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Introduction: Aging rural veterans have limited access to geriatric mental health services. The establishment of Veterans Health Administration (VHA) regional telehealth hubs, or Clinical Resource Hubs (CRHs), has the potential to improve access to specialist care via telehealth delivered across healthcare systems within each VHA region. We used the Consolidated Framework for Implementation Research (CFIR 1.0) to examine variations in the tele-geriatric mental health (tele-GMH) care models being used in four CRHs. Methods: We interviewed 11 CRH geriatric mental health providers and 12 leaders to (1) characterize the models of care, (2) identify factors in their region that support tele-GMH, (3) identify factors underlying model adaptations, and (4) learn about barriers and facilitators during implementation. The interviews were analyzed using a combination of CFIR-based coding and rapid qualitative analysis. Results: The services used multiple telehealth modalities; their care delivery approach ranged from consultative to continuity services. Aspects of the inner setting, specifically structural characteristics, implementation climate, and implementation readiness, influenced the model that each CRH implemented. Barriers were largely related to inner setting structural characteristics. Facilitators highlighted the importance of planning, iteration, and engaging stakeholders during implementation. Conclusion: Tele-GMH models varied in approach, tailoring their services to fit inner setting characteristics. Barriers and facilitators remained consistent across regions. Attending to inner setting characteristics, ongoing process improvement, and nurturing relationships with stakeholders is critical throughout the implementation of a tele-GMH program. Future research should examine the impact of the varied care delivery models on quantitative outcomes, including metrics related to access and healthcare utilization. [ABSTRACT FROM AUTHOR]

Objectives: To examine baseline factors (i.e., age, gender, mobile device proficiency, sensory impairment) associated with app engagement in a 12‐week mental health app intervention and to explore whether app engagement predicts changes in depression and anxiety symptoms among middle‐aged and older adults. Method: Mobile device proficiency, sensory impairment, depression, and anxiety symptoms were measured using questionnaires. App engagement was defined by metrics characterizing the core intervention features (i.e., messages sent to therapist, mindfulness meditation minutes, action tasks completed). Multiple regressions and multilevel models were conducted. Results: Forty‐nine participants (M age = 57.40, SD = 11.09 years) enrolled. Women (β =.35, p <.05) and participants with less sensory impairment completed more action tasks (β = −.40, p <.05). Depressive and anxiety symptoms measured within the app declined significantly across treatment. Clinical significant improvements were observed for depression in 48.9% and for anxiety in 40% of participants. App engagement metrics were not predictive of depression or anxiety symptoms, either incrementally in time‐lagged models or cumulatively in hierarchical linear regression analyses. Conclusion: App engagement is multifaceted; participants engaged differently by gender and ability. Participation in this digital mental health intervention reduced depression and anxiety symptoms, but these findings should be interpreted with caution as the study did not include a control condition. Our findings underscore the importance of considering individual factors that may influence use of a digital mental health intervention. [ABSTRACT FROM AUTHOR]

This program evaluation examined the feasibility, acceptability, and preliminary effects of an individualized coaching program to help older Veterans use VA mental health mobile apps to address mental health and well-being goals. The program delivers individual technical and clinical support to facilitate the use of mobile devices and VA apps. Participants completed assessments of mobile device proficiency, app use frequency, app comfort, quality of life, and mental health symptoms (completed by a subset, n = 11) pre- and post-participation. Of 24 enrollees, 17 completed the program and received an average of 7.58 (SD = 2.87) sessions including the initial assessment. Mobile device proficiency (t (16) = −3.80, p =.002) and number of days/week apps were used (t (16) = −2.34, p =.032) increased significantly from pre- to post-participation. Depressive and anxiety scores decreased significantly (t (10) = 3.16, p =.010; t (10) = 3.29, p =.008) among the subset completing those measures. Overall satisfaction was high; 100% reported they would recommend the program. Findings suggest the program is feasible, highly acceptable, and increases mobile device proficiency and use of apps. Coaching programs can equip older adults with the skills to use mental health apps. [ABSTRACT FROM AUTHOR]

