Psychology of consulting and coaching

O R I G I N A L R E S E A R C H

Telerehabilitation for Rural Veterans: A Qualitative

Assessment of Barriers and Facilitators to

Implementation This article was published in the following Dove Press journal:

Journal of Multidisciplinary Healthcare

Jennifer L Hale-Gallardo 1

Consuelo M Kreider 2,3

Huanguang Jia 1

Gail Castaneda 2

I Magaly Freytes 1

Diane C Cowper Ripley 2

Zaccheus J Ahonle 3

Kimberly Findley 1

Sergio Romero 1,2

1Department of Veterans Affairs, North

Florida/South Georgia Veterans Health

System, Gainesville, Florida, USA; 2Department of Veterans Affairs,

Veterans Rural Health Resource Center– Gainesville, Office of Rural Health,

Gainesville, Florida, USA; 3Department of

Occupational Therapy, University of

Florida, Gainesville, Florida, USA

Purpose: Telerehabilitation (TR) is increasingly being used to meet the rehabilitation needs

of individuals living in rural areas. Nevertheless, reports on TR implementation for rural

patients remain limited. As part of a broader evaluation, this study investigated barriers and

facilitators to the implementation of a national TR program to meet the needs of rural

Veterans Health Administration (VHA) patients.

Methods: This study applied a qualitative approach to the RE-AIM framework to investi-

gate barriers and facilitators impacting TR implementation. We conducted in-depth, semi-

structured interviews with ten program managers and medical directors within the VHA at

three time points during the first 18 months of implementation. Interviews were analyzed

using thematic analysis.

Results: Three themes were identified describing key cultural, infrastructural and logistical,

and environmental barriers impacting the reach, adoption, and implementation of TR. Within

the themes, facilitators for TR were also identified to include, allowing providers flexibility

in implementing TR, mentorship and development of creative approaches to TR training,

overcoming infrastructural and logistical TR barriers through championing, and continuous

sharing of lessons learned in a community of practice.

Discussion: This study explicates salient barriers and facilitators encountered during the first 18

months of implementation of a TR program within a national healthcare system in the United

States. Implementing TR to meet the rehabilitation needs of Veterans in resource-limited rural

environments requires creative approaches and flexibility, as well as perseverance and consistent

championing in order to overcome cultural challenges. This, in combination with infrastructural

challenges, such as lack of broadband, adds greater complexity to meeting the needs of rural

patients. This study provides new and in-depth understanding of the processes by which TR is

implemented in a large healthcare system and points to practical real-world lessons in imple-

menting TR for rural patients.

Keywords: telemedicine, health, culture, technology, evaluation, implementation science

Introduction Rehabilitation enhances the recovery of patients who suffer physical, cognitive, or

emotional trauma by improving their health and quality of life. For those with

mobility restrictions or who live in rural areas, however, rehabilitation is not always

accessible.1–4 In a study examining travel distances to healthcare for Veterans in the

United States, over half of the enrollees in the Veterans Health Administration

(VHA) traveled more than 25 miles;5 a majority of Veteran enrollees (58%) reside

in rural areas.6 For rural Veterans with disabilities who may face physical,

Correspondence: Sergio Romero Veterans Rural Health Resource Center – Gainesville, North Florida/South Georgia Veterans Health System, 1601 S.W. Archer Road, Gainesville, Florida 32608, USA Tel +1 352-264-3845 Email [email protected]

Journal of Multidisciplinary Healthcare Dovepress open access to scientific and medical research

