Veterans' Preferences for Remote Management of Chronic Conditions

Abstract

Background:

The Veterans Health Administration (VA) is investing considerable resources into providing remote management care to patients for disease prevention and management. Remote management includes online patient portals, e-mails between patients and providers, follow-up phone calls, and home health devices to monitor health status. However, little is known about patients' attitudes and preferences for this type of care. This qualitative study was conducted to better understand patient preferences for receiving remote care.

Methods:

Ten focus groups were held comprising 77 patients with hypertension or tobacco use history at two VA medical centers. Discussion questions focused on experience with current VA remote management efforts and preferences for receiving additional care between outpatient visits.

Results:

Most participants were receptive to remote management for referrals, appointment reminders, resource information, and motivational and emotional support between visits, but described challenges with some technological tools. Participants reported that remote management should be personalized and tailored to individual needs. They expressed preferences for frequency, scope, continuity of provider, and mode of communication between visits. Most participants were open to nonclinicians contacting them as long as they had direct connection to their medical team. Some participants expressed a preference for a licensed medical professional. All groups raised concerns around confidentiality and privacy of healthcare information. Female Veterans expressed a desire for gender-sensitive care and an interest in complementary and alternative medicine.

Conclusions:

The findings and specific recommendations from this study can improve existing remote management programs and inform the design of future efforts.

Introduction

Remote management improves access to care and decreases costs associated with patients traveling for traditional in-person medical appointments.¹ In 2010, the Veterans Health Administration (VA) launched an initiative to adopt a model that promotes remote management of healthcare called the Patient Aligned Care Team (PACT), the VA version of a patient-centered medical home, into its existing primary care clinics. PACT emphasizes team-based care and promotes enhanced accessibility to services.^2
–4 Remote management, the use of telehealth technology, remote monitoring and checkups, and virtual or phone-based patient education, is one component in the model to enhance access to care.⁵

Each PACT comprised a group of veterans who are managed by a medical team of providers and promotes remote management through the use of virtual assistance tools.⁶ These tools include the following: (1) MyHealtheVet, an online portal where veterans can track their health information, appointments and prescriptions, and communicate with their provider through a secure patient portal, (2) the VA Nurses Helpline, where veterans can call triage nurses for medical assistance and emotional support, and (3) Telehealth Services, which provide patient follow-up such as checking blood pressure and weight by VA-administered devices.^7
–9 These virtual communication tools maybe particularly effective for patients with chronic conditions that require regular self-management.

Prior research on remote management interventions for veterans has either evaluated how they affect specific health outcomes, how cost-effective or feasible they are compared to traditional care, or how individual aspects of remote management are utilized.^10

–15 While some studies have explored provider perceptions of VA remote management, few have studied patient perceptions.^16,17 A 2011 study examined veterans with chronic conditions attitudes toward remote management with a 12-item survey and one open-ended question, but called for a more thorough qualitative study to identify richer areas for program improvement.¹⁸ To our knowledge, no studies have qualitatively sought to understand veterans' preferences for remote management as a unique delivery of care. The goal of this study was to understand patients with chronic conditions preferences for remote management to inform existing and future programs.

Methods

Study Population And Setting

Seventy-seven (n = 77) veterans with hypertension or a history of tobacco use participated in 10 focus groups, average 8 participants (range 5–10), at two urban VA medical centers between October and November 2014. This study was built upon a 2012 cluster-randomized trial where nonclinical assistants were randomly integrated into existing PACTs for 8 months to provide additional remote management in two VA outpatient primary care settings.¹⁹ Veterans who had participated in any arm of the trial were considered eligible for this study because they received PACT remote management between visits, regardless of whether they had been provided additional remote management by an assistant during the study. The study sample included only veterans with hypertension or a history of smoking because they require self-management between visits and the remote management approaches are similar. Hypertension and tobacco use also affect substantial numbers of veterans, lead to significant morbidity and healthcare costs, and have effective treatments that are not fully optimized, and could thereby benefit from remote management tools.^20,21

