Telerehabilitation for Rural Veterans: A Qualitative Assessment of Barriers and Facilitators to Implementation

Figures & data

Table 1 Interview Guide Structured Using Qualitative Approach to RE-AIM Framework

RE-AIM Domain and Definition Used*	Prompts and Probes
Reach - What factors contribute to the participation/non-participation of patients in TR? What might have been done to get more patients to participate in TR?	Veterans What are barriers to serving rural Veteran patients with telerehabilitation? What are facilitators to serving rural Veteran patients with telerehabilitation? Are there specific patient profiles that are more frequently seen for telerehab? Who would be the ideal candidate for telerehab? What are some reasons that Veterans prefer tele to face to face? How many are declining the telerehab approach? Are you keeping track of this? What incentives are there to use one or the other? Are there any specific disincentives for the Veteran patients to use telerehab?
Effectiveness – Is telerehabilitation working to affect the outcomes noted? What other factors contribute to the results? Are the results of TR-EWI meaningful and how?	Metrics Do you have any idea on how to capture effort in telerehabilitation (instead of just uniques and encounters?) How helpful is the data you are collecting now in terms of helping you understand the reach of your program and how to expand that reach? What other kind of outcomes data could capture effectiveness of telerehabilitation? What services do you provide now that you have the telerehab mechanism that you did not provide before? How does the tele-health delivery increase your capacity and improve your quality of care? What are the new capacities that you did not have before? Are there things that we can measure in terms of cost? (provider time, mileage, other resources)
Adoption - What factors contributed to the facility and its providers taking up the TR-EWI program? What barriers interacted with the program to prevent adoption? Was there partial or complete adoption? Why did some providers participate, and others did not?	Sites How would you describe the adoption of tele-rehab from facility leadership? What drives the adoption of the different protocols? (expertise, what counts/credit, VA policy, population needs) Are there any obvious differences in the adoption of different protocols? How do you recruit other facilities? How do you create partnerships outside TR-EWI and the VA? What is the minimum requirement to become a community partner?
	Providers How do you identify providers for telerehabilitation? Who is the ideal provider for telerehabilitation? What proportion of providers who are approached say Yes? What proportion say No? Why do providers decline telerehabilitation? How many providers are telehealth ready? How do you increase the number of tele-rehab ready providers? Are there incentives at your facility to increase the # of telehealth ready providers? What are the barriers to becoming a telerehabilitation provider? How have the different rehabilitation specialists adapted their rehabilitation practice to tele-delivery? What are the facilitators to becoming a telerehabilitation provider? What advice would you give to other providers who want to use tele-delivery for rehabilitation?
Implementation – How was TR-EWI implemented? By whom and when? What influenced implementation or lack of implementation? How and why was TR-EWI program adapted or modified over time?	What kind of guidance and how much did you receive in establishing the program? What are the barriers for implementing telerehabilitation? What are the facilitators for implementing telerehabilitation? Describe steps required to set up a clinic. What kind of space is needed for a telerehabilitation clinic? Describe the variations and differences in implementing the different protocols. Which protocols are easiest to implement? Why? Based on experience, what protocols would you recommend for people to implement? What are the pros and cons for different technology used?
Maintenance** – Is the TR-EWI being implemented (and adapted) after the implementation core period? What is sustained, what discontinued, what modified- and why?	Please name the protocols that have been implemented thus far and state whether they are at-risk or not-at-risk of being sustained into the future. Describe the sustainability plans for each. Do you expect any changes in your existing relationships with the following entities? (Describe and explain reasons for anticipated changes.) Spoke sites Other services within your facility Collaboration with other Hubs Collaboration with VA National Program Office Collaboration with community partners and vendors Do you expect new Spokes to emerge as a product of the culture of collaboration that has been fostered over TR-EWI’s implementation? If so, please explain. Are there other rural collaborations on your radar that you have not had time to implement? TR-EWI has been very successful at increasing the number of rural Veterans served. Do you expect to continue to see increasing numbers of rural Veterans after TR-EWI funding ends? What additional things could be done to expand reach of TR-EWI to rural Veterans? How do you plan to continue tracking outcomes? What else can be tracked to document the impact of TR-EWI?

Notes: *All summary questions listed under RE-AIM Domain and Definitions were adapted from Holtrop, Rabin, and Glasgow.³¹ **Maintenance questions were not used during the time period reported in this study.

Table 2 Hubs and Rural Spoke Sites Used to Implement a Telerehabilitation Program for Rural Veterans

Hub	Rural Spoke Site
Richmond, Virginia	Charlotte Hall, VA
	Clarksburg, WV
Minneapolis, Minnesota	Sioux Falls, SD
	Tomah, WI
	Mason City, IA
San Antonio, Texas	Asheville, NC
	Victoria, TX
Seattle, Washington	Kailua Kona, HI

Table 3 Themes, Subthemes, and Barriers and Facilitators of Telerehabilitation (TR) Program Implementation

Themes and Subthemes	Theme Description	Representative Barrier(s)	Representative Facilitator(s)
Cultural Factors Influencing Reach and Adoption of TR  Veterans’ acceptance of TR	This theme describes the habits, skills, and practices involved in TR process from both Veterans’ and providers’ perspectives.	Veterans’ discomfort with newness of using technology within rehabilitation interactions Veteran forgoing mileage reimbursement	Caregiver availability to assist with technology and/or logistics Convenience offered by TR Ability to avoid potential exposure to triggering situations for Veterans with PTSD Use of smartphones/technologies that are already embedded in Veterans’ lives TR a benefit when Veterans are challenged in driving
Providers’ cultural acceptance of TR		Therapy practices that traditionally rely on manual procedures	Administrative strategies: Allowing providers autonomy and flexibility in implementing TR into their practice, which enabled them to discover what works Program leaders’ advocating for TR use among providers Mentorship and development of TR training in how to implement
Infrastructural and Logistical Factors for TR Implementation	This theme describes the infrastructure and logistical constraints to telerehabilitation.	Limited space that is quiet, private, ample enough for demonstrations, and flexible enough to meet clinicians’ dynamic scheduling needs Identifying and then procuring needed technology Coordination of services requiring an interdisciplinary approach	Administrative strategies: Program leaders’ championing of TR-related needs (eg, space, equipment) Availability of personnel (ie, technicians) dedicated to providing logistical support for the TR Development of systematic way of sharing TR lessons learned
Rurality as a Factor in TR Implementation	This theme describes the complexity involved in extending TR to rural, low-resource environments.	Complexity of providing health and rehabilitation services to Veterans living in rural, low-resource communities Staffing challenges; difficulty in recruiting rehabilitation professionals to rural clinics	When an urban care center was in close enough proximity to serve rural areas When there are schools and jobs available in rural communities to support families of rural TR technicians

Abbreviation: PTSD, post-traumatic stress disorder.

Holtrop JS, Rabin BA, Glasgow RE. Qualitative approaches to use of the re-aim framework: rationale and methods. BMC Health Serv Res. 2018;18(1):177. doi:10.1186/s12913-018-2938-8

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