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cognitive, or emotional obstacles to access needed rehabi-

litation, geographic barriers and the multiple visits fre-

quently required, further magnify the challenge.7

The VHA has been a forerunner in implementing tele-

health—the use of communication technologies to deliver

clinical services and healthcare remotely.8–11 In recent dec-

ades, the VHA has expanded its telehealth services to include

telerehabilitation (TR), a promising solution for rural Veterans

in need of rehabilitation to regain optimal functioning.12–16

Reports on TR show it offers advantages over face-to-face

rehabilitation by overcoming obstacles of travel distance and

time and expanding health system capacity.4,17–22

Implementing TR in a way that is satisfactory to both

providers and patients is a complex process.23,24 In the last

decade, extending the traditional model of point-to-point

telecare to include newer technologies, such as smart-

phones and internet-based telecommunications tools, has

required the integration and interoperability of technolo-

gies within dynamic and rapidly evolving healthcare

contexts.25 When these technologies are applied to rehabi-

litation within a large healthcare system, the complexity

increases.26 Moreover, these complexities are compounded

when extended to providing telerehabilitation to rural and

highly rural areas.27,28 As part of a broader evaluation, we

investigated barriers and facilitators to the implementation

of a VHA-wide TR program for rural Veterans.

Background on TR-EWI The Telerehabilitation Enterprise-Wide Initiative (TR-EWI)

was initiated in 2017 by the VHA’s Office of Rural Health

(ORH) in partnership with the program office of Physical

Medicine and Rehabilitation (PMR). The goal was to

expand the delivery of rehabilitation services by leveraging

centrally located, specialized rehabilitation expertise at

“Hubs” and extending this expertise to “Spokes.” These

Spokes included rural VHA facilities and Community-

Based Outpatient Clinics (CBOCs) that provide services to

rural Veterans who otherwise lack access to main VA facil-

ities. Preliminary analysis of patient utilization data sug-

gests that the TR-EWI program has supported dramatic

expansion of TR throughout VHA—achieving an 80.2%

increase in the number of rural Veterans who received TR

during fiscal years (FY) 2017 and 2018.29

Three Polytrauma Rehabilitation Centers (Richmond,

San Antonio and Minneapolis) and one Polytrauma

Network Site (Seattle) were selected and have been operating

as Hub sites for TR-EWI. Approved Spokes who applied to

expand TR for their patients were assigned to a Hub primarily

based on geographic proximity. Each Hub was allotted funds

to hire a physician, a program manager, two rehabilitation

therapists, a program assistant, and a telehealth technician.

Each Spoke was allocated funds to hire a rehabilitation thera-

pist and telehealth technician. As all Spokes were in rural

areas, the rehabilitation specialist at each Spoke was hired to

increase access to TR for rural Veteran patients. Hub sites

have the expertise of providing a broad array of rehabilitation

therapies and have provided mentorship and training to

Spokes on the therapeutic protocols needed most by their

rural patients. At the same time, Hubs meet additional reha-

bilitation needs of Veteran patients at Spokes through TR.

The original TR-EWI therapeutic protocols available at

each Hub included Amputee Care, Back Pain Clinic,

Comprehensive Traumatic Brain Injury Evaluation,

Home Safety Evaluation, Physical Therapy, Psychology,

Speech Therapy, and Assistive Technology. Hub sites pro-

vided this broad spectrum of specialized rehabilitation

services through clinical video telehealth (CVT). CVT

allows a VA provider to diagnose, monitor, and treat

medical conditions in real-time through interactive, secure

(ie, encrypted) video technology, either from one clinic to

another or directly to a Veteran patient’s home. When

extending TR from one clinic to another, specialized tele-

communications equipment on both ends is required.

Alternatively, when TR is conducted through VA Video

Connect, patients use their own devices such as a smart-

phone, tablet, laptop, or desktop with a webcam, to

securely connect via the internet to a VA provider regard-

less of where the Veteran or provider is located.

How therapeutic protocols have been organized and

delivered in TR-EWI has depended on the requirements

and structure of each clinic.15 For instance, the Amputee

Care protocol is conducted in several ways. First, a team of

amputation experts–usually a physician, a therapist, a pros-

thetist, and a rehab coordinator at the Hub–provide consults

to the telehealth technician who is with the patient at the

Spoke site. The team evaluates the patient with an amputa-

tion to determine the prescription for a prosthesis with the

support of the technician; the prescription is then sent to a

community prosthetist, and once fabricated, another virtual

visit is scheduled to check that the prosthesis is meeting

patient needs and complies with specifications as ordered.