We mailed focus group invitation letters to a total of 1,179 veterans who were (1) receiving care by PACT in the Manhattan or Brooklyn campuses of the VA New York Harbor Healthcare System, (2) had a history of hypertension and/or tobacco use, and (3) had previously responded to a mail-based survey as part of the earlier panel management study. The use of remote management was not an eligibility criterion to be considered for the study. We stratified focus groups by site, gender, and age (younger or older than 60 years). We chose a homogeneous purposeful sampling method to reduce variation, to facilitate group discussion, and to describe a particular subgroup in depth.²² By narrowing our sample down to only two chronic conditions, we also created more homogenous focus groups. However, we did not separate the focus groups by chronic condition as some participants had both hypertension and a history of tobacco use.

To have a sufficient sample size across sex-stratified groups, we recruited additional female veterans who had not been involved in the prior panel management study. These additional participants were considered eligible based on selection criteria 1 and 2. Interested participants were scheduled to 1 of 10 morning or evening focus groups to account for varying schedules. We conducted additional focus groups until we reached thematic saturation (wherein a common range of themes had emerged and we no longer discovered new information), therein, no additional focus groups were scheduled.²²

The study was approved by the Institutional Review Board at the VA New York Harbor. Each participant provided written informed consent and completed a demographic survey and a survey on current use of VA resources (i.e., MyHealtheVet, Telehealth, and Nurse Helpline), and communication technologies (i.e., texting and Internet). Patients were compensated $40 for their participation. The research team developed the focus group guide based on prior research on remote management.^19,23 Discussion questions focused on experience with current VA remote management efforts and preferences for receiving additional care between outpatient visits. One of two experienced facilitators on the research team led the focus groups and another researcher observed each group.

Data Analysis

We recorded survey responses in Research Electronic Data Capture (REDCap) portal and used descriptive statistics to aggregate the results. We audio-recorded all focus groups and a third-party service anonymously transcribed them. Transcripts were entered into NVivo8 qualitative software for data management and retrieval.²⁴ We analyzed transcripts using applied thematic analysis, an inductive set of procedures designed to identify and examine emerging themes from conceptual data.²⁵ Four researchers independently reviewed transcripts to develop an initial codebook and a team of two independently coded each transcript, modified the codebooks as themes emerged, and met to discuss and reconcile discrepancies until a final coded transcript was created. Disagreements around codes, themes, and subthemes were resolved by discussion with the team or going back to the original transcripts. Themes from interviews and focus groups were then organized using descriptive matrix analyses that visually displayed the range of related responses.²⁶ Rows of the descriptive matrix were organized by domain and construct, such as mode of communication and traditional or modern, and the columns represented a range of quotes that correspond to each construct. This allowed for a comprehensive analysis of the data and ensured we not only focused on the majority feeling among participants, but also the outliers.

Results and Materials

Participants

Patient demographics are shown in Table 1.

Table 1.

Participant Characteristics

VARIABLE	% OF PARTICIPANTS n = 77
Patient characteristics
Mean age (years)	59
Male	56
African American	64
Currently employed outside of the home	29
History of hypertension	78
History of tobacco use	72
Communication technology use
Sending at least 1 text message per day	43
Owns an Internet-enabled device	70
Use of VA remote management services
MyHealtheVet	29
VA telehealth service	13
VA nursing helpline	19

VA, Veterans Health Administration.

Themes

Several themes were identified from the data (Table 2) and described in detail with quotes. Based on these study findings described below, a list of recommendations for remote management programs was created (Table 3).

Table 2.

Recurrent Themes in Focus Group Responses

Attitudes toward current remote management efforts.

Mode and frequency of remote management communication.

Provider preferences for delivery of remote management.

Concerns about privacy and connection to PACT providers.

Complementary and alternative medicine, peer support and gender-sensitive considerations within remote management for women.

PACT, Patient Aligned Care Team.

Table 3.