Background: Older veterans with anxiety disorders encounter multiple barriers to receiving mental health services, including transportation difficulties, physical limitations, and limited access to providers trained to work with older persons. To address both accessibility and the shortage of available providers, evidence-based treatments that can be delivered via guided self-management modalities are a potential solution. Objective: This study aims to determine the feasibility and acceptability of a randomized controlled trial of 2 guided self-management interventions. This study compared the treatment effects of these 2 interventions (relaxation and health psychoeducation) on anxiety symptom severity and functioning in older veterans with anxiety disorders. Our exploratory aims examined factors related to home practices and treatment engagement and perceptions of the practices. Methods: Participants were randomized to one of two video-delivered interventions: (1) Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment (BREATHE)—breathing and progressive relaxation or (2) Healthy Living for Reduced Anxiety—psychoeducation about lifestyle changes. Telephone coaching calls were conducted weekly. Measures of anxiety, depression, and functioning were obtained at baseline, week 4 (end of treatment), week 8, and week 12. Participants completed a semistructured interview at week 12. Analyses included descriptive statistics to summarize measures of intervention engagement; mixed-effects models to characterize symptom change, and qualitative analyses. Results: Overall, 56 participants (n=48, 86% men; n=23, 41% from ethnic or racial minority groups; mean age 71.36, SD 6.19 y) were randomized. No difference in retention between study arms was found. The Healthy Living group (29/56, 52%) completed significantly more lessons (mean 3.68, SD 0.86) than the BREATHE group (27/56, 48%; mean 2.85, SD 1.43; t 53=2.60; P =.01) but did not differ in completion of coaching calls. In the BREATHE group, greater baseline anxiety scores (r =–0.41; P =.03) and greater severity of medical comorbidity (r =–0.50; P =.009) were associated with fewer completed practices. There was no effect of intervention on change in total anxiety scores or functioning. For specific anxiety subtypes, Healthy Living produced a greater decline in somatic anxiety compared with BREATHE. Qualitative analyses found barriers to practicing, including difficulty setting time aside to practice, forgetting, or having other activities that interfered with BREATHE practices. Some participants described adapting their practice routine to fit their daily lives; some also used relaxation skills in everyday situations. Conclusions: These findings suggest that a larger randomized controlled trial of guided self-management approaches to treating late-life anxiety is feasible; however, BREATHE was not effective in reducing anxiety compared with Healthy Living. Possible contributing factors may have been the reliance on a single technique. Progressive relaxation was reported to be enjoyable for most participants, but maintaining home practices was challenging. Those with milder anxiety severity and fewer health problems were better able to adhere to practices. Trial Registration: ClinicalTrials.gov NCT02400723; https://clinicaltrials.gov/study/NCT02400723 [ABSTRACT FROM AUTHOR]

Self-management may help older Veterans with mental health challenges and can overcome barriers to traditional psychotherapy. However, the reasons underlying older Veterans' treatment preferences remain unknown. The current study investigated older Veterans' perspectives on psychotherapy and self-management. Seventy-four Veterans ≥ 60 years old were included in this mixed methods study. Participants provided rationale(s) after ranking their preferences for psychotherapy and four self-management modalities. Logistic regressions examined whether depressive and anxiety symptom severity contributes to preferences. Qualitative analyses were conducted to investigate reasoning for preferences. Most participants preferred psychotherapy (64.9%) over self-management (35.1%). Logistic regressions showed that depressive and anxiety symptom severity was not significantly associated with preferences. Qualitative analyses revealed that past experience and access-related barriers were underlying the preferences. Themes unique to psychotherapy included the availability of emotional support and the process of information sharing. In contrast, ease of access was associated with self-management. Older Veterans preferred psychotherapy to receive support and to develop trust in meeting their goals. Older Veterans' needs point to the importance of providers' consideration of a person-centered approach and treatment collaboration. Notably, Veterans' preference for psychotherapy highlights the importance and need for human support in addition to self-management tools. [ABSTRACT FROM AUTHOR]

