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Abstract

Background:

Geriatrics specialists are scarce but needed to provide comprehensive, individualized care to older rural Veterans with complex needs. Tele-geriatrics and geriatric mental health (tele-GGMH) services, where clinicians provide specialized consultation and/or time-limited care to residents of a wide geographic area via telehealth, can help meet these needs. Clinicians referring Veterans patients to tele-GGMH services were surveyed to understand their reasons for requesting consultations and satisfaction with services provided.

Methods:

Veterans Health Administration clinicians from seven regions referring to tele-GGMH services between October 2021 and September 2023 completed the survey. Qualitative and quantitative analyses summarized referring clinicians’ experience and satisfaction with tele-GGMH services. Differences between rural- and nonrural-serving clinicians and prescribing and nonprescribing clinicians were examined.

Results:

Sixty-nine clinicians responded. Most learned about the tele-GGMH services via word-of-mouth and believed the service increased access to geriatric mental health care. Follow-through with specialists’ recommendations was associated with satisfaction, however nonprescribers and nonrural clinicians had decreased follow-through linked to lower satisfaction. Qualitative data indicated that the top reasons clinicians asked for consultation was to request specific services including subcategories of diagnostic clarification or evaluations, medication management or recommendations and nonpharmalogical interventions. The most frequent barrier reported was postservice barriers implementing the recommendations. Most additional feedback was of general satisfaction and appreciation.

Conclusions:

Tele-GGMH services are appreciated by referring clinicians and facilitate access to geriatrics expertise. Ability to follow through with the specialist’s advice predicted satisfaction with the service. Receiving assistance with specific services was the most frequent reason for requesting services.

Keywords

Military Medicine Psychiatry Telehealth

Introduction

Providing comprehensive, individualized care to older Veterans is particularly challenging in rural areas due to a lack of access to specialty mental health and geriatric medicine services in both the Veterans Health Administration and the community.¹ Older Veterans with mental health concerns need specialized support addressing the complex interaction between mental and physical health in aging,^2–4 such as age-friendly medication guidance, counseling for adjustment to cognitive or other functional changes, or emotional support for family caregivers of Veterans. While both specialized psychiatric care and geriatric medicine services are essential supports for older Veterans with mental health concerns, access to these resources is severely limited in rural areas. A viable way to increase access to care is through telehealth. The Veterans Health Administration (VHA) has long been recognized as leading provider of telemental health services through innovations such as VA Video Connect to provide video to home telehealth services in addition to providing services from one VHA facility (hub) to smaller clinics (spoke sites). The COVID-19 pandemic accelerated the uptake of telemental health services.⁵ However, evaluations of telemental health services demonstrate that older, rural Veterans are more likely to receive audio-only mental health (MH) services, which can be problematic when patients present with complex problems such as dementia, PTSD, and serious mental illness.^6,7

One such telehealth program, focused on increasing access to geriatrics services through connecting rural clinics to a national network of VHA geriatrics centers called Geriatrics Research, Education, and Clinical Centers (GRECCs). Through this program, called GRECC Connect, VHA clinicians with expertise in geriatrics provide virtual medical services to older rural Veterans and also education to rural clinicians since 2014.^8,9 GRECC Connect facilitates clinical consultations via video telehealth to address common geriatric syndromes including polypharmacy, fall risk, and multimorbidity. Evaluations of this program demonstrated high rates of satisfaction among rural Veterans as well as measurable clinical impacts such as medication changes.⁸ These findings demonstrate the feasibility and acceptability of a hub-and-spoke approach to increasing access to geriatrics disciplines, primarily geriatric medicine, in addition to other disciplines, including some MH clinicians.

Another hub-and-spoke model, the Clinical Resource Hubs (CRHs), was developed as VHA regional hubs with a large focus on increasing care to rural areas via video telehealth. Synchronous telehealth services for primary, MH, and specialty care between CRH clinicians and rural Veterans primarily offer direct care for specialized concerns, and asynchronous clinician-to-clinician consultations assist local teams in managing complex cases.⁶ An examination found CRH-based MH services were associated with increased utilization of services over time for Veterans of all ages.⁷ CRH services have expanded to include tele-geriatric medicine and geriatric mental health (tele-GGMH) services, use high rates of video-delivered care,^10,11 and could be a viable avenue for delivering specialized, age-friendly mental health care. An initial evaluation in one VHA region found services were valued by caregivers and referring clinicians.¹² However, a better understanding of the impact of services across multiple regions would strengthen evidence of feasibility and acceptability of tele-GGMH.