In a second instance, a tele-consult is made from the pros-

thetist at the Hub to the amputation clinic team who is work-

ing with the patient at the Spoke. A third way that this

therapeutic protocol is implemented is through a provider-

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led Amputee support group for Veteran patients from Hub to

Spoke.

Assistive technology via TR-EWI is another example of

how specialized expertise available at the Hubs is delivered

to personnel at Spokes. In this case, the Hubs provide gui-

dance on how to best assess patients needing AT devices,

such as wheelchairs and other mobility devices, sensory (eg,

hearing, vision, physical) aids, and accommodations for

activities of daily living. Typically, patient assessments are

conducted in conjunction with the technician at the Spoke in

three steps. The first session comprises the patient assess-

ment, the second session involves the fitting of the device,

and the third session is a follow-up to ensure that the device is

meeting patient needs.

Additional examples of protocols provide other cases

in point: For home safety assessments, an interdisciplinary

rehabilitation team at the Hub uses secure video to evalu-

ate the Veteran’s home for safety hazards and assess the

Veteran’s functional capacity to recommend home modifi-

cations; traumatic brain injury (TBI) specialists at the Hub

conduct initial TBI evaluations, follow-up visits, or family

conferences through secure video with patients at VA

community-based outpatient clinics (CBOCs) or at their

homes; and speech language pathologists, occupational

therapists or psychologists located at Hubs see patients

through TR at other VA facilities or at patients’ homes.

Methods An independent team of researchers at a VA medical center in

the southeast US was formed to evaluate TR-EWI as an IRB

exempt clinical improvement project. The team designed a

qualitative study employing the Reach, Effectiveness,

Adoption, Implementation, and Maintenance Framework

(RE-AIM).30 A semi-structured interview guide was devel-

oped based on guidance for approaching RE-AIM qualita-

tively by Holtrop, Rabin, and Glasgow (Table 1).31

A purposive sample was used to recruit key personnel

involved in implementing TR-EWI at each of the four

Hubs (Table 2). Ten stakeholders comprising program

medical directors and program managers participated in

telephone and/or video group interviews (three interviews

per four sites) quarterly during the first 18 months of

implementation (except at one site, for which an interview

occurred at a five-month interval). Group interviews were

repeated with the same individuals at all three time points

except for one site where a medical director was replaced.

Two other group interviews were conducted with the

PM&R program office using the interview guide.

Each group interview was co-moderated by three team

members for a duration of approximately 60 minutes.

Interviews were audio-recorded and hand-written notes

were taken. A total of fourteen group interviews (three inter-

views with each of the four Hub sites plus two more with the

PM&R program office) were conducted. Handwritten notes

from each co-moderator were compared to ensure consensus

and notes were transcribed into an electronic format. When

questions or a need for clarification arose, the audio was

consulted and reheard. A list of interview responses was

compiled in an excel spreadsheet for analysis within a table

delineating RE-AIM domains. A final list of interview

responses was compiled for coding, returning to audio

recording as needed to retrieve verbatim quotes.

Constant comparison of the data to emerging concep-

tualizations was used throughout the analytic process.

Initial analysis of the data was conducted by the first

author (JLHG) and centered on the inductive identification

of themes, whereby emerging conceptual categories were

confirmed by other members of the research team; a sub-

sequent analysis of the same data identified overlapping

data points that consolidated themes where appropriate.

Overview summaries of themes on barriers and facilitators

and top key points were generated for each RE-AIM

domain. A final analysis of the data and findings was

conducted by a new team member with qualitative

research expertise and extensive clinical rehabilitation

experience (CK) in order to assure reliability of themes

developed. From this final analysis, themes were con-

firmed, further refined, and barriers and facilitators veri-

fied. Rigor was enhanced by researchers’ ongoing

interactions with study participants and member checking,

the interdisciplinary nature of the study team, use of an

interview guide with questions developed in alignment

with the RE-AIM framework, and iterative cycles of ana-

lysis conducted by multiple researchers who have exper-

tise in qualitative research.

