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Telehealth Complementary and Integrative Health Therapies During COVID-19 at the U.S. Department of Veterans Affairs

Editor


Introduction

Throughout the COVID-19 pandemic, many health care systems, including the Veterans Health Administration (VA), expanded their provision of telehealth modalities for outpatient care.1–4 The provision of complementary and integrative health (CIH) therapies, such as chiropractic care, meditation, and acupuncture, which are nationally recognized evidence-based nonpharmaceutical options to manage pain, anxiety, and depression,5–,13 also had to quickly pivot to telephone/video during the COVID-19 pandemic.

Very few studies have examined the delivery of CIH therapies through telehealth.14–20 One such study was a randomized controlled trial14 illustrating the effectiveness of teledelivered versus in-person CIH therapies for several outcomes among patients experiencing pain. The benefits of virtual care are patients and providers can continue care in a safe environment; high patient satisfaction with being able to connect remotely for expert advice on home exercises; continued care; and providers’ ability to see patients’ physical home environments and makeshift workspaces, and gather accurate ergonomic information (e.g., home office setup) that otherwise would be unavailable to chiropractors during clinic visits.15–20

These studies also found challenges to the delivery of CIH therapies using telephone/video, which are similar to those for other outpatient telecare services.21,22 These include the potential for misdiagnosis, ethical and privacy concerns, not meeting patients’ expectations, technical difficulties connecting (e.g., internet bandwidth and access to appropriate camera-enabled technology), and lack of a quiet space at patients’ home environments during virtual visits.15–20

In addition, these delivery issues might be further complicated since CIH therapies include both practitioner-delivered (typically one-on-one) and self-care (typically group) services. Therefore, a more in-depth understanding of patients’ use of CIH using telephone/video, delivery issues, and the advantages and disadvantages of using virtual care is needed for both practitioner-delivered and self-care CIH therapies.

This study examines veteran patients’ utilization of self-care and practitioner-delivered CIH therapies using telephone/video, the advantages, and disadvantages of using those, and any health care delivery issues providers and veterans experienced with virtual care during the COVID-19 pandemic. The VA is the ideal setting to examine these issues given they provide more CIH therapies as medical care than any other health care system. Also, the VA is considered a national leader in the provision of telehealth services, with over two decades of experience in virtual care.23–26 This study’s results could be used to help other health care systems to improve their provision of and patients’ experience with CIH therapies and virtual care.

Methods

As part of the larger VA study Assessing Pain, Patient Reported Outcomes and Complementary and Integrative Health (APPROACH) examining the effectiveness of CIH therapies,27 a parallel mixed methods approach was used to examine three aspects of CIH therapies using telephone/video in the VA during COVID-19. First, utilization of these therapies was examined using VA administrative and clinical electronic health care data at 18 VA sites between January 2019 and December 2021 (aka study period), by calculating the quarterly number of in-person and televisits (for practitioner-delivered and self-care, separately).

Second, advantages and disadvantages, and third, health care delivery issues of virtual care were identified using a qualitative analysis of interview data collected from multiple virtual site visits with 70 key stakeholders at 18 VA sites between March 2020 and December 2021.

CIH therapies included three practitioner-delivered CIH therapies (acupuncture, chiropractic care, and massage therapy) and three self-care CIH therapies (Tai Chi, yoga, and mindfulness/meditation). The VA Central Institutional Review Board approved this study.

QUALITATIVE DATA COLLECTION AND ANALYSIS

One-hour semistructured interviews were conducted with key stakeholders who are most knowledgeable about the CIH services being offered at their site. This included CIH providers, Whole Health Program and Clinical Directors, and staff at 18 VA sites. Table 1 gives the number of interviewed key stakeholders by job category. Key stakeholders individually attended an average of one to four virtual site visits. Site visits were conducted to learn about provision of in-person CIH therapies and how sites rapidly pivoted to virtual care during the COVID-19 pandemic. For the qualitative analysis, verbatim interview notes were used as the primary data source.