In the present study, clinicians referring older Veterans to tele-GGMH services in seven VHA regions were surveyed across a 2-year period. We evaluated reasons for consultation, satisfaction with the service, and whether the service increased access to geriatric mental health care. We also examined satisfaction factors and whether response patterns differed among rural and nonrural clinicians and other factors related to satisfaction with the services.

Methods

Surveys were sent to referring clinicians requesting tele-GGMH services between October 2021 and September 2023. Tele-GGMH services were delivered by clinicians from multiple disciplines including geriatric psychiatry, geropsychology, pharmacy, neuropsychology (Years 1 and 2), and geriatric medicine (Year 2). Surveys were part of a broader evaluation project determined to be quality improvement and not human subjects research by the Stanford University IRB. The surveys were submitted to VHA national unions for concurrence. Emails sent to potential participants stated the anonymity and voluntary nature of the surveys.

Participant eligibility and recruitment

Referring clinicians were identified through electronic health record (EHR) data or by asking tele-GGMH clinicians for clinicians they had worked with in the past year. Ultimately, 229 clinicians were identified from EHR data and an additional 14 were identified by tele-GGMH clinicians.

Clinicians were invited by email to participate in the survey administered through REDCap, a secure online platform for collecting and managing data. An initial message and one follow-up reminder provided a link to the survey and explained that it was anonymous and voluntary.

Survey items

Surveys asked for the referring clinician’s discipline, work setting, VHA region (VISN; Veterans Integrated Service Network), rurality of patients, and comfort and training working with geriatric patients. Questions also asked how clinicians learned of the consultation, the amount and types of consultations (telehealth vs. e-consultation) requested in the past year, discipline of tele-GGMH clinician with whom they worked, and the reason for the request. Lastly, the survey asked whether services increased access to geriatric psychiatry, neuropsychology, and geriatric medicine (latter two asked in Year 2 only; see Supplemental File).

Four items elicited participant responses on a scale ranging from 1 (strongly agree) to 5 (strongly disagree) regarding satisfaction with the service, whether the care team benefitted from the consultation, whether the patient/caregiver appeared to benefit, and whether the clinician would recommend the service to other clinicians. These four items were summed into a total in which lower scores indicate higher satisfaction. The internal consistency was excellent (α = 0.93); a principal components analysis confirmed that the items contributed to one component (satisfaction) accounting for 83.2% of the total variance.

Open-ended questions asked about why clinicians requested the consultation, barriers to following through with recommendations, and additional feedback about the service.

Data analysis

Data were exported and analyzed in SPSS 29.0.2.0.¹³ The surveys were largely the same across both years with some added questions during Year 2, leading to missing data on those items in Year 1 (see Supplemental File). Responses were summarized using frequencies, percentages, and descriptive statistics. Chi-square statistics and t-tests examined differences between rural- and nonrural-serving clinicians in terms of the settings clinicians worked in and how they learned about the tele-GMH program. We additionally compared responses from prescribing and nonprescribing clinicians on how the program increased access to various geriatrics services, and whether they followed through on recommendations from tele-GMH consultants.

Mean imputation was utilized in the creation of the total score for four missing items (1.4% of data points) and for the item regarding follow-through on recommendations with three missing items (4.3% of data points). Two linear regression analyses tested main effects of factors associated with the total satisfaction score. The first regression examined whether rurality, prescriber group (dummy coded as 0 = nonprescriber, 1 = prescriber), and the number of consultations (coded as 1 = 1, 2 = 2 to 5, 3 = 6+) predicted satisfaction. The second examined whether rurality, prescriber group, and clinician follow-through on recommendations predicted satisfaction.

Open-ended responses were analyzed using content analysis.¹⁴ Three authors (C.C., C.E.G., M.B.H.) generated a list of deductive and inductive codes. Two authors (C.C., M.B.H.) then applied the codes with any discrepancies addressed through discussion (see Supplemental File).