Results This study was conducted during the first 18 months of

TR-EWI implementation. The data yielded three overarch-

ing themes (Table 3). The theme Cultural Factors

Influencing Reach and Adoption of TR describes ways of

interacting with the rehabilitation process through TR

from both the Veterans’ and the providers’ perspectives.

The Infrastructural and Logistical Factors Influencing

Implementation of TR theme delineates infrastructure

and logistical constraints to tele-delivery of rehabilitation.

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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 mechan- ism 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 rehabilita-

tion 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?

(Continued)

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The Rurality as a Factor in TR Implementation theme

illustrates the complexity involved in extending TR to

rural, low-resource environments.

Cultural Factors Influencing Reach and

Adoption of Telerehabilitation A factor frequently cited by interviewees as impacting TR-

EWI reach and adoption of TR is cultural acceptance.

Culture in TR can be defined as factors that relate to the

habits, skills and practice of delivering rehabilitation

remotely.32 Within VHA, TR presents providers and

patients a new way of interacting with each other; TR also

serves as a catalyst for changing understandings about what

it means to be a rehabilitation provider as well as what it

means to be a patient experiencing rehabilitation remotely.

Within this theme regarding cultural factors, two sub-

themes were identified and are described below.

Veterans’ Acceptance of Telerehabilitation

Interviewees reported only limited resistance among

Veterans to replace traditional, face-to-face rehabilitation

care with TR. As reported by interviewees, a minority of

rural Veteran patients faced personal-level barriers to TR.

Some Veterans were uncomfortable with the technologies

required for rehabilitation treatments provided at a

Table 1 (Continued).

RE-AIM Domain and Definition Used* Prompts and Probes

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 follow-

ing 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.

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distance. Additionally, some experienced logistical chal-

lenges in engaging in the TR visit at home without the

additional support of a caregiver to assist with logistics or

the therapeutic activities for the sessions. TR provided

both advantages and disadvantages, as described by one

interviewee:

The geriatric population has its pros and cons. [TR] is

difficult at times, as it is good to have a caregiver on

hand for those patients … to help them get set up and

help them feel more comfortable with [the telehealth visit].

Some patients are not comfortable doing something dif-

ferent or new, and get anxious …. For ongoing appoint-

ments (i.e., weekly) versus a one-time thing, [older

patients] who have more frequent appointments may be

more open to the idea of telehealth.

Among the minority of Veteran patients who were consid-

ered more reluctant to embrace TR were those who would

have to forego travel pay benefits that provide gas mileage

reimbursement. Other reluctant Veterans were those who

leveraged in-person appointments as opportunities to “get

out of the house,” as in the case of one Veteran who

declined TR for the chance to combine an in-person clinic

visit with a shopping trip to the city.

These exceptions apart, overall, interviewees reported

high acceptance of TR among rural Veterans. Facilitators

for rural Veteran use of TR centered on convenience and

accessibility of appointments. Veteran patients with the

most buy-in for TR were those who had ongoing or fre-

quent appointments or who worked full time:

For [the] most part, we hear a lot of positive feedback.

[TR] saves driving time, saves the Veteran time away from

work when they can connect on a lunch break. Or [it

helps] if there are physical reasons they can’t come [in],

whether it be that it’s hard for them to get into the VA or to

travel to the VA or if they don’t have transportation to the

VA.

Veterans with specific diagnoses that made entering a

VHA facility challenging, such as post-traumatic stress

disorder (PTSD), were said to be especially amenable to

TR. TR allowed them to avoid potentially triggering situa-

tions by receiving their rehabilitation treatment at home.

“[TR] also alleviates PTSD symptoms in Veterans who can

connect from home. It’s rare that people decline; most are

open to telehealth and find it beneficial.”

There was agreement among interviewees that while it

may be less than optimal for Veterans to access rehabilita-

tion sessions via the small screen of smartphones, for those

who regularly use mobile phones, the use of a technology

that was already embedded in their everyday lives facil-

itates acceptance of TR. In cases where patients had hear-

ing or vision impairments that reduced the ability to hear

or see through a device, driving impairments in these

patients rendered TR as a superior option to traveling for

in-person visits.

