Institutionalized persons with dementia often lack access to meaningful activity, which can lead to agitation, loneliness, and depression. Engagement in activity may improve negative symptoms but is difficult in most settings. In this study, we investigated the degree to which the Reading Buddies Program, in which occupational therapy graduate students read books with residents with dementia, engaged residents. We further assessed whether the level of engagement was affected by various parameters, including those related to interaction, environment, attention, attitude, and activity. The primary outcome measure was engagement percentage–duration of time the book was read divided by duration of time the person with dementia engaged with the book. As expected, increased attention, attitude, and activity parameters were associated with increased engagement. None of the environmental parameters significantly affected engagement. Overall, we found that reading with persons with dementia led to a very high level of engagement and appeared to reduce negative symptoms.

Date Presented 03/22/24 This paper presents three cases from interviews with caregivers who assisted older rural clients in OT video sessions, describing a range of family caregiver perspectives. Primary Author and Speaker: Megan E. Gately Additional Authors and Speakers: Dylan E. Waller, Matthew Maynard, Lauren R. Moo

BackgroundOlder adults face barriers to specialty care, such as occupational therapy (OT), and these challenges are worse for rural older adults. While in-home video telehealth may increase access to OT, older adults’ health- and technology-related challenges may necessitate caregiver assistance. ObjectiveThis study examines caregiver assistance with in-home OT video telehealth visits from the perspectives of OT practitioners at Veterans Health Administration (VHA). MethodsA web-based national survey of VHA OT practitioners about caregivers’ role in video telehealth was conducted between January and February 2022. Survey items were developed with input from subject matter experts in geriatrics and OT and identified patient factors that necessitate caregiver participation; the extent to which caregivers assist with different types of tasks (technological and clinical tasks); and the perceived facilitators of, benefits of, and barriers to caregiver involvement. ResultsOf approximately 1787 eligible VHA OT practitioners, 286 (16% response rate) participated. Not all survey items required completion, resulting in different denominators. Most respondents were female (183/226, 81%), White (163/225, 72.4%), and occupational therapists (275/286, 96.2%). Respondents were from 87 VHA medical centers, the catchment areas of which served a patient population that was 34% rural, on average (SD 0.22). Most participants (162/232, 69.8%) had >10 years of OT experience serving a patient cohort mostly aged ≥65 years (189/232, 81.5%) in primarily outpatient rehabilitation (132/232, 56.9%). The top patient factors necessitating caregiver involvement were lack of technical skills, cognitive impairment, and advanced patient age, with health-related impairments (eg, hearing or vision loss) less frequent. Technological tasks that caregivers most frequently assisted with were holding, angling, moving, repositioning, or operating the camera (136/250, 54.4%) and enabling and operating the microphone and setting the volume (126/248, 50.8%). Clinical tasks that caregivers most frequently assisted with were providing patient history (143/239, 59.8%) and assisting with patient communication (124/240, 51.7%). The top facilitator of caregiver participation was clinician-delivered caregiver education about what to expect from video telehealth (152/275, 55.3%), whereas the top barrier was poor connectivity (80/235, 34%). Increased access to video telehealth (212/235, 90.2%) was the top-rated benefit of caregiver participation. Most respondents (164/232, 70.7%) indicated that caregivers were at least sometimes unavailable or unable to assist with video telehealth, in which case the appointment often shifted to phone. ConclusionsCaregivers routinely assist VHA patients with in-home OT video visits, which is invaluable to patients who are older and have complex medical needs. Barriers to caregiver involvement include caregivers’ challenges with video telehealth or inability to assist, or lack of available caregivers. By elucidating the caregiver support role in video visits, this study provides clinicians with strategies to effectively partner with caregivers to enhance older patients’ access to video visits.

Abstract Rapid integration of telehealth in response to the COVID pandemic highlighted digital divide issues, specifically for video, which is a live, synchronous encounter. Older patients may have difficulty navigating a video session due to age, health-related impairment, or low technical competence. Further, specialty services which involve hands-on care, such as occupational therapy (OT), are more complex to translate to video, potentially necessitating a second person to assist with set-up or delivery of clinical care. Caregivers may aid in bridging the digital divide between patient and clinicians in a video session. However, little is known about caregiver willingness and capacity to assume a support role in video, particularly caregivers of rural patients, who have more complex care needs and face more issues accessing needed technology than urban patients. To understand the caregiver role supporting older rural patient engagement in video sessions, we conducted interviews with caregivers (N=25) of older rural veterans with an OT video visit. Interview topics included caregivers’ prior use of and general attitudes toward technology, and experiences of the video visit, including set-up and operation of technology and experience participating and supporting patient engagement. Findings revealed a range of rural caregiver perspectives about the role of technology to facilitate patient access to care, including enabling factors which highlighted caregivers’ education and training support needs. This study deepens our understanding of the importance of caregivers to support rural patient access of video sessions, informing development of strategies to optimize caregiver participation.

