Openness to Use of Telehealth During and After the COVID-19 Pandemic in a Sample of Rural Older Adults in a Federally Qualified Health Center

To the Editor

The COVID-19 pandemic has facilitated increased use of telehealth for primary and specialty care encounters, and recently there have been calls to expand its use in post-acute and long-term care settings.^{1 , 2} Telehealth expansion is particularly important for rural and underserved populations as it represents a medium to increase access and reduce disparities in health care delivery.³ However, despite the increase in availability, relatively little is known about whether rural older adults are open to using telehealth.

Methods

Sample

Participants were adults aged ≥65 years from one clinic affiliated with a network of rural southeastern federally qualified health centers. These clinics serve more than 22,000 primarily rural patients, of which approximately 3000 are aged ≥65 years. Approximately 38% of patients are racial or ethnic minorities: 27% are black and 11% Hispanic/Latino. As part of a larger quality improvement (QI) initiative, older adults who were active patients (n = 357) were contacted for participation in a brief survey. Sixty-five (18.2%) completed the survey (50 by e-mail, 15 by mail). Because this project was deemed QI, institutional review board approval was not required.

Measures

Included in a survey on COVID-19 health care needs and utilization, patients were asked 3 questions about using telehealth: (1) “If available, would you be willing to use video conferencing with members of your healthcare team (ie, a telehealth visit) to receive care or medical advice about your emotional health?” (2) “How would you describe your level of comfort at the prospect of using video conferencing with members of your healthcare team to receive care or medical advice about your emotional health?” (3) “In the future, after the COVID-19 crisis has resolved, which of the following BEST reflects your attitude towards telehealth?” Use of telehealth for mental health care vs all types of health care was emphasized as appropriate in the survey.

Results

Table 1 summarizes descriptive data for each item. Regarding item 1, 37 of 65 (56.9%) indicated that they would not be willing to use telehealth for mental health during COVID-19 compared with 28 of 65 (43.1%) who would. Regarding item 2, nearly half (32/65, 49.2%) indicated being somewhat or very uncomfortable at the prospect of using telehealth for mental health. Regarding item 3, more than one-quarter (17/62, 27.4%) indicated that they would not use telehealth for any health care needs after COVID-19; an equal number (17/62, 27.4%) indicated they would prefer to receive care mostly or all in person. All 28 who indicated a willingness to use telehealth for mental health during COVID-19 also indicated some degree of openness to telehealth for all care as appropriate after COVID-19.

Table 1.

Older Adults’ Openness to Telehealth Use

Question	n (%)
Willing to use telehealth for emotional health∗
Yes	28 (43.1)
No	37 (56.9)
Level of comfort using telehealth for emotional health∗
Very comfortable	13 (20.0)
Somewhat comfortable	11 (16.9)
Neither comfortable nor uncomfortable	9 (13.8)
Somewhat uncomfortable	7 (10.8)
Very uncomfortable	25 (38.4)
Attitude toward using telehealth for all care after COVID-19†
Would receive most or all care by telehealth as appropriate	8 (12.9)
Would receive some care by telehealth	20 (32.2)
Would receive most or all care in person	17 (27.4)
Would not use telehealth	17 (27.4)

^∗n = 65.

^†n = 62.

Discussion

This brief exploratory QI study queried older, rural adults about openness to using telehealth. Most indicated an unwillingness to use telehealth for mental health, many of whom expressed feeling uncomfortable about the prospect of doing so. Moreover, a majority indicated that they either would not use telehealth for any care or prefer to receive most or all care in person once the COVID-19 crisis subsides.

Recent research regarding openness to using telehealth similarly found that older adults are less willing.⁴ However, as rural residents may be less likely to access mental health services overall,⁵ older adults in this sample indicating unwillingness to use and high discomfort with telehealth for emotional needs deserves further study. Indeed, a recent study found that rural residents were more interested in telehealth for mental health than their urban counterparts; however, younger residents and those with greatest existing access to mental health care were most interested.⁶

Although older adults may be less willing to use telehealth, the present data suggest that a sizable minority are open to its use. Some may be against using it for mental health, but there are other contexts for which telehealth may improve access and quality of care. Older patients are often complex and face numerous physical and behavioral health comorbidities. Given that rural patients often also live in health professional shortage areas and face access challenges to receiving specialized care of all types,^{7 , 8} providers and organizations should consider other opportunities to incorporate telehealth into practice. Research shows that negative attitudes toward telehealth utilization are related to exposure and community-based strategies may improve uptake.⁹

This study is limited by its small convenience sample from a single clinic and limited response rate (18.2%) but provides a valuable snapshot of rural older adults’ attitudes toward telehealth. As its availability is not likely to diminish and infrastructure continues to improve, interventions are needed to increase awareness and engagement in telehealth for older adults, including those that highlight its benefits and provide instruction, particularly for rural residents with limited access to care.¹⁰