Results

Respondents

Sixty-nine referring clinicians completed the survey (Year 1: n = 37; Year 2: n = 32), yielding a response rate of 28.4%. Most had prescribing privileges (n = 48, 69.6%). Clinicians serving rural Veterans (n = 33, 48.5%) were more likely to work in primary care settings and less likely to have completed continuing education related to geriatrics compared with nonrural clinicians (see Table 1).

Table 1.

Characteristics of Referring Clinician Respondents by Rurality of Patients Served

Referring Clinicians	Serving Rural Patients Only (n = 33)	Serving Nonrural and combined patients (n = 35)	Total (n = 68)	Chi-square test
Setting
Primary care	17 (51.5%)	5 (14.3%)	22 (32.4%)	χ² (1) = 10.76, p = 0.001
Mental health	9 (27.3%)	7 (20.0%)	16 (23.5%)	χ² (1) = 0.50, p = 0.48
Home-based primary care	0 (0.0%)	2 (5.7%)	2 (2.9%)	χ² (1) = 1.94, p = 0.49
Nursing home	5 (15.2%)	13 (37.1%)	18 (26.5%)	χ² (1) = 4.22, p = 0.06
Inpatient	0 (0.0%)	2 (5.7%)	2 (2.9%)	χ² (1) = 1.94, p = 0.49
Other setting^a	4 (12.1%)	12 (34.3%)	16 (23.5%)	χ² (1) = 4.64, p = 0.05
Role				χ² (3) = 6.20, p = 0.10
Physician	11 (33.3%)	15 (42.9%)	26 (37.7%)
NP/APRN/PA/ Pharmacist	8 (24.2%)	14 (40%)	22 (31.9%)
Psychologist	8 (24.2%)	2 (5.7%)	10 (14.5%)
Social Worker	6 (18.2%)	4 (11.4%)	11 (15.9%)
Geriatric Training^b,c
Coursework	8 (24.2%)	17 (48.6%)	25 (36.8%)	χ² (1) = 4.32, p = 0.05
Continuing Education	9 (27.3%)	19 (54.3%)	28 (41.2%)	χ²(1) = 5.12, p = 0.03
Fellowship	2 (6.1%)	4 (11.4%)	6 (8.8%)	χ² (1) = 0.61, p = 0.67
Rotation	6 (18.2%)	13 (37.1%)	19 (27.9%)	χ²(1) = 3.03, p = 0.11
Other	2 (6.1%)	0 (0.0%)	2 (2.9%)	χ²(1) = 2.19, p = 0.14
Type of Consult Placed				χ² (2) = 4.30, p = 0.12
Regular (video, phone)	16 (50.0%)	9 (25.7%)	25 (37.3%)
e-consultation	5 (15.6%)	7 (20.0%)	12 (17.9%)
Both	11 (34.4%)	19 (54.3%)	30 (44.8 %)
Missing	1 (3.1%)	0 (0.0%)	1 (1.5%)
Number of Consults Placed				χ² (3) = 1.90, p = 0.59
1	4 (12.1%)	2 (5.7%)	6 (8.8%)
2–5	15 (45.5%)	15 (42.9%)	30 (44.1%)
6 or more	14 (42.4%)	17 (48.6%)	31 (45.6%)
Unknown	0 (0.0%)	1 (2.9%)	1 (1.4%)
Learn about Consult^c
Personal interaction with CRH provider	15 (45.5%)	19 (54.3%)	34 (49.3%)	χ² (1) = 0.53, p = 0.50
Colleague or service chief	15 (45.5%)	17 (48.6%)	33 (47.8%)	χ² (1) = 0.07, p = 0.80
Email about services	6 (18.2%)	8 (22.9%)	14 (20.6%)	χ² (1) = 0.23, p = 0.63
Meeting	9 (27.3%)	8 (22.9%)	17 (25.0%)	χ² (1) = 0.18, p = 0.67
Medical record	4 (12.1%)	10 (28.6%)	14 (20.6%)	χ² (1) = 2.81, p = 0.09
Flyer	5 (15.2%)	7 (20.0%)	12 (17.6%)	χ² (1) = 0.28, p = 0.60
No description	4 (12.1%)	7 (20.0%)	11 (16.2%)	χ²(1) = 0.78, p = 0.38

One respondent was missing rurality variable and was excluded from analyses.