Providers’ Cultural Acceptance of TR

The most frequently cited barrier for providers’ adoption

of TR was traditional rehabilitation cultural practice,

which has typically relied on manual manipulation and

face-to-face evaluations. Interviewees reported that the

most common barrier against provider adoption of TR

was translating what has been traditionally manual, in-

person therapies into TR. Not surprisingly then, the provi-

ders who were considered most hesitant to adopt TR were

chiropractors, physical therapists, occupational therapists,

and kinesiologists:

[We] haven’t heard much resistance in terms of “I don’t

like telehealth, it scares me,” but I know there are people

out there that think that way. We have some providers who

are reluctant to use [TR] or who feel it isn’t appropriate for

them, for example, providers whose services are hands-on.

[For example] for the [Kinesiology Therapy] Department,

as it is exercise-based, hands-on, using equipment/

machines, it’s been harder to visualize how they could

use it.

TR-EWI program leaders have employed several strategies

to overcome barriers within the culture of rehabilitation

practice. A primary facilitator for applying tele-delivery to

rehabilitation practice has been TR-EWI’s approach to

promoting TR in an open-ended, non-prescriptive way.

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

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This strategy entailed administrators’ affording providers

the autonomy and flexibility to incorporate telecommuni-

cations technology into their practice in ways that made

the most sense for them. For some providers, they began

by evaluating a patient in the clinic, where they could also

provide manual treatment and training in home-exercises;

this clinical strategy was then followed by a transfer of the

care into the patient home assisted via tele-technology.

Subsequently, with the patient at home, the provider

could then monitor patient safety during prescribed exer-

cises and observe, through the technology, the Veteran in

their home to better tailor existing or additional treatments.

In other situations, providers transitioned their patients to

TR every other visit, whereby TR served to lighten the

travel demands for the Veterans. In another example, a

pre-screening for driving therapy was provided remotely

before the driving rehabilitation appointment rather than

requiring the Veteran to travel twice to the facility.

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 expo-

sure 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, tech- nicians) 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 liv-

ing in rural, low-resource communities

● Staffing challenges; difficulty in recruit- ing 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.

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Interviewees also found that TR enhanced compliance

with mandatory follow-up clinics. For example, within

some clinics, such as the wheelchair clinic, follow-up is

required within four weeks of the Veteran receiving a

wheelchair. Interviewees found that TR enabled increased

compliance, which reduces risk to Veterans of health

hazards due to ill-fitting chairs.

Advocating for TR use among clinical providers was

another important facilitator for TR adoption. TR-EWI

program leadership at Hubs championed the adoption of

TR through provision of information via email listservs,

presentations at staff meetings, weekly cross-service meet-

ings with leaders in and outside of rehabilitation, and town

hall discussions. In the end, TR-EWI program leaders

served as de-facto telehealth champions at their respective

Hubs where they encouraged and facilitated providers in

and outside of rehabilitation to become telehealth ready.

As champions, these leaders served as mentors to their

facilities for implementing TR in partnership with other

VHA services, such as primary care, as well as non-VA

providers and vendors in the community.

Importantly, TR-EWI program leaders also facilitated

rehabilitation practice transformation through the creation

of training on how to deliver rehabilitation through telecom-

munications technology and adopt TR. As an illustration, for

providers who had difficulty imagining how their therapies

could translate into TR, one Hub launched the production of

case study videos to help providers envision how rehabilita-

tion experts could apply their therapies remotely. Through

audiovisual case studies, providers were exposed to exam-

ples of therapists who transitioned their practices to TR, and

where appropriate and desired by patients, gradually

decreased the need for face-to-face sessions. These training

tools were important for helping providers envision a new

culture of rehabilitation practice. “The more providers know

about [TR] and understand how they can use [TR] with their

specific caseload, the more they [adopt and] promote tele-

health.” As described by another interviewee:

Physical Therapy (PT) is typically hands-on, so they had

more difficulty seeing how they would use tele, but there

has been a good response. [They are] starting to use it.