Objectives: The perception of being a burden is a well-known risk factor for dying by suicide. Research on factors that precede the state of perceived burdensomeness, such as fearing being a burden, is necessary. We investigated the extent to which health status, elevated depressive symptoms, and elevated anxiety symptoms are associated with fear of being a burden in late life. Method: Older adult participants (N = 155) completed the Geriatric Anxiety Scale (GAS), Patient Health Questionnaire (PHQ-8), and demographic and health questions. Fear of being a burden, assessed with a supplemental item on the GAS, was categorically grouped as 'no fear' or 'some fear'. Using logistic regression, we examined predictors of fear of being a burden. Results: In the first step, elevated depression was associated with fear of being a burden (OR = 2.30, 95% CI: 1.09, 4.89, p =.03), but health status was not significant. In the second step, elevated anxiety was significant (OR = 2.63, 95% CI: 1.15, 5.99, p =.02); depression was no longer significant. Conclusion: Contrary to expectations, anxiety more strongly predicted fear of being a burden than depression. Future research should further investigate the role of anxiety in fear of being a burden and ways of intervening. [ABSTRACT FROM AUTHOR]

This study examined the acceptance, feasibility, and preliminary effects of a guided self-management intervention using video delivery and a telephone coach on anxiety and activity engagement. Ten Veterans aged 60 years or older with anxiety disorders determined by Structured Clinical Interview for Diagnostic and Statistical Manual 5th edition (SCID-5) at baseline visit participated in this non-randomized study examining a 4-week guided self-management intervention for anxiety. Feasibility was examined using participation engagement with the intervention. Measures of anxiety (Geriatric Anxiety Scale, PROMIS Anxiety Scale, Anxiety Control Questionnaire), depression (Patient Health Questionnaire 9-item), and activity participation (modified Activity Card Sort) administered at baseline and final (week 8) visit provided estimates of preliminary intervention effects. The Geriatric Anxiety Scale also was administered by phone at week 4. Participants completed a semi-structured qualitative interview at the final visit, which provided information about the acceptability, benefits of intervention, and barriers to engagement. All participants (N = 10) reported that the intervention somewhat or completely met their expectations, demonstrating intervention acceptability. Intervention completers (n = 9) experienced reduced anxiety over the first 4 weeks, alongside significant improvements in anxiety control and personalized activity goals across 8 weeks. However, anxiety symptoms tended to return to baseline at follow-up. Participants identified the relaxation videos and promotion of a daily relaxation routine as the most helpful intervention components. Findings indicate that the intervention may improve activity participation and reduce anxiety. Thus, guided self-management interventions show promise for reducing distress and maintaining engagement later in life. [ABSTRACT FROM AUTHOR]

More than half of Veterans are aged 65 years or older and many reside in rural areas where geriatric psychiatrists are scarce. One innovative solution to reach these Veterans is to use regional telehealth hubs, called Clinical Resource Hubs (CRH) which serve multiple health care systems in a VA region (Veterans Integrated Service Network; VISN). In one region (VISN 23), a Tele-Geriatric Psychiatry Consultation was developed to carry out specialty geriatric psychiatry consultation and education remotely to rural VISN regions. Since its inception and success in delivering specialty care across health care systems, three more regions (VISNs 1, 9, 20) implemented a Tele-Geriatric Psychiatry Consultation Service to meet the needs of geriatric rural Veterans. In this consultation model, the geriatric psychiatrist consults with referring providers on cases but does not prescribe and provides a treatment plan for follow-up to the local provider. As new VISNs implemented the service, the model was adapted to meet each region's specific needs. Interviews with mental health leadership in the CRH were examined to understand decision points and factors that guided these differences in models of care. An independent evaluation team conducted a series of interviews with 5 Mental Health leaders in CRH and 10 consultant mental health providers. Using a rapid qualitative approach and thematic analysis, we identified factors and themes that leaders identified in tailoring the Tele-Geriatric Program to their regions. Interviews from 10 program consultants will be analyzed using the same approach to validate themes and assess for further important themes in implementation. This project was determined to not be human subjects research. The three model adaptations were: (1) continuity model where Veterans with geriatric specific concerns are paneled to the team in the CRH for continuity mental health care; (2) a hybrid model consisting of consultation and continuity care; and (3) a treat-and-return model, where Veterans receive a time-limited episode of care from the CRH team for stabilization and then the patients are returned to local providers following that episode. In panel management, the geriatric psychiatrist is responsible for service delivery, intervention, and prescriptions. All leaders identified that filling gaps in Geriatric services and tailoring those services to the existing infrastructure guided the development and implementation of their models. Additionally, the importance of marketing at leadership and provider levels to market the service was emphasized. Themes of prioritizing provider relief, provider buy-in and turnover in local providers and leadership emerged as factors that guided VISNs away from the original consultation model. Understanding the factors influencing the adoption different models of care will help guide subsequent adaptations of tele-geriatric mental health services. Further limitations and implications will be discussed. VA Office of Rural Health. [ABSTRACT FROM AUTHOR]

