Christine E. Gould

Objective: Veterans Health Administration Clinical Resource Hubs are regional telehealth hubs that provide Veterans access needed to geriatric mental health (GMH) services without long drive times to urban centers to find specialists. This analysis characterized the GMH telehealth services to examine differences between rural and non‐rural Veterans. Methods: Electronic health record data were extracted (October 2021 to September 2023) for encounters delivered by telehealth GMH teams staffed by geriatric psychiatrists, pharmacists, geropsychologists, and neuropsychologists. Variables included Veteran demographics, diagnoses, severity of care needs, services delivered and visit modality. Descriptive statistics, chi‐square and t ‐tests summarized the data and examined rural and non‐rural differences. Results: GMH clinicians completed 9282 encounters with 2013 Veterans (Mean age = 75.8). Most services were video to home (48.2%) followed by video to clinic (25.4%), and phone (22%) with no differences in service delivery modality among rural and non‐rural Veterans. Rural Veterans had a higher proportion of psychotherapy and dementia‐related services, and lower proportions of medication management and services for depression, anxiety, and serious mental illness compared with non‐rural Veterans. Conclusions: Older Veterans access virtual GMH care for a wide range of mental health and cognitive disorders. The apparent higher utilization of psychotherapy and dementia services for rural compared with non‐rural Veterans may relate to barriers to obtaining these services locally, although it may be partially explained by variations in virtual team compositions and settings served. Relevance to Clinical Practice: This evaluation suggests high acceptability of video‐delivered care for older, rural Veterans with high care needs.

Background: Access to geriatric mental health (GMH) care is limited in rural areas. To meet this need, the Veterans Health Administration provides specialty tele-GMH care for aging rural veterans via regional telehealth hubs. Objective: This study aims to create a roadmap describing key phases and determinants underlying the implementation and sustainment of tele-GMH services as part of a qualitative longitudinal evaluation of tele-GMH teams. Methods: Semistructured interviews were conducted with clinicians from all 8 tele-GMH teams (n=25) at 3 time points across a 3-year period (October 2021-September 2024). Interview (n=46) data were summarized into key domains using a templated rapid qualitative approach, guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Further thematic analysis and team discussion elucidated the findings. Results: We identified key activities and determinants of success in three phases: (1) preimplementation (engaging leaders, securing funding/hiring, and defining services); (2) implementation scale-up and expansion (advertising, addressing challenges, seeking feedback, refining, and growth); and (3) sustainment (maintenance). Activities within each phase were cyclical and iterative (ie, nonlinear). Barriers to implementation included unfamiliarity with local aging resources; facilitators included tailoring strategies and engaging referring clinicians. Conclusions: Similar processes emerged across regions in the development and sustainment of tele-GMH services, allowing for the creation of a unified roadmap. Limitations including sampling bias are discussed. Further work could apply and evaluate the utility of the roadmap to guide creation of tele-GMH services in new regions to enhance access to specialty care for aging rural veterans.

Background: Mobile mental health apps may provide an accessible, scalable, and private avenue for older veterans who may not otherwise seek or receive care to address their mental health concerns. However, older veterans may experience barriers to using these apps that need to be addressed to facilitate effective use. Such support could be effectively implemented within the US Veterans Health Administration to facilitate the use of the United States Department of Veterans Affairs’ established mental health apps and to benefit older veterans with mental health concerns. Objective: This study aimed to (1) assess older veterans’ interest in and barriers to using mental health apps to address problems such as difficulties with social connection, and (2) develop and pilot a coaching program to address barriers that older veterans experience in using mobile devices and apps. Methods: Rapid qualitative analysis of semistructured qualitative interviews with 12 older veterans identified themes regarding interest, barriers, and preferences for support for using mobile apps. These themes informed the development of a coaching program, which was piloted with 13 older veterans to assess acceptability, feasibility, and resultant signals of changes in mobile device proficiency. Results: Most veterans expressed interest in using mental health apps. One of the most common barriers was familiarity and proficiency with mobile devices and app technology. Other common barriers included usability or accessibility of the technology or app, motivation, and memory. Veterans reported interest in receiving coaching support. Though the majority of veterans expressed some preference for more individualized and in-person support, they identified both benefits and drawbacks to all potential coaching modalities (group vs one-on-one, in-person vs remote)—including issues of individualizable and guided assistance, feasibility and accessibility of the support, and group settings as potential avenues for social connection as well as potential susceptibility to challenging social dynamics and interactions. Mobile Device and App Learning (MoDAL)—a 2-session, interactive, remote educational group—was developed and piloted. Most veterans who participated found MoDAL helpful. Participants’ mobile device proficiency showed a statistically significant improvement on average pre- to post-MoDAL, although this effect was small, and the small sample size limits the strength of the conclusions. Conclusions: Older veterans do have some interest in using mobile mental health apps to address mental health–related issues. However, they experience critical barriers, including a lack of familiarity and proficiency with the technology. MoDAL may improve older veterans’ comfort and proficiency with mobile devices and apps, which could address one of the barriers that impacts downstream engagement in mental health apps and other virtual care modalities.

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.