Through case studies, they are starting to see how they can

gradually decrease [the] amount of sessions and transfer

recommendations, strategies, [and] some exercise plans

into the home.

By demonstrating to providers how tele-delivery can com-

plement or replace aspects of in-person rehabilitation care,

TR-EWI has been able to create new opportunities for

increasing both access and enhancing care, even for thera-

pies that are not typically amenable to TR.

Infrastructural and Logistical Factors for

TR Implementation Procuring appropriate equipment and having enough band-

width capacity in the network were recurrent barriers to

TR implementation. Additionally, finding appropriate

space in already space-limited facilities was also identified

as a recurring barrier for TR. For example, provider space

for TR needs to be insulated from background noise that

can affect the quality of the video call:

Space can still be an issue if you don’t have the private

area or private clinic space to conduct your visit. You need

a quieter space versus, you know, like an open clinic that

can be harder to conduct the visit in.

Just as importantly, the space must be ample enough for

the therapist to conduct treatment; for example, to demon-

strate how to do a prescribed exercise requires enough

space for the camera to capture the full body of the

therapist.

Interviewees also noted that providing space to part-

time therapists or for ad-hoc treatments was a logistical

challenge. This has meant coordinating and managing a

shared space, which adds another logistical barrier in the

form of management and efficient allocation of that space.

As one interviewee noted:

Most of the providers are not going to become full-time

tele-rehab providers, so it is challenging to get space and

equipment that can be used on a rotating basis. And [the

question remains] who is going to manage that space?

Logistical issues were also important to resolve in TR

implementation. Some therapeutic protocols, such as assis-

tive technology, required an interdisciplinary approach and

the coordination of multiple specialists. As one intervie-

wee explained:

Assistive technology is more complex by nature so we’re

pursuing an interdisciplinary assistive technology wheel-

chair clinic involving the physician, the PT, the OT and …

our rehab engineer who specializes in assistive technology.

So, right now we’ve been conducting weekly meetings to

try to set this clinic up, but it’s heavy on the administrative

needs to … process through all that is required due to the

complexity of this clinic.

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Implementing TR without the requisite infrastructure and

logistical resources, could be, as stated by one interviewee,

“very discouraging to providers.” Interviewees suggested

that if obstacles remained to these basic requisites for TR,

providers could be so discouraged as to be unlikely to try

tele-delivery of their therapies again, thus abandoning TR.

Several facilitators were identified as contributing to

the uptake of TR. Overwhelmingly, interviewees discussed

the importance of site champions and hospital leadership

support. Interviewees reported that procuring dedicated

clinic space and equipment for TR, and efficient schedul-

ing mechanisms, were primarily mitigated through the

perseverance of site champions and buy-in from facility

leadership. Moreover, when facilities had a telehealth

coordinator who was well integrated into the range of

hospital and clinic services, these individuals were instru-

mental in working with TR-EWI program leaders in creat-

ing TR clinics and integrating TR logistical needs into the

facility’s existing processes. Additionally, when clinical

technicians who could be dedicated to telehealth were

available, these personnel were also described as vital for

coordinating TR space and scheduling:

Everything that [we’ve been] doing takes a lot of time to

coordinate and process. It includes multiple team members

from different areas so a good working relationship with

everybody is important.

As a final facilitator, the development of a systematic way

of sharing TR lessons learned was described as fundamen-

tal to resolving challenges to TR implementation. From

the launch of the program and throughout its implementa-

tion, TR-EWI program leaders prioritized the frequent

sharing of lessons learned. This was done through Hub

and Spoke monthly, quarterly, and annual meetings at all

sites. This continuous sharing of lessons learned allowed

for a more rapid and synergistic deployment of TR through

the program. This strategy also served to maximize the

exchange of experience and ideas across sites, which cre-

ated a community of practice that could leverage for the

VHA a collective wealth of experience.