Table 1. Key Stakeholders by Job Category
JOB CATEGORIES NO. OF KEY STAKEHOLDERS
Whole health clinical director 18
Whole health program director 19
Whole health staff (e.g., nurse manager, administrative officer, data analyst, program assistant, and coach supervisor) 16
CIH providers (e.g., chiropractor, acupuncturist, massage therapist, meditation/mindfulness center director, instructors/therapists of movement, Tai Chi or Qigong, yoga, and pain clinic provider) 17
Total 70

Two health services researchers used a matrix analysis approach28 to organize the note contents into a matrix and reviewed the content together. They identified three domains of interest: (1) utilization of CIH therapies using telephone/video, (2) advantages and disadvantages of using virtual care for CIH therapies, and (3) health care delivery issues of virtual care for CIH therapies during COVID-19. The researchers then independently identified themes that emerged for each domain. Through ongoing meetings with the lead author, consensus was reached on the emergent themes and representative examples. Thereafter, data were condensed and synthesized into identified themes with representative examples for each domain.

Results

UTILIZATION OF CIH THERAPIES USING TELEPHONE/VIDEO

During the study period, veterans had 326,620 practitioner-delivered CIH therapy visits and 309,980 self-care CIH therapy visits. Table 2 gives the overall number of CIH therapy visits and percentage that were televisits for 3 years (2019, 2020, and 2021). In 2019, before onset of COVID-19, only 0.2% of practitioner-delivered CIH therapies and 2.8% of self-care CIH therapies were televisits. However, after the onset of COVID-19 in 2020, 17.3% of practitioner-delivered CIH therapies and 53.7% of self-care CIH therapies were televisits. In 2021, this use decreased for practitioner-delivered CIH therapies (5.4%), but further increased for self-care (82.1%). Figure 1 breaks these numbers into yearly quarters to depict this shift to virtual care more clearly.

Fig. 1.

Fig. 1. Quarterly number of complementary integrative health therapy visits by delivery mode and service type (January 2019 to December 2021).

Table 2. Total Number of Visits and Percentage Telehealth Visits by Practitioner-Delivered Versus Self-Care Complementary Integrative Health Therapies by Year (2019–2021)
  TOTAL NO. OF VISITS % TELEHEALTH VISITS
2019
 Practitioner-delivered care 121,277 0.2
 Self-care 112,761 2.8
2020
 Practitioner-delivered care 89,838 17.3
 Self-care 85,298 53.7
2021
 Practitioner-delivered care 115,505 5.4
 Self-care 111,921 82.1

Acupuncturists, chiropractors, and massage therapies pivoted to using either telephone or video to provide one-on-one care as substitute for in-person visits. These visits were predominantly educational, follow-ups, instruction on how to do home exercises, and assessments. For example, acupuncturists educated patients on how to do acupressure at home. One site noted they developed a detailed manual on acupressure points that their acupuncturists discussed with patients to ensure continuity of care, giving patients a type of care they could do at home during the pandemic.

Some chiropractors provided patients with education and guidance on which types of exercises and CIH self-care therapies could be done at home; this included connecting patients to CIH self-care classes that the site was offering and emphasizing the importance of these therapies. No site reported offering telemassage therapy.

For CIH self-care therapies, in-person classes rapidly pivoted to telehealth group classes for yoga, Tai Chi (or Qigong), and meditation/mindfulness using VA’s Video Connect. At most sites, virtual group classes for CIH self-care therapies were welcomed by many veterans. As such, sites expressed plans to continue offering these classes even when in-person CIH group classes resume.