^aOther Settings included: dementia clinic, outpatient neurology, PCMHI, SCI/D, or had no description.

^bOne respondent did not answer the question on receiving geriatric training; however, did respond affirmatively to multiple training categories, therefore implying that they had received geriatric training.

Respondents could select >1 answer.

APRN, advanced practice registered nurse; CRH, clinical resource hub; NP, nurse practitioner; PA, physician’s assistant.

Consultation

Referring clinicians reported they learned about the service largely through personal interaction with the tele-GGMH clinician(s) (n = 34, 49.3%) and/or a colleague or service chief (n = 33, 47.8%) and less so through meetings, the EHR, emails, or flyers. Ninety percent (n = 62) had placed more than one consultation and 31 had placed more than five consultations in the previous year. Many referring clinicians requested both telehealth and e-consultations (n = 30, 43.5%) or only telehealth visits (n = 25, 36.2%); a minority only requested e-consultations (n = 13, 18.8%). Rural clinicians were marginally more likely to place referrals compared with nonrural clinicians; however, there were no differences in how they learned about the service (see Table 1).

Access to services

Most referring clinicians strongly agreed (n = 44, 64.7%) or agreed (n = 19, 27.9%) that the service increased access to geriatric psychiatry. A similar pattern emerged regarding access to other specialties (geriatric medicine/neuropsychology) as ascertained in the Year 2 survey (see Table 2).

Table 2.

Survey Likert-Type Items (n = 68)

		n (%)
	M (SD)	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Patient/caregiver benefited	1.6 (.79)	38 (55.9%)	21 (30.9%)	7 (10.3%)	2 (2.9%)	0 (0.0%)
Would recommend	1.28 (.62)	54 (79.4%)	10 (14.7%)	3 (4.4%)	1 (1.5%)	0 (0.0%)
Satisfied with consult	1.44 (.72)	45 (65.6%)	18 (26.5%)	3 (4.4%)	2 (2.9%)	0 (0.0%)
Care team benefited	1.5 (.78)	42 (61.8%)	21 (30.9%)	3 (4.4%)	1 (1.5%)	1 (1.5%)
Followed through with recommendations^a	1.58 (.70)	36 (54.5%)	22 (33.3%)	8 (12.1%)	0 (0.0%)	0 (0.0%)
Increased access to geriatric psychiatry	1.47 (0.78)	44 (64.7%)	19 (27.9%)	3 (4.4%)	1 (1.5%)	1 (1.5%)
Increased access to geriatric medicine^b	1.79 (1.05)	8 (57.1%)	2 (14.3%)	3 (21.4%)	1 (7.1%)	0 (0.0%)
Increased access to neuropsychology^b	2.29 (1.38)	2 (28.6%)	3 (42.9%)	1 (14.3%)	0 (0.0%)	1 (14.3%)

^aTwo respondents did not provide an answer.

^bQuestions only asked on year 2 survey; Services not available in all VISNs.

Follow through with recommendations

Most referring clinicians strongly agreed (n = 36, 54.5%) or agreed (n = 22, 33.3%) that they followed through with recommendations (see Table 2). Nonrural clinicians (M = 1.76) followed through on recommendations less often compared with rural clinicians (M = 1.36), t(66) = −2.58, p = 0.01. Additionally, non-prescribers (M = 1.93) were less likely to follow through on recommendations compared with prescribers (M = 1.42), t(67) = 3.01, p = 0.004.

Factors associated with satisfaction

Overall satisfaction with services was high with a mean total satisfaction score of 8.87 (SD = 3.52) and scores ranging from 6 to 22 with lower scores indicating higher satisfaction.

The first regression found that rurality (rural, nonrural), the number of consultations placed (1, 2–5, 6+), and prescriber group (nonprescriber, prescriber) did not significantly predict satisfaction, F(3, 66) = 0.88, p = 0.46, R² = 0.04. The second regression examining whether rurality, prescriber group, and clinician follow-through predicted satisfaction was significant, F(3, 67) = 17.77, p < 0.001, R² = 0.43. Lower follow-through with recommendations predicted less overall satisfaction with the service (see Table 3).

