey on COVID-19 health care needs and utilization, patients were asked 3 questions about using telehealth: (1) “If available, would you be willing to use video conferencing with members of your healthcare team (ie, a telehealth visit) to receive care or medical advice about your emotional health?” (2) “How would you describe your level of comfort at the prospect of using video conferencing with members of your healthcare team to receive care or medical advice about your emotional health?” (3) “In the future, after the COVID-19 crisis has resolved, which of the following BEST reflects your attitude towards telehealth?” Use of telehealth for mental health care vs all types of health care was emphasized as appropriate in the survey.
Results
Table 1 summarizes descriptive data for each item. Regarding item 1, 37 of 65 (56.9%) indicated that they would not be willing to use telehealth for mental health during COVID-19 compared with 28 of 65 (43.1%) who would. Regarding item 2, nearly half (32/65, 49.2%) indicated being somewhat or very uncomfortable at the prospect of using telehealth for mental health. Regarding item 3, more than one-quarter (17/62, 27.4%) indicated that they would not use telehealth for any health care needs after COVID-19; an equal number (17/62, 27.4%) indicated they would prefer to receive care mostly or all in person. All 28 who indicated a willingness to use telehealth for mental health during COVID-19 also indicated some degree of openness to telehealth for all care as appropriate after COVID-19.
Table 1Older Adults’ Openness to Telehealth Use
| Question | n (%) |
|---|---|
| Willing to use telehealth for emotional health | |
| Yes | 28 (43.1) |
| No | 37 (56.9) |
| Level of comfort using telehealth for emotional health | |
| Very comfortable | 13 (20.0) |
| Somewhat comfortable | 11 (16.9) |
| Neither comfortable nor uncomfortable | 9 (13.8) |
| Somewhat uncomfortable | 7 (10.8) |
| Very uncomfortable | 25 (38.4) |
| Attitude toward using telehealth for all care after COVID-19 | |
| Would receive most or all care by telehealth as appropriate | 8 (12.9) |
| Would receive some care by telehealth | 20 (32.2) |
| Would receive most or all care in person | 17 (27.4) |
| Would not use telehealth | 17 (27.4) |
∗ n = 65.
† n = 62.
Discussion
This brief exploratory QI study queried older, rural adults about openness to using telehealth. Most indicated an unwillingness to use telehealth for mental health, many of whom expressed feeling uncomfortable about the prospect of doing so. Moreover, a majority indicated that they either would not use telehealth for any care or prefer to receive most or all care in person once the COVID-19 crisis subsides.
Recent research regarding openness to using telehealth similarly found that older adults are less willing.
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However, as rural residents may be less likely to access mental health services overall,5
older adults in this sample indicating unwillingness to use and high discomfort with telehealth for emotional needs deserves further study. Indeed, a recent study found that rural residents were more interested in telehealth for mental health than their urban counterparts; however, younger residents and those with greatest existing access to mental health care were most interested.6
Although older adults may be less willing to use telehealth, the present data suggest that a sizable minority are open to its use. Some may be against using it for mental health, but there are other contexts for which telehealth may improve access and quality of care. Older patients are often complex and face numerous physical and behavioral health comorbidities. Given that rural patients often also live in health professional shortage areas and face access challenges to receiving specialized care of all types,
7
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providers and organizations should consider other opportunities to incorporate telehealth into practice. Research shows that negative attitudes toward telehealth utilization are related to exposure and community-based strategies may improve uptake.9
This study is limited by its small convenience sample from a single clinic and limited response rate (18.2%) but provides a valuable snapshot of rural older adults’ attitudes toward telehealth. As its availability is not likely to diminish and infrastructure continues to improve, interventions are needed to increase awareness and engagement in telehealth for older adults, including those that highlight its benefits and provide instruction, particularly for rural residents with limited access to care.
10
References
- Trends in the use of telehealth during the emergence of the COVID-19 pandemic—United States, January–March 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1595
- Innovation through regulation: COVID-19 and the evolving utility of telemedicine.J Am Med Dir Assoc. 2020; 21: 1007-1009
- Connected health: A review of technologies and strategies to improve patient care with telemedicine and telehealth.Health Aff. 2014; 33: 194-199
- Prevalence and characteristics of telehealth utilization in the United States.JAMA Netw Open. 2020; 3: e2022302
- Rural residents with mental health needs have fewer care visits than urban counterparts.Health Aff. 2019; 38: 2057-2060
- The relationship between access to mental health counseling and interest in rural telehealth.J Rural Ment Health. 2021;
- County-level estimates of mental health professional shortage in the United States.Psychiatr Serv. 2009; 60: 1323-1328
- Transforming rural health care: High-quality sustainable access to specialty care.Health Affairs Blog. 2014;
- Feasibility of Internet-delivered mental health treatments for rural populations.Soc Psychiatry Psychiatr Epidemiol. 2014; 49: 275-282
- Utilization barriers and medical outcomes commensurate with the use of telehealth among older adults: Systematic review.JMIR Med Inform. 2020; 8: e20359
Article info
Publication history
Published online: July 13, 2021
Footnotes
This publication was supported in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US Government. The funder had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.
The authors declare no conflicts of interest.
Identification
Copyright
Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