ADVANTAGES AND DISADVANTAGES OF USING VIRTUAL CARE FOR CIH THERAPIES

Table 3 gives the three identified domains (advantages and disadvantages, as well as health care delivery issues of using virtual care during COVID-19), the themes for each domain, and an example for each theme. Three advantages of using virtual care were identified: (1) increased access to CIH self-care therapies offered at multiple clinic locations, (2) increased receptivity to engaging in CIH self-care therapies safely from patients’ homes, and (3) increased flexibility with staffing classes. Regarding the increased access, transitioning to tele-CIH self-care classes allowed for more extensive reach to rural veterans, who may not have participated when classes occurred in person due to inconvenience of commuting significant distances to the VA.

Table 3. Advantages, Disadvantages, and Virtual Health Care Delivery Issues of Complementary Integrative Health Therapies at the U.S. Department of Veterans Affairs During COVID-19
DOMAINS THEMES EXAMPLE
Advantages Increased access Veterans able to take classes at home avoided traffic/significant commuting distances reducing significant barriers for rural veterans who might otherwise not participated in person
  Increased receptivity Veterans of different demographics (e.g., younger, or rural veterans) were willing to try virtual classes
Increased flexibility with staffing classes Staff able to take over for an instructor at another site on short notice; an in-person class might have been cancelled
Disadvantages Patient preference for in-person services Loss of comradery and social connection among veterans that used to occur during in-person group classes
  Less engagement due to distractions Veterans may also try to multitask while joining a virtual group class from home
Strain on staffing Some sites required self-care classes to have a back-up staff member to address safety issues that may arise, further straining staff availability
Health care delivery issues Technical difficulties Veterans’ ability to navigate the VA video software/platform to connect remotely
  Lack of access to needed technology Some veterans have limited/lack of access to the internet or camera-enabled devices
Difficulty tracking telehealth use Tracking utilization of virtual platforms and obtaining class encounter credit for participants
Capacity restrictions Virtual yoga and Tai Chi/Qigong classes limited to six to eight participants so staff can see all patients clearly on the screen for visual safety assessment

Also, veterans were now able to attend classes offered by the main facility instead of being limited to classes offered at their nearest clinic. Sites noted that the increased convenience for patients resulted in patients’ being more receptive to the classes, especially among younger or rural veterans. Regarding the issue of increased flexibility of staffing the virtual classes, sites noted that using virtual classes made it easier for instructors to remotely cover other classes when other staff were absent, even from a different clinic location, whereas an in-person class would have been cancelled.

Three disadvantages of CIH therapies using telephone/video were identified: (1) patients’ preference for in-person services, (2) patients’ reduced engagement due to distractions, and (3) strains on staffing. Although veterans have become more receptive to virtual self-care CIH classes, sites noted many veterans still preferred attending in-person classes. They posited that virtual group classes led to loss of comradery and social connection that occurred during in-person classes.

Veterans often also appeared to multitask while joining a virtual group class from home, thus, leading to less engagement in the therapy compared with when they attended class in person. Some virtual self-care classes required having back-up staff members present in case issues with patient safety arose, increasing the need for staffing, which was already tight because of the intense burden the pandemic waves brought.

HEALTH CARE DELIVERY ISSUES OF CIH THERAPIES USING TELEPHONE/VIDEO

Four delivery issue themes emerged regarding (1) technical difficulties, (2) patients’ lack of access to needed technology, (3) practitioners’ difficulty tracking telehealth use, and (4) capacity restrictions. Most sites noted that many veterans, particularly those who are older with hearing/visual impairment, experienced technical issues using the VA’s video platform. To assist with these issues, VA hospitals and clinics provided technical support and equipment to patients, such as shipping iPads to qualified veterans or specifically instructing veterans how to connect to the video classes. Sites also reported some veterans experienced limited or no access to needed technology, such as internet connectivity and camera-enabled devices.

Typically, 20 participants can attend in-person group classes. However, with virtual yoga, Tai Chi, and Qigong classes, sites had to limit the number of attendees (approximately six to eight participants per class) due to safety protocols. This is because yoga, Tai Chi, and Qigong instructors need to see all patients clearly to ensure safety for all patients (e.g., proper alignment in poses to avoid injuries). Sites shared that some staff have experienced challenges in visually assessing someone’s ability or mobility during virtual self-care classes and in interacting with patients during virtual group classes.