Abstract Rural patients at Veterans Health Administration (VHA) are older and have more complex chronic conditions than Veterans receiving care outside VHA. Rural patients face challenges accessing care, particularly specialty services which are often in urban areas. Though video telehealth can increase access to care by older patients, video was underutilized by this group even during the rapid increase in use of video in response to COVID. The unequal uptake of video telehealth by older patients during a time when there were limited options suggests a gap in our understanding of the factors involved with older adults’ utilization of video telehealth. To explore these factors, we interviewed occupational therapy practitioners who were high users of video telehealth (N=27) about their experiences with video telehealth. According to interviews, successful utilization of video telehealth involves consideration of complex factors operating at the person (i.e., patient and clinician) and environmental levels. Person-level factors for the patient and/or family caregiver include technological literacy, sensory impairments, and stress tolerance. Clinician person-level factors include confidence with technology, attitudes towards video (including perceived benefits for clinical care), and specific skills like communication and flexibility. Environmental level factors include the physical setting (e.g., whether the patient/clinician are in a private space), availability of technical assistance for patients and clinicians, caregiver assistance on the patient side, and presence of a device and adequate broadband for patients. Elucidating the network of factors involved with video telehealth may enable sustained integration of video telehealth by rural patients most in need of care.

Abstract Virtual Reality (VR) is a safe and effective adjunctive care option with multiple clinical applications. An interdisciplinary VR program aimed at improving quality of life for veterans receiving inpatient hospice and palliative care was implemented at the VA Bedford Health Care System. Principles from the 4Ms of Geriatrics (Mentation, Mobility, Medications, and Matters Most) guided evaluation and outcomes. Implementation involved decision-making around hardware and software, learning about processes at other facilities, financing, and creating policies and procedures. Project development began in 2021 and data collection began in March 2023. Veteran residents enrolled in inpatient hospice and palliative care were invited to participate. As of August 2023, 22 VR visits were conducted with 13 veterans. Preliminary data suggests VR can be used with a wide range of individuals receiving hospice and palliative care. Analysis of pre-post measures indicate improvement in mood (62%) and overall day (81%), and reduced pain. Barriers to engagement include staffing (e.g., availability), technology (e.g., VR technical issues), hospital procedures/policies (e.g., infection control, COVID-19), and patient factors (e.g., interest, symptoms). Facilitators include hospital support, interdisciplinary collaboration, and understanding of the setting and patient preferences/ needs. Although conception to implementation took two years, a VR program to improve quality of life for veterans enrolled in hospice and palliative care appears to be feasible and clinically beneficial. Experience has shown that flexibility, adaptability, and an individualized approach facilitate engagement. Best practices in the application of VR within the hospice and palliative care setting will continue to be evaluated and honed.

Older adults are an underserved population with a broad-spectrum of care needs due to multi-morbidity, including increasing rates of mental health conditions. Though a prime target for tele-behavioral health due to access barriers, older adults face a persistent digital divide that necessitates clinician training and education to ensure interprofessional tele-behavioral health is tailored to their needs. This paper presents findings from a simulation learning program designed to teach students about the role of video telehealth with populations with diverse needs. Occupational therapy (OT) students enrolled in a Master’s program between 2017 and 2018 conducted a simulated video telehealth session geared for an older adult. Sessions were recorded and annotated by students, who then provided feedback on their experience of the simulation via reflective essays ( N = 27). Essays were analyzed using conventional content analysis with themes revealing the benefits of simulation in providing students with an opportunity to experience the often unpredictable nature of video telehealth. Themes also revealed perceived limitations of video and the negative impact of age-related conditions and age itself on older adults’ ability to engage in video, reflecting ageist stereotyping and bias as potential barriers to novice practitioners’ integration of video telehealth with older adults. Simulation provides students an opportunity to engage in active learning and problem-solving in the moment, fostering students’ development of clinical reasoning while promoting reflective practice. Findings reveal the importance of supporting students’ recognition of biased attitudes to ensure equitable application of tele-behavioral health care, especially to populations with complex needs.