Purpose: Rural older Veterans have limited access to specialty care. In the Veterans Health Administration (VHA), tele‐geriatric mental health (tele‐GMH) services provide mental health care to older Veterans through regional telehealth hubs. However, older Veterans may still face gaps in access to geriatric medicine and specialty services, exacerbating unmet needs at the intersection of mental and physical health. We assessed unmet needs for geriatric medicine and related specialty services for rural older Veterans served by tele‐GMH. Methods: We surveyed 32 clinicians in 6 VHA geographic regions who referred Veterans to tele‐GMH services in fiscal year 2023, 25 of whom served rural Veterans. We also conducted semi‐structured interviews with 11 tele‐GMH clinicians. Survey data were summarized using descriptive statistics, and interviews were analyzed utilizing rapid qualitative analysis. We also described workflows of tele‐GMH clinicians as they align with the “4Ms” of age‐friendly care (Mentation, Medications, Mobility, What Matters). Findings: Referring clinicians serving rural Veterans reported lower access to geriatricians than those serving both rural and nonrural Veterans (14.3% vs 36.4%, respectively). Reported access to additional specialty services, as well as local aging services, was also limited. Based on interviews, facilitators for connecting Veterans to services included tele‐GMH clinicians’ knowledge of local resources. Tele‐GMH clinicians reported barriers including high demand, geography, and frequent staff turnover. Tele‐GMH clinicians highlighted the utility of the 4Ms to enhance quality of care. Conclusions: Integrating geriatric medicine into tele‐GMH programs supports the delivery of high‐quality, age‐friendly health care, optimizing VHA workforce capacity and improving care coordination within VHA and non‐VHA systems.

The current workforce lacks enough trained psychologists specializing in geriatric mental health (i.e., geropsychologists) to meet the population's needs. The Veterans Health Administration (VHA) Geriatric Scholars Program-Psychology Track (GSP-P) targets this gap by providing intensive post-licensure training to enhance geropsychology skills and competencies. Further professional development is offered through an advanced workshop that includes structured independent learning plans (ILPs) with subject matter expert consultation over a 6-month period. To evaluate the program, we conducted a survey that included closed-ended questions for perceptions of learning on a 5-point Likert type scale and open-ended questions to characterize the perception of the ILP experience, local challenges and solutions, and impact on the population level. The response rate was 78.9% among 19 scholars. Scholars strongly agreed that participation in the ILPs improved their geropsychology knowledge (M = 4.8 of 5/strongly agreed) and skills (M = 4.5 of 5). Content analysis of activities completed and challenges was conducted. A rapid thematic analytic approach guided by the Kirkpatrick (2016) learning evaluation model was used to analyze scholars' responses to open-ended prompts. Qualitative findings confirmed a positive reaction to learning, acquisition of new knowledge, skills and competencies, which led to practice change that, in turn, had a positive impact on VHA organizational goals. After completing the ILP, scholars described their commitment to continue and grow in geropsychology training, which suggests that the GSP-P model, with mentored independent learning for continuing professional development, might be expanded within VHA and exported to other healthcare settings.

Background: Older veterans with anxiety disorders encounter multiple barriers to receiving mental health services, including transportation difficulties, physical limitations, and limited access to providers trained to work with older persons. To address both accessibility and the shortage of available providers, evidence-based treatments that can be delivered via guided self-management modalities are a potential solution. Objective: This study aims to determine the feasibility and acceptability of a randomized controlled trial of 2 guided self-management interventions. This study compared the treatment effects of these 2 interventions (relaxation and health psychoeducation) on anxiety symptom severity and functioning in older veterans with anxiety disorders. Our exploratory aims examined factors related to home practices and treatment engagement and perceptions of the practices. Methods: Participants were randomized to one of two video-delivered interventions: (1) Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE)—breathing and progressive relaxation or (2) Healthy Living for Reduced Anxiety—psychoeducation about lifestyle changes. Telephone coaching calls were conducted weekly. Measures of anxiety, depression, and functioning were obtained at baseline, week 4 (end of treatment), week 8, and week 12. Participants completed a semistructured interview at week 12. Analyses included descriptive statistics to summarize measures of intervention engagement; mixed-effects models to characterize symptom change, and qualitative analyses. Results: Overall, 56 participants (n=48, 86% men; n=23, 41% from ethnic or racial minority groups; mean age 71.36, SD 6.19 y) were randomized. No difference in retention between study arms was found. The Healthy Living group (29/56, 52%) completed significantly more lessons (mean 3.68, SD 0.86) than the BREATHE group (27/56, 48%; mean 2.85, SD 1.43; t53=2.60; P=.01) but did not differ in completion of coaching calls. In the BREATHE group, greater baseline anxiety scores (r=–0.41; P=.03) and greater severity of medical comorbidity (r=–0.50; P=.009) were associated with fewer completed practices. There was no effect of intervention on change in total anxiety scores or functioning. For specific anxiety subtypes, Healthy Living produced a greater decline in somatic anxiety compared with BREATHE. Qualitative analyses found barriers to practicing, including difficulty setting time aside to practice, forgetting, or having other activities that interfered with BREATHE practices. Some participants described adapting their practice routine to fit their daily lives; some also used relaxation skills in everyday situations. Conclusions: These findings suggest that a larger randomized controlled trial of guided self-management approaches to treating late-life anxiety is feasible; however, BREATHE was not effective in reducing anxiety compared with Healthy Living. Possible contributing factors may have been the reliance on a single technique. Progressive relaxation was reported to be enjoyable for most participants, but maintaining home practices was challenging. Those with milder anxiety severity and fewer health problems were better able to adhere to practices. Trial Registration: ClinicalTrials.gov NCT02400723; https://clinicaltrials.gov/study/NCT02400723