Discussion

This article examines veteran patients’ utilization of three self-care and three practitioner-delivered CIH therapies that used telephone/video, their advantages, and disadvantages, and health care delivery issues providers and veterans experienced with virtual care during the COVID-19 pandemic. To our knowledge, this article is one of the few to explore these issues. Several of the study findings are worth further highlighting. The novel finding from this study is the identified health care delivery issues that were reported in the context of tele-CIH self-care group therapies.

Similar to findings in a prior VA study,20 in the absence of in-person CIH therapy visits during the pandemic, care delivered by chiropractors and acupuncturists shifted to using telehealth modalities (video or telephone) to provide consultations, follow-ups/check-ins, connect patients to CIH self-care classes, offer guidance on home exercises, and how to perform acupressure. CIH self-care therapies shifted from in-person group classes to virtual online group sessions using video.

Compared with practitioner-delivered care, utilization of CIH self-care therapies increased significantly between 2019 and 2021; another study also found similar results, where televisits in yoga, Tai Chi, Qigong, and meditation/mindfulness increased in the first 6 months of the pandemic.29 Our findings suggest that CIH self-care therapies delivered virtually were better received at most study sites; due to this unanticipated success of tele-CIH self-care group therapies, the provision of tele-CIH self-care therapies is likely to continue in the VA beyond the pandemic.

In contrast to previous telehealth research, which primarily focuses on one-on-one care, much of our study findings focus on the advantages and disadvantages of using tele-CIH self-care group therapies. Our study sites reported increased access to and knowledge of self-care classes as advantages to the transition to tele-CIH self-care therapies. Veterans (especially those living in rural areas) were able to take classes from the comfort of their home and avoided traffic and significant commute time.

Other studies have also reported similar advantages to using tele-CIH self-care group therapies.30–33 However, as reported in another study,30 one disadvantage to using tele-CIH self-care group therapies is that patients may feel a loss of comradery, social connection, and sense of community that may be experienced during in-person group classes. Given the importance of building comradery, creating social connections, and creating a community,34,35 continuing to offer in-person CIH self-care therapy classes is critical.

Consistent with prior studies,36–40 health care delivery issues that veterans experienced with CIH therapies that were delivered by telephone/video included technical issues and lack of access to needed technology (e.g., internet bandwidth, video capability, computer devices, adequate/high-speed internet coverage, and connectivity). These concerns emphasize the importance of addressing the digital divide,41–43 where select groups, such as older individuals, those living in rural areas, and individuals with socioeconomically disadvantaged backgrounds, may have limited resources and access to telehealth technology.

Since 2016, the VA has distributed tablets/iPads to qualified veterans44; some of our study sites explained that this technical support, in addition to IT support/education to both patients and providers, facilitated access to CIH therapies delivered by telephone/video at the VA and helped to mitigate these delivery issues. Despite technical issues and lack of access to needed technology, similar to prior studies,45–47 there were several advantages to providing tele-CIH self-care therapies as already discussed.

In addition, providers experienced delivery issues as well, such as challenges in tracking virtual visits in the electronic health record, particularly for group sessions that may be self-scheduled and/or allow drop-ins and depending on which type of teleplatforms was used. The initial onset of the pandemic required a shift in coding of telehealth encounters, where, for example, specific clinic code modifiers were used to indicate a video or a phone visit, depending on the specific clinic and type of service provided (primary care, CIH, etc.). The use of these codes was closely tied to the new telescheduling grids (e.g., telephone and video), which had to be created for each VA provider immediately after the onset of COVID-19.48

The study findings also identified new health care delivery issues in the context of tele-CIH self-care group therapies, which to our knowledge have not been reported elsewhere. Given that most telehealth research is on one-on-one care, an important contribution of this study is the identification of new barriers to the provision of tele-CIH self-care group therapies. Sites reported that self-care tele-CIH classes, such as yoga, Tai Chi, or Qigong, had capacity limits of six to eight participants. Although this helped instructors to be able to better observe patients and try to ensure their safety during the class, there were still difficulties in seeing all patients clearly on the computer screen, particularly when instructors were also trying to teach the classes.

