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BACKGROUND: Geospatial analyses illustrating where the Home Improvements and Structural Alterations program (HISA) have been prescribed suggest that home modification (HM) services under US Department of Veterans Affairs (VA) is not prescribed and used uniformly across the US. METHODS: The objective of this study was to identify county characteristics associated with HISA use rates, such as county-level measures of clinical care and quality of care, variables related to physical environment, and sociodemographic characteristics. Multiple regression analysis was used to predict county-level utilization rate from county-level variables. RESULTS: County-level HISA use was highly skewed and ranged from 0.09 to 59.7%, with a mean of 6.6% and median of 5%. Percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = −8.99, P = .005). The higher the proportion of uninsured adults the lower the HISA utilization rate. The county rate of preventable hospital stays was positively related to county-level HISA utilization rate (b = .0004, P = .009). County-level predictors of housing quality were not significantly associated with county-level HISA utilization rate. CONCLUSIONS: Our research fills a gap in the literature about the impact of county-level variables and the geographic distribution and use of HISA. More research is needed to understand and account for geographical variation in HISA use. This work serves as a first step at quantifying and predicting HISA utilization rate at a broad level, with the goal of increasing access to HMs for veterans with disabilities.

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 investigate 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 implementing TR for rural patients.

Housing is considered a social determinant of health, with poor housing conditions being associated with poor health. Veterans with disabilities are more likely to experience a housing crisis because of combat experiences and employment instability. We identified facilitators and barriers to finding and maintaining rental housing. We sought to understand the housing needs of Veterans with military-related disabilities using the biopsychoecological model (BEM) as an organizing framework. Our sample consisted of 39 Veterans who were renters. This qualitative descriptive study used an online or paper questionnaire to capture data on the Veterans’ experiences in searching for rental housing. Thematic analysis of responses resulted in the following themes based on the BEM: lack of quality housing, quality of the neighborhood, communication, policy, and reintegration. Findings provide insights that can assist agencies in tailoring services to Veterans to help them find quality homes that are accessible,...