Abstract Caregivers’ role facilitating older adults’ participation in diverse health care services delivered using video telehealth (i.e., live sessions) is not well-understood. This study surveyed occupational therapy (OT) practitioners across Veterans Health Administration (VHA) about caregiver participation in VA Video Connect (VVC), VHA’s videoconferencing platform. 293 OT practitioners participated in the survey, with 47% reporting that caregivers participated in VVC often. The foremost reported patient factors necessitating caregiver participation in video visits were patient lack of technical skills (76%) and cognitive impairment (72%). Barriers to caregiver participation in video visits included poor connectivity and caregivers’ own age or health related impairments, while benefits included increased collaboration with family (87%). This study enhances our understanding of caregivers’ participation in video telehealth, highlighting factors driving caregiver participation and suggesting strategies to optimize this service delivery format for older adults.

Background Telehealth has rapidly expanded since COVID-19. Veterans Health Administration (VHA), the largest integrated health care system in the United States, was well-positioned to incorporate telehealth across specialties due to existing policies and infrastructure. Objectives The objective of this study is to investigate predictors of occupational therapy (OT) practitioners’ adoption of video telehealth. Methods This study presents data from a convenience sample of VHA occupational therapy (OT) practitioners administered pre-pandemic, in fall 2019. Survey development was guided by the Promoting Action on Research Implementation in Health Services framework, and gathered clinician attitudes, experiences, and perspectives about video telehealth to deliver OT services. Items included telehealth usage, perceived effectiveness of specific OT interventions, and perceptions about evidence. Our outcome variable denoted practitioners’ level of adoption of video telehealth: telehealth users (adopters), non-users who want to use telehealth (potential adopters and reference group), and non-users who do not want to use telehealth (non-adopters). In multiple multinomial logistic regressions, we tested whether level of adoption was associated with years of VHA work experience and perceived strength of evidence. Results Of approximately 1455 eligible practitioners, 305 VHA occupational therapy practitioners participated in the survey (21% response rate). One hundred and twenty-five (41%) reported using video telehealth, whereas 180 (59%) reported not using video telehealth. Among non-users, 107 (59%) indicated willingness to adopt telehealth whereas 73 (41%) were not willing. More VHA work experience predicted higher odds of being an adopter than a potential adopter; perceptions of stronger evidence regarding video telehealth predicted higher odds of being a potential adopter than a non-adopter. Conclusion Clinician beliefs and years of experience exerted an influence on clinicians’ use or willingness to use video telehealth. Efforts to enhance adoption of video telehealth should address clinicians’ beliefs regarding the innovative nature of and organizational resources necessary to foster utilization.

In a 2011 article in this journal entitled “Whites See Racism as a Zero-Sum Game That They Are Now Losing” ( Perspectives on Psychological Science, 6, 215–218), Norton and Sommers assessed Black and White Americans’ perceptions of anti-Black and anti-White bias across the previous 6 decades—from the 1950s to the 2000s. They presented two key findings: White (but not Black) respondents perceived decreases in anti-Black bias to be associated with increases in anti-White bias, signaling the perception that racism is a zero-sum game; White respondents rated anti-White bias as more pronounced than anti-Black bias in the 2000s, signaling the perception that they were losing the zero-sum game. We collected new data to examine whether the key findings would be evident nearly a decade later and whether political ideology would moderate perceptions. Liberal, moderate, and conservative White (but not Black) Americans alike believed that racism is a zero-sum game. Liberal White Americans saw racism as a zero-sum game they were winning by a lot, moderate White Americans saw it as a game they were winning by only a little, and conservative White Americans saw it as a game they were losing. This work has clear implications for public policy and behavioral science and lays the groundwork for future research that examines to what extent racial differences in perceptions of racism by political ideology are changing over time.

Background: Persons with dementia are generally older and often have multiple other chronic conditions, necessitating several healthcare visits each year. Most live in the community supported by unpaid family caregivers who often assist with healthcare management. Little is known about caregiver and person with dementia experience engaging with the healthcare system, which may be more complicated in the context of cognitive changes such as memory loss. Methods: This is a targeted subanalysis of a major code, experience of the healthcare system , which emerged from a qualitative study investigating perspectives of family caregivers ( N = 24) of community-dwelling persons with dementia about telemedicine. Results: Caregivers were asked to describe their experiences taking persons with dementia to medical visits. Caregivers' detailed descriptions of the process resulted in three categories related to their experience of the healthcare system: Preparing for Visits, Visit-Related Time and Travel, and In-Visit Experience. Categories revealed the complexity of dyads' participation in healthcare both in and around actual clinic visits. Findings also highlighted the often-negative impact of person with dementia cognitive symptoms on various stages of the process, which was partly offset by perceived benefits related to social participation and interactions with care teams. Conclusions: This study improves our understanding of the experience of engaging with the healthcare system for caregivers and persons with dementia. By explicating the complex factors involved with participating in healthcare visits outside the bounds of clinic walls, this study offers insights for clinicians and systems supporting persons with dementia and caregivers.