Table 3.

Linear Regression Models Examining Factors Associated with Satisfaction Total Scores

Predictor Variable	Coefficient	Standard Error	t-Statistic	95% Confidence Interval (CI)	p-value
Model 1
Intercept	11.69	0.75	6.24	[7.94, 15.43]	<0.001
Rural^a	−0.23	0.90	−0.26	[−2.03, 1.57]	0.80
Number of consults^b	−0.93	0.68	−1.37	[−2.29, 0.43]	0.18
Prescriber group^c	−0.71	0.99	−0.72	[−2.68, 0.43]	0.47
Model 2
Intercept	3.19	1.16	2.76	[.881, 5.50]	0.008
Rural^a	−1.24	0.69	−1.80	[−2.62, 0.14]	0.08
Prescriber group^c	0.50	0.76	0.65	[−1.03, 2.02]	0.52
Followed through	3.78	0.53	7.20	[2.73, 4.83]	<0.001

0 = nonrural, 1 = rural.

Number of consults = 1 = 1; 2 = 2–5; 3 = 6, or more.

1 = prescriber (physician, nurse practitioner/advanced practice nurse, physician assistant, clinical pharmacist), nonprescriber = 0 (psychologist, social worker).

Reason for requesting consultation

Qualitative analysis of open-ended responses yielded four categories of reasons why referring clinicians requested consultations: (1) specific services requested (n = 42, 68.9%), (2) patient presenting concerns (n = 28, 45.9%), (3) general expertise (n = 6, 9.8%), and (4) family/caregiver support or education (n = 5, 8.2%; see Table 4 for further descriptions and example quotes). The most prevalent category was specific services requested and encompassed the subcategories of diagnostic clarification/evaluation, medication management/recommendation, and nonpharmacological interventions. The second most prevalent category, patient presenting concerns, included dementia-related behavioral concerns, cognitive changes, mood symptoms, or managing complex needs. The following quote exemplifies patient presenting concerns met by the service:

Table 4.

Referring Clinician Reason for Consultation (n = 61)

Category	Subcategory	Example Response
Specific Services Requested (n = 42):Clinicians requesting specific services	Medication management/recommendations (n = 18): medication assistance, adjustments, or medication recommendations	“Assistance with medication management appropriate for a geriatric patient and to collaborate as a multidisciplinary team to address the Veteran’s complex needs.”
	Nonpharmacological Interventions (other than medication; n = 16): treatment planning/management (e.g., psychotherapy)	“Requesting additional assistance due to increased needs of the patient related to dementia diagnosis.”
	Diagnostic Clarification/Evaluation (n = 19): diagnostic clarification, evaluation, or assessment related to the Veteran’s presenting problem	“Evaluation of cognitive decline and worsening MH symptoms.”
Patient presenting concerns (n = 28):Patients seen for behavioral, complex needs, cognitive, or mood symptoms	Cognitive (n = 11): cognitive/memory concerns. Include dementia if no mention of behaviors	“Cognitive decline.”
	Behavioral (n = 12): dementia-related behaviors such as agitation, “challenging” behaviors with mental health/psychiatric conditions (e.g., aggression)	“Assistance with patients with dementia with behavioral disturbance.”
	Mood (n = 8): mood symptoms or other mental health symptoms other than behaviors or cognitive decline	“Caregiver support, mood management, polypharmacy review.”
	Complex needs (n = 7): difficulties managing patients with complex needs or “complex cases” due to several reasons including comorbidities, complex social needs	“Complexity of patients illness and comorbid conditions.”
General expertise (n = 6):General requests for care/expertise	N/A	“VVC care for new, older adult patients unable to attend face-to-face consultation visits (patients in far reaching areas of [state]).”
Family/Caregiver support or education (n = 5):Provision of education or support services to patient’s family	Support (n = 4): requests for caregiver support	“Spouse’s difficulty dealing with dementia.”
	Education (n = 3): requests for caregiver education on what to expect throughout disease progression	“Need medications for patients and education for families.”