Rurality as a Factor in TR Implementation One theme that was extensively reported on was the com-

plexity of extending services to rural patients. This com-

plexity served as a major barrier to TR implementation in

rural settings. While rural Veterans participating in TR-

EWI reported a high degree of satisfaction with TR (paper

forthcoming), rurality impacted TR implementation in

several ways. For TR that was delivered to Veterans’

homes, a lack of stable broadband and poor connectivity

could generate frustration and interfere with successful

rehabilitation treatment for patients. Additionally, intervie-

wees noted that for rural Veterans with complex health

problems in low-resource environments, the services

patients’ needs are often the ones that are the most difficult

to provide.

One example discussed involved the fitting of wheel-

chairs through the assistive technology clinic. While reha-

bilitation expertise was available at the Hub, its

implementation still required hands-on fitting, assessment,

measurement, trial, equipment, and transfers into a wheel-

chair; the need for skilled hands-on assistance complicated

these types of tele-rehabilitation consults. While having a

person on-location in the rural community was necessary

for such TR, it posed real challenges; as one program

manager asked rhetorically, “Where do you get a [skilled

hands-on] person if the Veteran lives four hours away?”

Vendors in the community could be an option, but there

are questions to consider such as if a vendor can accom-

plish the task at a reasonable price. Alternatively, a tele-

health technician at [a] VA [facility] could be trained to do

the kinds of highly-skilled tasks needed for fitting assistive

technology, but to do this would require [the technician] to

travel long distances with the equipment: you need a big

van, a ramp, etc., and a lot of time too … for a single

Veteran that lives very far away.

The lack of an existing network of rehabilitation support

for rural Veterans is exacerbated by geographical distances

as well as the resource limitations that are characteristic of

rural communities. This makes reaching the most rural

Veterans where they live far more challenging. As one

interviewee pointed out, even when there is a plan to

provide services, environmental limitations can impede

the execution of the plan:

Things can go off-track very fast. The resources become a

significant barrier the more rural you get, resulting in a

situation where Veterans who can be more readily served

are those who are not as far away.

Another commonly cited barrier for rural TR are staffing

challenges in rural communities. Although approved

Spokes received funding support, not all Spokes could

make use of the funding to hire personnel for TR in rural

areas. In the case of one Hub, recruiting a telehealth

technician for their Spoke proved insurmountable due to

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the region’s lack of schools, housing, and job opportunities

for trailing spouses:

If you are prioritizing highly rural areas then almost by

definition, those are not the areas that have schools that are

good for young families, or that a spouse can come and

easily find a job.

Choosing appropriate Spokes in rural areas thus entails

what one interviewee referred to as “the goldilocks phe-

nomenon”— the setting chosen must be close enough to an

urban area to remain viable for staffing but far enough that

it serves a rural population. To facilitate implementation of

TR for rural Veterans, the Hub discussed above overcame

staffing barriers by changing its Spoke to another site that

was less rural and had a pre-existing telehealth technician.

Overall, interviewees expressed that the nature of low-

resource environments entails more work to serve fewer

people. One interviewee emphasized that while “best prac-

tices” is a current buzzword, these are often imagined in

the context of ample resources, readily accessible equip-

ment, and plentiful skilled personnel, which is far from a

reality for most rural areas:

When we consider what we want to do, we’re wishful, and

we are hopeful that we can do as much as can. But when

we think about what is within our means, it is improving

practice, not necessarily best practice, that we can do.

Discussion This study identifies and explicates the most salient barriers

and facilitators encountered during the first 18 months of

implementation of a TR program within a national health-

care system in the United States. It contributes new and in-

depth understanding of the processes by which TR is imple-

mented in a large healthcare system. The main goal of TR-

EWI has been to increase rehabilitation access and enhance

rehabilitation quality to provide the best care to rural

Veterans. By inquiring into factors impacting TR for rural

Veterans, this study suggests that TR-EWI has successfully

applied creative approaches to addressing the many com-

plex barriers that accompany translating rehabilitation into

tele-delivery for rural patients.

Most notably, this study contributes nuanced understand-

ing of cultural barriers to TR reach and adoption. Barriers

were found at both the Veteran level and the level of the

rehabilitation provider. While cultural barriers are generally

some of the most challenging barriers to overcome,33 study

findings indicate that, at both the clinician and the patient

level, TR-EWI has begun to foster a transformation in the

cultural practice of rehabilitation.