Informal caregivers, typically unpaid family/friends, may experience negative psychosocial effects due to the demands of the caregiving role. Informal caregivers' perspectives and experiences are often overlooked in patient care despite their immense involvement with patients. In this study, we explored the impact of a virtual geriatric psychiatry consultation service on the informal caregivers of rural-residing patients. The Department of Veterans Affairs deployed this program through a regional telehealth hub to provide specialty geriatric consultation for rural populations, who may encounter barriers to care such as transportation and insufficient resources. 7 caregivers of older patients with multiple chronic physical and behavioral health conditions enrolled in a virtual geriatric psychiatry consultation service in the Midwest region were interviewed from July to December 2021. The program evaluation team conducted semi-structured interviews to gather information on consultation experience, perceived support, and understanding of patient's diagnosis. Interview transcripts were summarized using rapid analysis techniques, and domain summaries were formed based on the interview questions. Summaries were then analyzed for themes. The following themes emerged from analysis of caregiver interviews. Most caregivers were comfortable using telehealth and appreciated the convenience of the virtual care service. Caregivers reported the consultant made them feel heard and includes their perspectives in care decisions; provided hope regarding patients' diagnoses and treatment; empowered caregivers to look up health information and ask questions about medications; provides education on health conditions, medications, and medical procedures; and improved quality of life through the consultation process. Although this consultation service was developed to meet specialized clinical needs of rural geriatric patients, the consultant had the indirect effect of enhancing self-efficacy for these patients' informal caregivers. Support for caregivers is a critical need, particularly in rural areas with scarce resources. This service is currently being adapted in other regions, and it will be of interest to observe whether similar positive impacts are seen with more representative caregivers, in other regions, and with patient/caregiver dyads served by other providers. This small study suggests that training other disciplines to offer caregiver support would have a beneficial effect on caregivers, who are a vital and often overlooked part of patient care. This study was funded by VA Office of Rural Health. [ABSTRACT FROM AUTHOR]

Delivering geriatric psychiatry services through telehealth increases equitable access to this specialty, especially for those residing in rural areas. One such telehealth approach uses consultative care via patient referral from providers across the continuum of care including primary care, inpatient care, and nursing homes. Perceptions of access and comfort with the consultative process and experience were qualitatively analyzed to better understand providers' motivations for referring patients to this consult service and benefits received from the service. Interviews were conducted with Veterans Health Administration providers who referred patients to a tele-geriatric psychiatry consultation service between October 2020 and September 2021. Eleven qualitative semi-structured interviews were completed offering feedback regarding the consultation experience and impact. Qualitative analysis began using summary template analysis to create domains based on the interview questions. Changes to the template were made based on consensus and all interviews were coded. Master domain summaries were created and re-categorized by grouping related ideas and themes. Two of the multi-source summaries created included, 'Consultation Experience & Most Helpful Aspects' and 'Service Impacts, Access & Comfort Changes.' The tele-geriatric psychiatry consultation service was described as purely consultative assistance guiding clinical workup and providing recommendations from either a chart-review or clinical encounter with the patient over telehealth. The most highly valued features focused on the consultant's knowledge, collaboration, communication and trustworthiness, the ease of the consultation process, and accessibility. Access impacted both providers and patients. One provider spoke of finding specialized care "I don't think there's even community geriatric psychiatry out here, if there is, it would be hard to find." Many providers had increased levels of comfort caring for geriatric patients after having direct or indirect education from the geriatric psychiatrist. One provider acknowledged, "It's been very educational. Just her approach to talking with some of these patients and-like the questions that she'll ask..." Providers reported gaining specific knowledge about medication dosing in older patients and behavioral approaches to supporting patients with distress behaviors. Referring providers reported the tele-geriatric psychiatry consultation service was accessible, timely and collaborative. Providers experienced increased comfort and decreased burden from having access to the geriatric psychiatrist's expertise and assistance with patients experiencing distress. Additionally, the geriatric psychiatrist's example and collaboration benefited the provider both immediately and in future encounters. Expansion of services like this one may be beneficial for other rural sites and providers. VA Office of Rural Health [ABSTRACT FROM AUTHOR]

