Veterans Hospital Administration Telehealth Utilization for Recreation and Creative Arts Therapies: A Brief Report

Introduction

The United States Veterans Health Administration (VHA) began implementation and testing of telehealth in 2003 and telehealth services have risen rapidly this past year.¹ For example, there was a 1,653% increase in weekly video visits from February 2020 to November 2020 with >40,000 telehealth visits completed daily.² Since the coronavirus disease 2019 (COVID-19) pandemic, telehealth is increasingly being implemented across disciplines.^3–5 Recreation therapy (RT) and creative arts therapy (CAT) are provided as an integral part of Veteran care and employ complementary and alternative health interventions to support physical and psychological health (i.e., functional outcomes in cognitive, physical, psychosocial/emotional, social, and leisure domains). Examples of RT interventions are crafts, nature groups, sports, or exercise groups including yoga and Tai Chi. CAT comprises art, dance, drama, music, and poetry with art therapy and music therapy being the most frequently used mediums at the VHA. The majority of RT and CAT services are in-person, but virtual RT and CAT were being implemented before the COVID-19 pandemic and have rapidly increased in the last year to provide continuation of care and support the needs of Veterans.^6–8 The objective of this quality improvement study was to conduct a nationwide assessment of VHA RT and CAT telehealth utilization to inform strategic planning that will support training, protocol development, equipment, and guidance for better telehealth implementation.

Materials and Methods

A cross-sectional semistructured survey was deployed to 136 facilities across 18 U.S. regions known as Veterans Integrated Service Networks (VISNS). The facilities employ ∼986 full-time equivalent (FTE) RT and CAT therapists. A point of contact from each facility was identified by the National Rehabilitation and Prosthetic Service, Recreation Therapy Service and contacted by e-mail to complete the online survey. Points of contact for facilities were primarily an RT/CAT service chief, supervisor, or lead therapist. In smaller facilities without a direct supervisor, the seniormost therapist was the point of contact. The brief survey included both close-ended (six items) and open-ended (four items) questions. Summary statistics were calculated. For duplicate responses from a facility (n = 5), only the most recent response was included for calculating facility-level variables. For other variables, all responses were included in analyses. We conducted a thematic content analysis using the open-ended survey responses and frequencies of themes were tabulated. An iterative process was used to identify themes. A primary coder with CAT expertise applied the themes, and a secondary coder reviewed them for accuracy. Any disagreement between coders was discussed and consensus reached. This query that collected facility level data was designated a quality improvement project and did not require approval by an Institutional Review Board.

Results

A total of 97 responses were returned between November 5 and November 25, 2020, yielding a response rate of 71% from facilities. The responses represent 17 of 18 VISNS and 667 FTE RT and CAT therapists. Table 1 provides a summary of results from close-ended questions. The median number of FTE RT and CAT therapists per facility was 6 (interquartile range 3–9). Some respondents included therapy assistants in their totals and some combined two half-time therapists into a response of one FTE. Approximately 67% reported more than half of their RT/CAT FTEs were telehealth capable; however, 19% of facilities reported 0% of their FTEs were telehealth capable. The majority of facilities (61%) reported having the clinical grid installed to capture proper clinic workload; the remaining facilities either did not (22%) or were unsure (17%). Respondents reported staff comfort level with telehealth on the higher end of the scale (median = 7), with 14% reporting 10 for comfort (scale 1–10, with 10 indicating the most comfortable).

Barriers to Telehealth Delivery

The most consistently reported barrier to telehealth utilization was Veteran’s lack of understanding (33%). For this question related to barriers, respondents could also complete an open-ended text field to indicate other barriers. Among these responses, lack of administration support (4%) and setting or environmental restrictions (10%), such as inpatient services only or lack of private office space to facilitate sessions, were identified as barriers to telehealth delivery of RT/CAT. Two responders indicated that they did not have barriers or were easily able to overcome them, and one response indicated difficulty with medical record documentation and a stop code for administrative purposes. The most used telehealth services were therapy interventions (66%) and assessments (54%).

Improving Staff’s Comfort with Telehealth Delivery of RT/CAT in VHA

Thematic analysis of 110 suggestions for improving staff’s comfort with telehealth delivery of RT/CAT yielded 5 themes (Table 2). The most frequent themes for increasing comfort were training (36%), experience (26%), and having the proper equipment/stable internet connections (21%). Many requests favored hands-on training that included examples and models of best practices. Five responders reported having no need to increase staff’s comfort level and seven wrote in not applicable.