This may lead to instructors feeling concerned about patients’ safety and injury when delivering teleyoga.49 Consequently, some sites required tele-CIH self-care classes to have a back-up staff member present during the class to help the instructor and address any safety issues should they arise, which put a strain on staffing. Ensuring that instructors feel comfortable with safety protocols while teaching the class is an important aspect of tele-CIH self-care delivery and should be incorporated in trainings, especially if hybrid models continue beyond the pandemic.

LIMITATIONS AND STRENGTHS

Our study has several limitations. First, since the topic of telehealth was not the main focus of the larger APPROACH study, limited information on provision of telehealth services was collected during the interviews. However, given the rapid and unexpected shift to CIH therapies delivered by telephone/video with the onset of the COVID-19 pandemic, study participants discussed the transition to virtual care during the calls. Second, patient perspectives were not included in the study, so the findings are limited to the viewpoints of CIH providers and CIH program managers.

Since patient satisfaction is key in determining delivery of health care services,16,47 future research should focus on understanding patients’ experiences and perspectives about CIH therapies delivered by telephone/video, especially because they are not evidence based. Future research should also assess the efficacy and safety of the different tele-CIH self-care therapies in pain management since there is very limited research on this topic.

Finally, it should be noted that given that every VA is different, one of the major strengths of the study was the inclusion of 18 VA sites, which allowed this study to examine the experiences and perspectives of multiple VA sites with regard to the provision of CIH therapies using telephone/video. Furthermore, given that the VA is a leader in providing patient care through telehealth services, many of the lessons learned from this study are applicable to other VA and non-VA hospitals delivering CIH therapies using telephone/video.

Conclusions

The rapid shift to tele-CIH self-care therapies during the COVID-19 pandemic raises important questions to be considered beyond the COVID-19 pandemic regarding the potential advantages and disadvantages, as well as the delivery issues providers and veterans experienced with tele-CIH self-care therapies. First and foremost, more research is needed to determine the efficacy and safety of tele-CIH self-care therapies in pain management and other patient outcomes. For practitioner-delivered CIH therapies, the quick shift to virtual care was mostly intended to provide continuity of care during a time in which access to in-person care was restricted.

In contrast, despite the health care delivery issues and disadvantages, group self-care (yoga, Tai Chi, Qigong, and meditation/mindfulness) classes through telehealth will likely continue in some manner beyond the COVID-19 pandemic given the advantages identified in this study. More research is needed to examine the effectiveness of tele- and/or hybrid CIH therapies for self-care and identify strategies on how to mitigate the delivery issues noted in this study.

Authors’ Contributions

C.D.-M. conceptualized and designed the study, collected data, carried out the analyses, drafted the initial article, and reviewed and revised the article; M.S. collected data, carried out the analyses, interpreted the data, critically reviewed, and revised the article for important intellectual content; M.L.U. assisted with the acquisition of data, carried out the analyses, interpreted the data, and critically reviewed the article for important intellectual content; J.H.D. assisted with the acquisition of data, conducted the data analysis, assisted with design of the study, critically reviewed, and revised the article; S.L.T. and S.B.Z. conceptualized and designed the study, interpreted the data, and critically reviewed the article for important intellectual content.

Disclaimer

The views and opinions of authors expressed herein do not necessarily state or reflect those of the Veterans Health Administration or the U.S. Government.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by U.S. Department of Affairs (VA) Health Services Research & Development (HSR&D), Service Directed Research 17-306 (S.L.T./S.B.Z., PIs).

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