To bridge the gap between limited access to geriatric psychiatry expertise and the high psychiatric needs of rural Veterans, a tele-geropsychiatry consultation model of care was developed to serve a 5-state rural region. This consultation program, led by a geriatric psychiatrist, delivers tele-consultation services via video, phone, and e-consultation to Veterans and their health care teams across the Veterans Health Administration continuum of care (e.g., outpatient, in-home, Community Living Centers). This abstract aims to (1) ascertain referring providers' frequency of using the service and common referral reasons, (2) elicit barriers to following through with recommendations, and (3) examine perceptions of whether the service increased access to specialty care. An exploratory aim examined differences in reasons for referrals and barriers to following through with recommendations between providers with prescription privileges and those without. Eighty referring providers were sent an electronic survey comprised of multiple-choice and text response questions. Open-ended questions asked respondents to indicate their discipline, the main reason(s) for requesting the consult(s), general feedback, and barriers to following through with recommendations. Descriptive statistics were used to summarize quantitative responses. Qualitative content analysis was employed to categorize the open-ended data and compare responses by provider group (i.e., prescriber versus non-prescribers). The response rate for the surveys was 58.75% (n = 47). Twenty-eight referring providers were prescribers (physicians, mid-level providers, pharmacists; 74%); 10 were non-prescribers (psychologists, social workers, a registered nurse; 26%); nine did not indicate their discipline. About 60% of respondents described their level of comfort in working with geriatric mental health-related presenting problems as "comfortable" (36%) or "very comfortable" (23%). Seventy-nine percent of referring providers placed 2 or more consults in the last fiscal year, 17% placed one. Most respondents strongly agreed that they followed through with the geriatric psychiatry consultant's recommendations (78%), and that the consult(s) increased access to geriatric psychiatry care that would not have otherwise been available (87%). Reasons for consultation were categorized into three groups: (1) assistance with diagnostic clarification (18%), (2) medication recommendations to treat behavioral and/or psychiatric disturbances (29%), and (3) geropsychiatry expertise (53%). Access to geropsychiatry expertise included requests related to managing dementia-related behaviors (25%), psychiatric symptoms such as anxiety, depression, and paranoia (31%), complexity due to several reasons including co-morbidities and social situations (22%), and non-specific requests for assistance (22%). General feedback highlighted the importance of timely response to consult, collaboration with local teams, individualized medication and behavioral plans, and establishing strong rapport with patients and families via tele-health. Twenty-eight percent of respondents (n = 13) reported barriers related to following through with recommendations. Of those, seven indicated that the main barrier was the need to put in orders as the consultant does not place orders due to covering multiple healthcare systems. Variations in qualitative response patterns by prescribers and non-prescribers will be presented. Providers requesting this tele-geropsychiatry consultation service span a wide range of disciplines. More than half indicated some level of comfort in working with geriatric mental health-related presenting problems, yet the majority of respondents placed two or more consults in the past year, thus supporting the merit for specialty geriatric mental health care to address complex neuropsychiatric issues and behavioral disturbances. This consultation supplements the consistent coverage provided by the core healthcare team that includes non-prescribing and prescribing providers. The main barrier to following through with recommendations was related to placing orders as a non-prescribing provider; however, this is a main component of the program that allows for broader reach. The key finding that the telehealth service increases access to geropsychiatry expertise that would not otherwise be available highlights the feasibility, acceptability and potential for tele-health consultation to support teams in managing patients with complex needs. This model of tele-geropsychiatry consultation across multiple health care systems is a highly scalable solution that increases access to specialized expertise for providers caring for older Veterans residing in rural areas. Office of Rural Health Salt Lake City team (VRHRC-SLC). [ABSTRACT FROM AUTHOR]