19 responses (31%) encompassed more than one category or subcategory, thus percentages total > 100%. Fourteen (23%) responses encompassed both services and patient presenting concerns, while 3 (4.9%) encompassed both services and family/caregiver support.

We are a CLC (Community Living Center, the VHA nursing home equivalent) without access to local psychiatry. We heavily rely on the CRH to help with our many Veterans with cognitive decline, encephalopathy, and various psychiatric presentations. While we are not a locked facility, we treat veterans with a higher acuity and we frequently need assistance with veterans with behavioral disturbance.

-Psychologist in CLC

Barriers to receiving services

Twenty referring clinicians (29%) provided examples of barriers. Five types of barriers were identified (see Table 5). Barriers prior to service delivery (n = 4, 20%) primarily encompassed lack of availability for appointments. Barriers during service (n = 4, 20%) included specific concerns such as timeliness, lack of personalization of recommendations, and general unhelpfulness. Post-service delivery barriers (n = 8, 40%), included barriers to implementing recommendations, which often required the requestor to prescribe medication, requesting additional referrals, or encouraging teams to implement the recommended changes. One neuropsychologist wrote, “Neuropsychology is a silo, and we don’t have a team to ensure the recommendations are followed. I have to cross my fingers and nudge the [primary care] teams to implement the CRH recommendations.” Patient-level barriers (n = 3, 15%) were related to the Veteran’s characteristics or situation, for example a Veteran who was homeless and used substances. Finally, general barriers (n = 3, 15%) encompassed responses not captured in other categories such as “[N]othing is better than onsite [face to face] and availability for urgent matters. Otherwise this has gone very well.” (Physician at a CLC).

Table 5.

Referring Clinician’s Described Barriers to following through with Recommendations (n = 20)

Barrier/Challenge	Definition	Frequency (n (%)	Example Response
Barrier prior to receipt of services	Barriers encountered prior to service delivery (i.e., before patient encounter). This may include difficulty finding consult request in the medical record system (CPRS or Cerner), not understanding the scope of the program, lack of appointment availability, or delays in scheduling.	4 (20%)	“The only barrier to the services I experienced was resistance from the local/on-site treatment team in utilizing the geriatric hub. I would have placed more consults to the hub had it not been for some local team members discomfort with utilizing specialists.”
Barrier during service delivery	Response describing barrier to some aspect of services rendered including dissatisfaction with services rendered (e.g., referral question not answered), and/or documentation of the services delivered/encounter in the medical record.	4 (20%)	“Lack of timeliness of evaluation.”
Post-service barrier related to implementing recommendations	Response describing barriers to carrying out plan or recommendations from CRH consultant (e.g., referring provider needs to put in orders) or absence of follow-up care from consultant.	8 (40%)	“Some barriers were getting a hold of decision makers to make sure that they were consenting to the pharmacological interventions that were recommended.”“Often times the PCP is not aware that the Veteran has been referred to the CRH and places an additional consult for Geri memory clinic.”
Patient-level barriers	Individual level barriers such as Veteran’s personal characteristics or situations impacting services (e.g., unwillingness to follow through with recommendations, technology difficulties/low tech literacy).	3 (15%)	“The Veteran was homeless. Being able to establish routine and decreased substance use was a challenge.”“Technology is not always a place of skill for rural older veterans and their households. older veterans tend to need more hands on care and sometimes this is a dangerous band aid to expanding rural elder care for veterans.”
General barriers	Responses that are not better captured by another category.	3 (15%)	“Nothing is better than onsite [face to face] and availability for urgent matters. Otherwise, this has gone very well.”

More than 1 barrier could be applied to a single quote. 20 barriers were reported by respondents.

Additional feedback about service

Twenty-nine referring clinicians (42%) shared additional feedback, which included expressions of gratitude and general satisfaction (n = 14, 48.3%) and the benefit of having access to specialists providing services for patients with complex needs (n = 8, 27.6%). Some respondents mentioned specific issues (n = 5, 17.2%), such as difficulties scheduling appointments and concerns about the specificity or timeliness of evaluations and corresponding notes. Two clinicians (6.9%) positively mentioned the communication and collaborative skills of the tele-GGMH consultants.