Objectives: Quality dementia care, which recognizes caregivers as vital care partners, is a scarce resource. Innovative solutions like video telehealth may increase the reach of extant clinicians; however, little is known about perceived barriers and facilitators to in-home video telehealth for dementia management from the perspectives of caregivers.Methods: Twenty-four caregivers of community-dwelling Veterans with dementia participated in semi-structured interviews. Questions gathered perceived facilitators and barriers to in-home video telehealth for dementia management through experience with related technology. Transcripts were analyzed using directed content analysis which was guided by factors previously identified as influencing older adults’ adoption of technology.Results: Caregiver experience with related technology was mostly facilitative to video telehealth, which was thought best suited for follow-up care. Increased access and decreased patient-caregiver stress were potential benefits. Barriers included perceived limitations of video and the belief that persons with dementia would have limited ability to manage technological aspects and to engage in video telehealth on their own.Conclusions: This study improves our understanding of the factors that caregivers perceive as barriers and facilitators to in-home video telehealth for dementia management.Clinical Implications: Strategies to optimize video telehealth include capitalizing on caregivers’ social network and providing targeted training.

The current article examines the role of caregivers to support patient participation in video telehealth, using data from interviews with occupational therapy practitioners at Veterans Health Administration. We found that caregiver participation allowed patients who might otherwise not be able to access video telehealth to do so, with patient factors, such as low technical literacy, contributing to caregiver involvement. In addition, caregiver participation varied by type of task performed. There were also benefits and barriers to caregiver participation. This study enhances our understanding of caregivers' role enabling patients to access video telehealth, which has implications for nursing professionals. [Journal of Gerontological Nursing, 48(10), 15-20.].

Abstract Occupational therapy (OT) helps older adults improve their ability to perform day-to-day tasks. Veterans Health Administration (VHA) is the single largest employer of occupational therapy (OT) practitioners in the United States and a forerunner in telehealth. As a result of COVID, OT video visits increased by nearly 2000% from 2019 to 2020. To ascertain barriers and facilitators to this shift in care delivery, we conducted interviews between January and April 2021 with OT practitioners (N=27) who were high users of VA Video Connect (VVC), VHA’s videoconferencing software. OT participants were from rural and urban settings, and had completed an average of 536 VVC appointments each in 2020. Participants used VVC to deliver a variety of OT services, including mental health groups and home safety interventions. Facilitators to VVC included, a) Patient characteristics, such as positive perceptions of VVC and technological skill, b) OT clinician characteristics, like flexibility, level of experience, and desire to increase patient access to care, and, c) VHA’s telehealth infrastructure. Barriers included, a) Patients’ lack of familiarity or skills with technology, particularly older patients, b) challenges translating traditionally hands-on care to video, and c) unreliable internet connectivity, particularly for rural patients. This study broadens our understanding of video telehealth service delivery for care which has historically been delivered in brick-and-mortar settings. Understanding challenges and enablers to video telehealth highlights opportunities to increase access to those who face barriers, such as older, rural patients.

Abstract Rapid expansion of telehealth in response to COVID revealed a digital divide for many patients, particularly older adults. Given the technical complexity of video visits (which may include downloading novel software and enabling a camera and microphone), video visits may be out of reach for older patients with less technological experience or with age and condition-related changes such as sensory loss or cognitive impairment. Involving caregivers in video visits (particularly technical set-up) may not only increase patient access but also enhance clinical care by allowing for collaboration with family. Caregivers may themselves benefit from video visits, given that video offers increased options for caregiver support. Though caregivers are often identified as critical components to older adults’ accessing telehealth and may also benefit from telehealth services, caregivers’ own technical needs are not well-understood. This symposium discusses caregivers’ involvement in telehealth from multiple perspectives. The first presentation includes findings from a national clinician survey about caregivers’ support role in occupational therapy video visits, including barriers and benefits (Gately et al). The second presentation includes findings from a regional survey of interprofessional clinicians about telehealth modalities to provide dementia family caregiver support during COVID-19 (Quach et al). The third presentation includes family caregivers’ technology assistance requirements before and during a virtual, seven-session group skills training program, including benefits of individualized assistance (Moo et al). The fourth presentation includes caregiver perspectives about tele-geriatrics visits, highlighting caregivers’ support role and enhancements of video versus phone (Boudreau et al).

