Can telemedicine reach rural, older veterans on the edge of or caught in the digital divide? – Unique considerations for two distinct populations

Figures & data

Table 1. Demographic characteristics of rural, older veterans highly correlated with disparities in digital access.

Characteristics correlated with disparities in digital access (DDI)	Demographics of Rural Veterans
Age	Rural Veterans enrolled in VA’s health care system are significantly older [than urban Veterans]: 55 percent are over the age of 65^a
Disabilities	58 percent of rural enrolled Veterans have at least one service connected condition^a [The older, rural] Veteran population is medically complex and more likely to be diagnosed with diabetes, obesity, high blood pressure and heart conditions that require more frequent, ongoing care^a
Educational Attainment	A higher percentage of rural Veterans (44%) compared to urban Veterans (33%) have completed less than a high school degree^c
Infrastructure (Built Environment)	27 percent do not access the internet at home^a
Socio-economic status	44 percent earn less than $35,000 annually^a 7% live in poverty^b
Other Variables Identified by Darrat et al. (2021)	Demographics of Rural Veterans
Gender	92 percent of enrolled rural Veterans are men^a
Marital/Partnered status	Information pertaining to the general Veteran population (not specific to rural Veterans): ‘Veterans are more likely to be men and live alone than non-Veterans … Household demographics have an effect on fixed and mobile subscriptions among Veterans. As Veterans are more likely to be men living alone, they also tend to have the lowest subscription rates to fixed and mobile broadband’^d Studies consistently highlight the importance of caregivers^a to older Veterans’ ability to access telemedicine^e,fb

^ahttps://www.ruralhealth.va.gov/aboutus/ruralvets.asp#:~:text=VA%20recognizes%20the%20need%20to,budget%20to%20rural%20Veteran%20care. Accessed December 26, 2023.

^bhttps://www.census.gov/library/publications/2017/acs/acs-36.html. Accessed December 26, 2023.

^cU.S. Census Bureau, American Community Survey, 2014 Prepared by the National Center for Veterans Analysis and Statistics. Accessed December 26, 2023.

^dFederal Communications Commission USA. Report on Promoting Broadband Internet Access Service for Veterans, Pursuant to the Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018. Prepared by the Wireline Competition Bureau. Submitted to the Senate Committee on Commerce, Science, and Transportation House of Representatives Committee on Energy and Commerce. May 2019.

^eGately ME, Waller D, Metcalf EE, Moo LR. Occupational Therapy Practitioner Perspectives of the Role of Caregivers in Video Telehealth. J Gerontol Nurs. 2022 Oct;48(10):15–20. doi: 10.3928/00989134–20220908–02. Epub 2022 Oct 1. PMID: 36169296; PMCID: PMC9577539.

^fDryden EM, Kennedy MA, Conti J, et al. Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers. Health Serv Res. 2023; 58(Suppl. 1): 26–35. doi:10.1111/1475–6773.14055.

Figure 1. National sample of community-based outpatient clinic staff (n = 50) affiliated with GRECC connect hub sites on east and west coast, as well as the south and mid-west regions of US.

Table 2. Social risk factors and gaps in care of rural, older veterans identified by CBOC staff (listed alphabetically in each column).

Cardiology	Home-based care	Pulmonology
Caregiver respite, resources	Mental health care	Technology/connectivity
Dementia diagnosis, care	Outreach/education	Transition to long term care
Food insecurity	Palliative Care	Transportation services

Table 3. Quotes from CBOC staff highlighting contextual factors that leave rural, older veterans on the edge of the digital divide.

Infrastructure	‘I have Veterans that in theory have the technology and they know how to use it, but their internet is not strong enough … So, I have not been able to do any video visits … The lack of high-speed internet in our area is huge’. (Psychologist)
Access to technology	‘It seems that it’s really hard for a lot of them to access virtual care other than just the phone. I don’t know if that’s … because they don’t have the technology or the familiarity with it’. (Psychologist)
Digital literacy combined with physical limitations	‘You’re asking an 80-year-old man to not only navigate an email but navigate an iPad. “Click here, click there”. Some might have Parkinson’s. Some might have hearing loss. Some have sight issues. We’re trying to make everything more acceptable to them, but we’re also [asking] them to do something that is hard for them and not familiar and that they’re not comfortable with’. (Telemedicine Technician)

Figure 2. Veterans caught in the digital divide—another social determinant of health of rural, older veterans.

Table 4. Convergence of multiple types of isolation and other social risk factors as the social ecological context of rural, older veterans caught in the digital divide.

Off the Grid	‘They live in tiny communities that branch out on the peninsula with 60 to 70 miles [in] between … Many of these patients live up in the mountains, or they live in areas that are very off the grid. They don’t have computer access or cellphone access’. (Clinic Manager) ‘Older Veterans—there are a number of them, especially again with PTSD, … they’re living off the grid. If they had local places where they could just drop in and connect for basic needs, medical needs and mental health needs, that would be amazing’. (Social Worker)
Lack of safe shelter/housing	‘We also have a very large homeless population, unfortunately, living in the area that live … in the trees and, … in little caves, trying to survive out here’. (Clinic Manager)
Intersection-ality (Geography, Age, SES)	‘A lot of our more rural patients … don’t tend to have on-line access … Many are very poor and almost homeless or on the edge of homeless, living in trailers out on little pieces of land … By the time they call into the Call Center and sit on hold for five or ten or 20 minutes … [or we] try to call them back and get through to them, it’s not easy even when we do finally make contact. That system isn’t working well for that population. The younger patients are more savvy on computers and cellphones, and they seem to be much more reachable, and they may have more financial means, too; that may be part of it’. (Primary Care Physician)

Figure 3. Condensing a 9-page instruction manual into a tip sheet with older veteran input.

Figure 4. Tip sheet for a successful VA telemedicine appointment.

Figure 5. Agency for healthcare research and quality.

Darrat, I., Tam, S., Boulis, M., & Williams, A. M. (2021). Socioeconomic disparities in patient use of telehealth during the coronavirus disease 2019 surge. JAMA Otolaryngology Head & Neck Surgery, 147(3), 287–27. https://doi.org/10.1001/jamaoto.2020.5161

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Data availability statement

The data that support the findings of this study are available from the corresponding author (KAN) upon reasonable request.