Effects of the Covid‐19 Pandemic on Early Implementation of a Nationwide Telehealth Program: A Qualitative Study

RESEARCH OBJECTIVE: External environment is an important factor in the success of large‐scale healthcare initiatives. However, there is limited understanding of how external shocks may shape early implementation. In October 2019, the VHA Office of Primary Care launched national Clinical Resource Hubs (CRHs) to provide staffing gap coverage for primary care and mental health services. Through a “hub” and “spoke” model, providers at 18 regional hubs deliver virtual and in‐person care to patients at spoke clinics. Using CRH implementation as a case study, we consider the impact of Covid‐19 on early implementation efforts. STUDY DESIGN: We conducted semi‐structured interviews about early implementation experiences with eight program office leads and six regional hub directors from June–September 2020. Data were analyzed using a rapid analysis approach, which entailed interview summaries cross‐validated by two project team members. Summaries were synthesized with consensus checks to identify major themes regarding CRH implementation from key interview domains. Data were aggregated across roles. POPULATION STUDIED: National program office leaders and regional hub directors involved in implementation. PRINCIPAL FINDINGS: The Covid‐19 pandemic was perceived as both facilitating and hindering implementation. For example, it accelerated achievement of some goals including telehealth emergency management support which was “fast tracked” in response to the pandemic during the first year of implementation although not required until year two. Hub providers also expanded support for regional nurse advice telephone call centers (a year 3 implementation goal) during March and April. In addition, Covid‐19 was recognized as a “game changer” in terms of increasing the acceptability of telehealth as an effective mode of care among VA national offices and spoke sites during a time of restricted in‐person appointments. The pandemic also posed significant implementation barriers. Hub directors reported difficulty establishing relationships at new spoke sites due to sites' focus on patient care during Covid‐19 surges. Additionally, they faced collaboration challenges, such as the inability of the national program office leaders to travel in person to assist with spoke site set‐up due to travel restrictions. In response to these challenges, leaders made several program modifications. Marketing efforts were broadened through increased outreach to potential spoke sites, in‐person visits to establish new spoke sites were suspended in favor of virtual training, and patient care delivery was modified to include in‐home telehealth visits. Respondents expected that these modifications may become permanent after Covid‐19 has ended, thereby altering CRH processes. CONCLUSIONS: Our findings demonstrate the complex effects of Covid‐19 on early program implementation, acting as both a facilitator and barrier in service provision, marketing, and training. Because some VA healthcare systems had telehealth pilot programs already in place, they may have been more “ready” to expand virtual visits when Covid‐19 struck. IMPLICATIONS FOR POLICY OR PRACTICE: The program modifications we identified in response to Covid‐19 carry actionable lessons for healthcare organizations similarly impacted by external environmental factors. Telehealth capacity and specifically the capacity to switch from in‐person to virtual modes of patient care and provider training may facilitate emergency response. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.