Date Presented 04/01/2022 Postpandemic, OT practitioners must make clinical judgments about the continuation of telehealth for specific clients. However, there is a lack of research on the factors that influence both practitioners’ and clients’ decision-making processes in using telehealth and promote success. The purpose of this research was to uncover ways in which OT practitioners drew from clinical reasoning, expertise, and resilience to guide service delivery modality decision making. Primary Author and Speaker: Timothy Dionne Additional Authors and Speakers: Lauren Little, Megan E. Gately

The Reading Buddies Program was developed as a service-learning component of an Occupational Therapy Practice with Older Adults course as a collaboration between Tufts University and the VA Bedford Health Care System. The purpose of this service-learning program was to challenge graduate students' implicit biases and improve communication skills when working with older adults with significant cognitive impairments. Through this collaboration, occupational therapy students provided individualized, activity-based care to Veterans with advanced dementia. In this qualitative study, a total of 55 guided reflection papers submitted by students were analyzed using NVivo. Four major themes emerged: "I was a fish out of water," "I finally took a risk," "And then I thought, maybe I should give myself a little credit," and, "I am still experimenting with how I feel," illustrating student outcomes and perceived benefits of participation in the Reading Buddies Program. Each theme reflected the development of clinical reasoning which was the targeted impact. Outcomes confirm service-learning as an effective tool and suggest further use for academic programs, emphasizing the potential of creative partnerships to meet educational goals while providing valuable programming to vulnerable populations.

The 2020 National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers identified the need for person-centered dementia care throughout the care continuum. Challenges include adapting health care to meet the complex needs of persons with dementia and their caregivers across a variety of settings.To understand dementia caregivers' experience of the health care system, we conducted qualitative interviews with twenty-four middle-to-older age caregivers of community-dwelling people with dementia. Data were analyzed using conventional content analysis whereby the coding team sought to identify barriers and facilitators to person-centered dementia care.We identified three categories and associated sub-categories related to caregiver experience: 1) Preparing for the Visit, with sub-categories Physical Challenges and Emotional Preparation; 2) Visit-Related Time and Travel, with sub-categories General Travel Challenges, Physical Limitations, Cognitive Limitations, and Benefits; and, 3) In-visit Experience, with sub-categories Physical Challenges and Emotional Preparation. Preparing for visit statements revealed barriers, such as patient resistance to attending visits due to not understanding the need. Visit-related time and travel statements reflected a balance of challenges and facilitators, including general challenges such as traffic and dementia-specific challenges such as patient agitation around visit wait times. Facilitators reflected the benefit of visits as opportunities for social participation. In-visit experience statements reflected a mix of challenges and facilitators. Challenges included person with dementia difficulty participating in the health care visit due to poor insight and inability to answer questions, while facilitators included caregivers' positive engagement with the care team. Across categories, caregivers assumed high-level responsibility to accommodate for person with dementia physical and cognitive challenges.Categories underscore the complexity of health care management for a person with dementia both in and around actual clinic appointments, highlighting both challenges related to person with dementia cognitive deficits and perceived benefits related to visits as opportunities for social participation and accessing resources. This study offers relevant insights about tailoring health care to accommodate for person with dementia deficits while supporting their caregivers.

OBJECTIVES:COVID-19 negatively affected older adults' well-being and quality of life, particularly individuals with dementia. My Life, My Story (MLMS) was developed at Veterans Health Administration as an opportunity for Veterans to interact and share life stories using guided interviews. This paper describes a program evaluation of MLMS delivered to Veterans with cognitive concerns and their caregivers using telehealth technology during COVID-19.METHODS:Fourteen Veteran-caregiver dyads completed MLMS interviews with occupational therapy trainees using telehealth technology. Most (10 of 14) participating Veterans had mild-to-moderate dementia. Trainees ascertained Veteran and caregiver demographics such as age and recent cognitive evaluation scores via chart review. Trainees also gathered Veteran-caregiver technology and interview experience through post-interview program evaluation questionnaires.RESULTS:Dyads reported generally positive interview and technological experience, despite technological glitches occurring in most (approximately 70%) interviews. Caregivers assisted with videoconferencing setup and participated in ten interviews.CONCLUSIONS:Veterans with cognitive concerns successfully participated in virtual MLMS interviews during COVID-19. Caregivers enhanced Veteran engagement and often provided technological support.CLINICAL IMPLICATIONS:Telehealth technology enabled participation in My Life, My Story by individuals with cognitive concerns and their caregivers. Post pandemic, clinicians may consider integrating telehealth technology with patients facing access challenges.