Recommendations for Patient-Centered Remote Management Programs

1. Tailor remote management efforts to individual preferences for:

• Mode of remote management communication (i.e., phone, text, MyHealtheVet messaging, letters, and email).

• Frequency of remote management (i.e., daily, weekly, or only before a scheduled appointment).

• Status of remote management personnel (i.e., nonlicensed versus licensed contact person).

• Scope of remote management (i.e., appointment reminders, medication reminders, motivational discussion, and resource sharing).

• “Opt-in” and/or “Opt-out” choices.

• In person training or online training to learn technologically complicated tools (e.g., how to log into an online patient portal to check medical records).

2. Ensure that the remote management is connected to the veterans; PACT . Explicitly state that the information will be relayed to their primary care team and that all remote management is a part of that team.

3. Veterans expressed a desire for continuity of providers . Consider maintaining consistency between remote management staff members, the PACTs they work with, and the veterans they communicate with.

4. Train all remote management staff with the knowledge and interpersonal skills necessary to conduct high quality, effective, and patient-centered remote management.

5. To reduce concerns over privacy and confidentiality , explain to veterans that remote management is coming directly from their PACT providers and discuss institutional steps to protect confidentiality.

6. Incorporate complementary and alternative medicine options and peer support, especially for female veterans who reported a desire for gender-sensitive care.

Attitudes Toward Current Remote Management

The majority of participants who were utilizing remote care appreciated current VA remote management efforts, which include appointment reminder calls, calls to support behavior change, and posthospital discharge check-ins.

“…I said I'm going to quit, I'm going to quit, and I did for three months and that phone call, those phone calls helped.”

“I've gotten good information from the VA and secure messaging from the nurse saying “Hey. How (are) you doing with the patches?”

Difficulty with some of the more advanced technological tools such as MyhealtheVet came up in several focus groups as well and some patients asked for the tools to be more “simplified.” As one participant noted, “I've signed up three times and it's hell just to get your own information online. You can't really see it. You still have to go through so much, and it's frustrating.”

It is important to note that some participants in each focus group reported being unaware of the remote management efforts that were already in place at their VA. One discussion highlighted this sentiment well, “They got a lot of programs here.” “Yeah but we don't know half of them.” “The VA should publicize it [remote management] more.”

Mode And Frequency Of Remote Management Communication

All participants reported strong preferences for services tailored to individual needs and an “opt in/opt out” choice to receive additional remote care. As one participant noted, “We all have different stories.” Preferences for mode of remote management ranged as a function of participants' age, familiarity, access, and mastery of technology. While some participants cited preferences for text messaging, either directly with their PACT or through MyHealtheVet, others reported that they would prefer phone calls and printed letters “that can be put on the refrigerator.” Many of the older participants expressed a preference for more traditional forms of communication.

“The messaging is probably the best way (be)cause…you could be sitting down here and it won't really bother people.”

“So I don't have a computer…I have a cell phone and I don't understand that one either. I'm old fashioned.”

Participants also expressed interests in having options for the frequency of communication, ranging from daily contact to once every 6 months.

“I think it depends on the situation. Like myself, you know, I don't have a daily problem so they can call me once every six months. But if somebody is on a program or somebody is trying to lose weight or something you have to change the amount, you know, when you should contact them. Everybody is an individual.”

Several participants emphasized the importance of tailoring remote management programs to fit different schedules and lifestyles. Specifically, some veterans said that the VA and components of remote management are difficult to access for patients who work full time.

“…I know the majority of the veterans that access VA health facilities have the time to access that because they may not be working, but a lot of vets do, you know, and that's what stops a lot of vets from sometimes accessing the programs that are available to them.”

“I never answer my cell phone, you know. Because I'm working or I'm busy or whatever, so she [my medical provider] leaves messages.”

Provider Preferences For The Delivery Of Remote Management

The majority of participants stated that they wanted any provider of remote management to be directly linked to their PACT. They strongly emphasized that any information they provided during these remote management communications should be directly relayed back to their PACT providers.