In our study, logistical constraints to TR, such as space,

equipment, and scheduling considerations, served to chal-

lenge TR’s implementation. Procuring appropriate equip-

ment was also a recurrent barrier to TR implementation.

Just adding a camera to an existing workstation is not

enough to optimize TR. For TR, a one-size-fits-all

approach does not always work and a range of options is

needed depending on the specific therapy. On the provi-

ders’ end, there are portable units and dedicated units;

having a portable unit is advantageous, especially if an

unanticipated video consult is needed. Moreover, while a

rehabilitation counseling session could be successful using

basic video teleconferencing equipment, fitting a prosthe-

tic device would need to capture different dimensions to

show the patient how to use the device appropriately. TR

equipment needs to be adaptable to different scenarios.

Findings regarding infrastructural barriers to rural care,

specifically lack of broadband, are consistent with pub-

lished research regarding telehealth in rural areas.34 As

such, extending the reach of TR to Veterans who reside in

rural, low resource environments entails finding solutions to

infrastructure. Implementing TR to meet the rehabilitation

needs of Veterans in resource-limited rural environments

requires creative approaches and flexibility. This, in combi-

nation with logistical constraints to TR, adds greater com-

plexity to meeting the needs of rural patients.

We thus found that rurality brings its own unique set of

challenges that are important considerations in extending

TR to Veterans living in rural locations. Study findings

suggest that rurality may be worth considering as a type of

patient complexity that may need to be accounted for

when treating rural patients; similar to the ways that

comorbidities are taken into consideration when appraising

a patient’s complexity.

A strength of this study is the novel use of the RE-AIM

framework for guiding qualitative inquiry into TR imple-

mentation. The RE-AIM framework was originally devel-

oped to improve reporting of health promotion and

healthcare research findings and facilitate their translation

into real-world settings;35 however, the qualitative appli-

cation of RE-AIM has been less frequent in the health

services research.36 Consequently, this study is novel in

two ways. First, we developed our qualitative interview

guide based on RE-AIM domains, which gave structure to

an interview process that was conducted in three phases

over the first 18 months of TR-EWI implementation. The

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RE-AIM structure served as a useful framework for adjust-

ing the focus of the interviews in a way that allowed

continuity of the sequential interviews over time. This

structure allowed for flexibility in the interviews’ foci as

implementation of the TR-EWI program evolved over

time. Secondly, we applied RE-AIM to evaluate the imple-

mentation of a care delivery system, which was a different

application from how RE-AIM is typically applied to

develop and test interventions.37 We found that applying

RE-AIM pragmatically37 was useful in guiding our quali-

tative evaluation of the barriers and facilitators to TR.

Our use of qualitative thematic analysis, in combina-

tion with the small sample size, limits the generalizability

of study findings. However, the sample of program man-

agers and medical directors, by virtue of their vantage as

administrators, were able to speak to the process of pro-

gram implementation with depth and nuanced understand-

ing of both practitioner and administrative concerns. As

such, our interviewees provided meaningful insight into

the complexities of implementing a TR program to indivi-

duals residing in rural locations. This study contributes in-

depth knowledge regarding the process of providing TR

for rural Veterans, and most notably, points to practical

real-world lessons with implications for how TR can be

implemented and sustained into the future.

Acknowledgments We acknowledge Jessica Barton for her thoughtful review

of the revised manuscript. We would also like to recognize

the outstanding editorial support of Lynn Dirk, MAMC,

through affiliation of the North Florida/South Georgia

Veterans Health System with the North Florida

Foundation for Research and Education, Inc. Funding

was provided by the Office of Rural Health, U.S.

Department of Veterans Affairs.

Disclaimer The opinions expressed herein are those of the authors and

do not necessarily reflect those of the US Department of

Veterans Affairs, or any of its affiliated institutions.

Disclosure The authors report no conflicts of interest in this work.

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