Therapy Interventions

There were 297 identified RT and CAT interventions offered through telehealth. As given in Table 2, therapists reported a wide range of individual and group interventions through telehealth, with interventions having an exercise focus being most frequent (21%). The CAT combined (art, music, and other CAT) comprised 15% of interventions delivered. See Table 3 for a description and detailed activities for each intervention category.

The most frequently requested training topic was for intervention/platform-specific training (22%), such as how to implement telehealth for groups or adaptive sports. However, 25% responded none/not applicable for future training needs. There were additional comments from 49 respondents. Approximately 33% of these comments were positive statements about the use of telehealth and its benefits for Veterans. Many positive comments reflected expanded reach of services to Veterans. Other emergent themes from additional comments were a need for administrative support, Veteran needs related to successful use of telehealth, suggestions for networking, and comments specific to platforms, interventions, staffing, or setting (Table 2).

Discussion

Results from this study support previous findings of identified barriers to telehealth utilization including technology issues and lack of patient knowledge, especially among patients who are older or have limited technology experience.^9,10 Themes that emerged across all responses in this study were training, Veteran barriers, and problems related to equipment or technology. In addition, more regular use and direct experience with different technologies was important for incorporating telehealth into practice. The bridge between training and experience was a frequent request for hands-on training, mentors in the field, and models or protocols to help guide therapists. About one third of respondents reported that Veterans’ lack of understanding was a barrier to telehealth use. In additional comments, there was an expressed need to train Veterans on technology use or troubleshoot technological problems with them. Older Veterans and those with hearing or visual impairment were identified as needing additional support to utilize telehealth services. Alternately, some therapists felt that telehealth allowed certain Veterans to receive services that were not previously accessible. Requests for better equipment, the need for stronger internet connection, and preferences for different platforms were also themes found across questions. However, there was lack of agreement for a specific platform; whereas some requested to continue with WebEx over VA Video Connect (VVC), others stated that Zoom (currently not used) has better technology for facilitating groups. Finally, the need for administrative support (including documentation, additional staff, needs particular to the setting where sessions were facilitated, and support from supervisors) was identified across questions.

A limitation to this study was that individual points of contact for each facility were responding to the survey based on information gathered from multiple RT and CAT therapists at each facility. Although facility-level data provided a rapid and general assessment of current use, it may have failed to capture more nuanced issues pertinent to specific therapists. Follow-up studies are currently underway that will help address these limitations. The first study is a direct survey of all CAT therapists working in the VH, including interviews with a subset of therapists. The second, a pilot study of a telehealth music therapy intervention, will include interviews with Veterans. Findings from these studies will provide more nuanced information about the context in which therapists work and Veteran self-identified facilitators and barriers to their participation in telehealth CAT sessions. In addition, VHA has set up “Digital Divide” consults at each facility to assist Veteran patients with their telehealth connections. Our direct survey study with CAT therapists includes questions on the availability and use of the service that can inform greater integration of CAT services with the Office of Digital Divide as a way to help overcome challenges Veteran’s experience while using telehealth CAT. Other limitations were reliance on self-report and potential issues of generalizability of findings to therapists outside the VHA organization.

Conclusion

Results from facility key informants provided an overview of how telehealth was deployed for the delivery of RT/CAT across VHA. Identified themes across questions were the need for increased training and experience, especially in the form of hands-on training and training that is specific and relevant to the therapists’ services, support, and training to help Veterans understand and use the technology, and support from administration. Moving forward, based on respondents’ feedback, potential solutions from the synthesis of this query include the following:

• Identification of superusers of telehealth to serve as mentors at the VISN level.

• Established networking groups through Microsoft Teams organized by therapist specialty or topic.

• Dedicated positions to deploy RT and CAT telehealth services.

• Workshops and continuing education dedicated to specific interventions or apps.

• Guidelines, protocols, and models for best practices of RT and CAT telehealth delivery.

It is recommended that future research include direct feedback from Veterans, hybrid models that address effectiveness and implementation, and integration with the Office of Digital Divide to improve Veteran access.

Ethical Approval

This study was quality improvement. Ethical Approval was not required.

Authors’ Contributions

H.A.B. and D.O. contributed to the study conception, framing, and data collection. K.M.S. and M.E.F. contributed to the data preparation and extraction, and K.M.S., M.E.F., S.L.R., and T.M.D. to the data analysis. The first draft of the article was written by K.M.S. and M.E.F. All authors commented on the subsequent versions of the article. All authors read and approved the final version of article.

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported in part by the United States (U.S.) Department of Veterans Affairs (VA) Health Services Research & Development Service (HSRD), Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI) (QUE 20-010) and a VA HSRD Research Career Scientist Award for T.M.D. IK6HX002715. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. The funding agency had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.