“As long as it's within my team [PACT]…I'd prefer it stays within my team because this is my team so they're supposed to know what's going on.”

A frustration that came up in most groups was a lack of continuity of care among VA providers. As one participant explained, “Every time that I come over here for an appointment, I find myself with a new doctor that doesn't really know what's going on with me and I start all over again explaining to them the situation.” While continuity of care within remote management was not explicitly discussed, remote management programs should be aware of patient's preference to meet, either virtually or in person, with the same provider.

Participants also stated that it would be important for the remote management provider to have strong interpersonal skills.

“If you see that the person is sincere and kind when the phone rings with that number, you're going to get those images automatically and those are positive images.”

The sentiment that a lack of interpersonal skills would undermine the success of remote management programs was also discussed.

“You can train people, but if they don't have a passion for it and they're not comfortable doing it, it's not going to work.”

Participants were asked how they would feel if someone who was a “nonlicensed” medical professional (e.g., a VA staff member who is not a nurse, medical doctor, or psychologist) contacted them. Responses ranged from a minimum requirement that the remote management provider be someone who is trained and “knowledgeable” and part of their PACT team to feeling “uncomfortable” having someone who is not a nurse or a doctor review their medical history.

“When they're part of the team, when they're not a medical professional, that's fine, because they're just passing the information from my primary care.”

“Because if they're not a licensed professional so on and so forth I'd feel kind of awkward about them knowing my medical history, other than that I wouldn't mind.”

Privacy And Confidentiality In Connection With Pact

Some participants expressed concerns about privacy and confidentiality if additional remote management team members are given access to their medical records. This was an unexpected finding, as these concerns were spontaneously presented by at least one participant in every focus group.

“I have an issue with somebody knowing my medical history, because not only do you know my diseases, what I'm doing, all my personal information, also because you have to have some type of data to identify me.”

“That's just too many people knowing too much stuff. And I just feel that's how we get all these errors and we get everything stolen.”

Complementary And Alternative Medicine And Peer Support For Women Veterans

Complementary and alternative medicine as part of remote management emerged organically as a theme among female participants only. Female participants expressed interest in “holistic healing,” including alternative health options for “mental balance,” “smoking cessation,” and “weight control,” and described a desire to implement lifestyle changes that would reduce dependence on medication.

“When I first started with the VA I noticed that they'll drop drugs on you in a heartbeat and I'm not one to do that. I like natural medicine as much as possible or, you know, do what I can for myself.”

Female participants also stated that they would like opportunities to collaborate and to “share some of the problems that they're having with weight or smoking” with fellow female veterans to facilitate behavior changes. Many women reported that the VA primarily serves men and that more programs should consider the unique needs of female veterans.

Discussion

Participants stressed the importance of tailored remote management, a direct link to their PACT, and strong interpersonal skills for VA staff. Some participants were only comfortable with a licensed medical professional from the VA contracting them. They were also concerned with potential violations of privacy and confidentiality. Female participants expressed an interest in complementary and alternative medicine and connection to other female veterans.

Our findings dovetail with existing literature on remote care. Two studies evaluated new telehealth programs and showed that veterans are not only receptive to remote management but also want personal assistance or in-person connections. A 2015 study interviewed female veterans to understand their experiences with an online pilot diabetes prevention program. Participants found the program convenient, that it integrated well into daily life, and made them feel accountable in achieving their health goals. However, similar to our findings that veterans found some of the remote management tools technologically complex, some did not like logging into a system and found it to be too impersonal.²⁷ Another 2013 study interviewed homeless veterans to evaluate interest and acceptance of a care coordination telehealth program for chronic disease management. Most participants were satisfied with the program, but similar to our findings that women want connection to other female veterans, also wanted peer social assistance.²⁸ While remote management can make care convenient and cost-effective, it is imperative to emphasize personalization and human connection.