Discussion

Our evaluation provides insight into referring clinicians’ perception of the usefulness of and their satisfaction with tele-GGMH services. A vast majority of respondents requested multiple consultations, often a mix of e-consultations and telehealth visits. Most referring clinicians learned of the service through person-to-person endorsements, underscoring the importance of direct communication with referring clinicians for implementation of virtual care programs.

Many respondents indicated that tele-GGMH increased access to geriatric psychiatry, which was also qualitatively endorsed. Similar to findings for other programs such as GRECC Connect, tele-GGMH services enabled rural clinicians to obtain expertise with older Veterans with complex needs, potentially addressing the geriatric workforce shortage^8,15 and demonstrating the acceptability of CRH-delivered geriatric MH services in addition to general MH services.⁷ This extends previous work¹² evaluating a geriatric MH service in one region delivered by a single clinician and is the first evaluation of multi-site, multiple clinician CRH-delivered geriatrics and geriatric MH services from the perspective of referring clinicians.

The regression analysis indicated that satisfaction was associated with clinician follow-through on recommendations. Interestingly, rural clinicians and those with prescribing privileges were more likely to follow through on recommendations, possibly because of the additional steps non-prescribers need to take related to medication recommendations, prescribing or deprescribing. This finding underscores the challenge of consultation which allows more Veterans to receive services, yet may increase responsibility and workload of referring clinicians.⁹

These findings indicate how successfully implementing tele-GGMH services requires collaborative consultations with referring clinicians. Because the geriatric specialty workforce is currently under-staffed,^12,13 telehealth facilitates the provision of geriatrics care to rural patients who need it without geographic restrictions as demonstrated by this and the GRECC Connect program.^8,16

This study has some limitations. First, some of the referring clinicians identified via EHR review may not have been aware of how the service was ultimately delivered because the request was forwarded to multiple departments or clinicians on behalf of the original requestor. Second, clinicians who refer less frequently may not have responded feeling less familiar with the service. Third, the data collection format (survey) did not allow for elicitation of additional information from respondents, which may have yielded a more comprehensive understanding of their experiences. The critiques of the service as well as benefits suggest that the responses represent a range of opinions. Finally, due to the unique structure of the VHA, our findings may not be generalizable beyond this health care system.

Conclusions

Tele-GGMH services from CRHs provide accessible and comprehensive specialized care for older Veterans in rural areas. The assistance provided to patients with complex needs often eases the coordination efforts of the referring clinicians. Since the survey, tele-GGMH has expanded to additional regions. Further work is needed to examine ways to improve implementation and care coordination with minimal burden to referring clinicians.

Footnotes

Acknowledgments

The views expressed by the authors do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Previous Presentation

Portions of these data were presented at the 2023 Gerontological Society of America Annual Scientific Conference in New Orleans, LA.

Authors’ Contributions

C.C. developed, created, and distributed the survey, assisted in formal analysis and article writing. C.H.D. assisted in writing the article and guided formal analysis. M.B.H. contributed to qualitative analysis and revising the article. A.P. supervised qualitative analysis and revising the article. M.B. and L.P. revised the article. C.E.G. conceptualized and led the investigation as the principal investigator, participated in formal analysis, wrote portions of the article, and revised the article.

Author Disclosure Statement

No interests to disclose.

Funding Information

This work was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-009747 [FY2021-2023]; #PRFY-010206 [FY2024]. The contents do not represent the views of Department of Veterans Affairs or the United States government. C.H.D. is supported by the VA Advanced Fellowship in Geriatrics.

Supplemental Material

Abbreviations Used

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Supplementary Material

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Connecting Aging Rural Veterans with Tele-Geriatrics and Geriatric Mental Health Services: Referring Clinicians' Surveyed Perspectives

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Participant eligibility and recruitment

Survey items

Data analysis

Results

Respondents

Consultation

Access to services

Follow through with recommendations

Factors associated with satisfaction

Reason for requesting consultation

Barriers to receiving services

Additional feedback about service

Discussion

Conclusions

Footnotes

Acknowledgments

Previous Presentation

Authors’ Contributions

Author Disclosure Statement

Funding Information

Supplemental Material

Abbreviations Used

References

Supplementary Material