Our participants' feedback that strong staff interpersonal skills and continuity of care will improve remote management delivery aligns with other studies linking patient satisfaction with provider communication style.²⁹ Previous studies have also cited provider characteristics and continuity of providers as key factors associated with patient satisfaction.^30
–32 Both incorporating VA staff members who work in remote management into the PACT model and ensure that patients meet with, either virtually or in person, the same provider consistently, will help build trust with the patient and cohesion within the healthcare team.

Our participants' concerns about privacy and confidentiality echo previous research indicating that patients prefer limited sharing of personal health information.³³ Future programs should keep this in mind and communicate that patient health information will not be breached.

Similar to our findings among women veterans, existing literature states that veterans are open to and believe in complementary and alternative medicine.³⁴ Research has suggested that these alternative options may fill a void in conventional medical care systems.³⁵ A 2017 study also found that female Veterans suggested that the VA facilitate opportunities for collaboration and peer support in a male-dominated healthcare facility.^36,37 Remote management for these services may be especially critical for women veterans who may be more hesitant to attend in-person VA-sponsored health programs due to the nature of the predominantly male environment.³⁸

Our results that veterans have preferences for individualized, tailored care aligns with the VA's commitment to veteran-centered care.³⁹ Therefore, improving or designing programs to align with their preferences, as we have described in this study, will be critical to meet this goal.

Limitations

This work has several limitations. Most notably, patients were from one urban area and may not be representative of all veteran's perspectives. Also, we only included patients with hypertension or a history of tobacco use. While we did not focus on remote management content for specific conditions, but rather general preferences for the service itself, patients with other chronic conditions such as diabetes may have different preferences for remote care. Another limitation is that focus group-based study designs may produce selection biases; those who choose to participate in research may be a different population than those who do not. Participants who volunteered to participate may have more positive experiences with remote management than those who chose not to participate. However, we encountered and reported on a range of attitudes about existing services.

Social desirability bias is also a possible threat to validity. To account for this potential bias, researchers reminded participants that the study was confidential, their responses would not affect their care at the VA, and there were no correct answers. In addition, due to the small number of women in the original 2012 cluster randomized trial, we had to include female veterans from the general VA population. Last, use of remote management services was not part of the eligibility criteria and our study sample has a high percentage of individuals who had not used remote services. However, including these veterans' perspectives may help program planners to tailor services to engage current nonusers. It also highlighted a lack of knowledge around existing services. It is important to understand preferences of these less engaged patients.

Conclusions and Recommendations

As our healthcare industry continues to focus attention and resources toward innovative use of technology, engaging veterans in remote management with existing healthcare tools, like MyHealtheVet and Telehealth Services, is going to be critical to maintain quality and reduce cost. Results and specific recommendations from these focus groups can aid efforts to improve and design patient-centered remote management programs. See specific recommendations based on our findings (Table 3).

Dataset Availability

The datasets supporting the conclusions of this article are available in the VA Informatics and Computing Infrastructure repository. Within the repository, the survey data are stored in REDCap and the coded transcripts with codebook are stored in Nvivo v8.

Footnotes

Acknowledgment

The research leading to these results was funded through an HSR&D grant from the VA Health Services Research & Development Service (EDU 08-428-2).

Authors' Contributions

E.S. attended all groups and moderated some of the focus groups, conducted the analysis, and wrote and edited the article. K.B. attended most focus groups as note-taker, conducted the analysis, and wrote and edited the article. A.J. oversaw data entry and management of questionnaire results, moderated some focus groups, and assisted with writing the article. N.S. attended several focus groups as note-taker, coded the transcripts, and assisted with writing and editing the article. K.B. assisted with study design, attended some focus groups as note-taker, and assisted with writing the article. S.S. assisted with study design, edited the focus group guide and survey, and assisted in framing the article, writing, and editing. M.S. assisted with study design, and assisted in framing the article, writing, and editing. All authors provided final approval for the submission of this article and are accountable for all aspects of the work. Our Ethics statement is listed in the section of the article.

Disclosure Statement

No competing financial interests exist.

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