Feasibility of a COVID-19 Rapid Response Telehealth Group Addressing Older Adult Worry and Social Isolation

Abstract

Objectives:

During the early months of the COVID-19 pandemic, virtual and telephone visits rapidly replaced most in-person care within the Veterans Health Administration (VA) to reduce the virus spread. To address the emerging mental health needs of older Veterans (e.g., social isolation) in the context of chronic underlying mental health needs (e.g., trauma), we developed an 8-week virtual group treatment manual. This article describes the results from a survey of geriatric mental health clinicians who used the COVID group manual to determine its acceptability and feasibility in these settings.

Methods:

Clinicians across three VA integrated care settings (home-based primary care, community living centers, and geriatric primary care) were surveyed about their experiences implementing this treatment (n = 21).

Results:

Clinicians found this intervention to be effective with their patients and useful and adaptable beyond the early pandemic period.

Conclusions:

This group teletherapy intervention was feasible and acceptable when treating Veterans in integrated geriatric healthcare settings. Despite technical challenges experienced by older Veterans, clinicians found this manual to be effective in addressing COVID-related worry and social isolation.

Clinical Implications:

This rapid response manual has remained clinically useful in geriatric mental health care settings beyond the initial weeks of the pandemic.

Introduction

In early January 2020, the World Health Organization (WHO) was notified that a new type of coronavirus (COVID-19) was the cause of an outbreak of respiratory infections in Wuhan City, China. The outbreak spread rapidly worldwide and by mid-March the WHO declared COVID-19 to be a pandemic (World Health Organization [WHO], 2020). In response, the Centers for Disease Control and Prevention (CDC) recommended physical (social) distancing and self-quarantine to reduce the risk of interpersonal transmission, particularly for groups at high risk of complications from the disease such as adults 65 and older and individuals with preexisting medical conditions (Centers for Disease Control and Prevention [CDC], 2020). Large healthcare organizations such as the Veterans Health Administration (VA) shifted toward telehealth services to help reduce transmission risk and conserve medical supplies (Pierce, Perrin, Tyler, McKee, & Watson, 2020). During April 2020, more than 90% of U.S. residents were under shelter-in-place orders (Mervosh, Lee, Gamio, & Popovich, 2020) and a trend analysis found that 61% of 6,146 U.S. hospitals adopted telehealth between January and March 2020 (Hong, Lawrence, Williams, & Mainous, 2020).

Specific groups, such as older adults, are a high-risk group for both COVID-19 and subjective isolation, commonly referred to as loneliness (National Academy of Sciences et al., 2020). According to recent investigations, older adults have reported higher depression and loneliness following the onset of the pandemic due to social distancing measures (Killgore, Cloonan, Taylor, & Dailey, 2020; Krendl & Perry, 2020). Though some older adults restrict their social engagement to their most important relationships to maximize emotional well-being in later life (Carstensen, Fung, & Charles, 2003), the pandemic eliminated many opportunities for both meaningful and casual social engagement (Smith, Steinman, & Casey, 2020). Outlets for socialization that may also serve as fundamental coping strategies for older adults, such as community and senior centers (Harandi, Taghinasab, & Nayeri, 2017), were suddenly unavailable. One potential consequence of limited contact with friends and loved ones is increased loneliness (Nelson, Pettit, Flannery, & Allen, 2020). Loneliness is consistently associated with negative health outcomes for older adults, including higher rates of depression and mortality (e.g., Luo, Hawkley, Waite, & Cacioppo, 2012), the effects of which are comparable to behavioral risk factors such as smoking (Bedard-Thomas et al., 2019; Holt-Lunstad, Robles, & Sbarra, 2017).

In addition to social isolation and loneliness, older adults may also experience increased anxiety stemming from stressors associated with the pandemic, particularly early on in the outbreak (Gaeta & Brydges, 2020). Uncertainty and conflicting information regarding COVID-19 contagiousness, prevalence and risk have been associated with heightened anxiety, panic disorder, and depression in the general population (Qiu et al., 2020). Due to their heightened risk of poor health outcomes from COVID-19, primary concerns include the possibility of suffering from unpleasant symptoms or dying from the virus (Pearman, Hughes, Smith, & Neupert, 2020). They may experience worry about their family members’ health status or the condition of their retirement accounts following plunging stock prices and unstable markets (Mann, Kruger, & Vohs, 2020). These COVID-19 related anxieties may be aggravated by public access to continuous media coverage highlighting increasing cases, hospitalizations, and mortality rates (Gao et al., 2020), and ageism in the media exacerbated during the pandemic (Bergman, Cohen-Fridel, Shrira, Bodney, & Palgi, 2020; Monahan, Macdonald, Lytle, Apriceno, & Levy, 2020). Further, older Veterans, particularly those who are medically complex or who have prior trauma exposure, have particularly salient mental health needs at this time (Marini, Pless Kaiser, Smith, & Fiori, 2020). Increased social isolation and anxiety related to the COVID-19 pandemic could lead to mental health crises in the older adult population (Luchetti et al., 2020; Sepulveda-Loyola et al., 2020; Wand, Zhong, Chiu, Draper, & De Leo, 2020).

Treating the uptick of mental health concerns among one of the populations most vulnerable to COVID-19 required widespread shifts in care delivery due to social distancing and infection control measures. Remotely delivered interventions via telehealth have been essential in addressing older adults’ mental health care needs during this period of face-to-face restrictions (Gorenko, Moran, Flynn, Dobson, & Konnert, 2020). The VA, which had already been consistently implementing telehealth prior to the onset of the pandemic (Chen et al., 2019; Shreck et al., 2020), was able to respond quickly to these evolving Veteran needs (Pierce et al., 2020). The VA has been at the forefront of telemental health care for over a decade, including the delivery of televideo services to Veterans’ homes and satellite outpatient centers (Deen, Godleski, & Fortney, 2012; Godleski, Darkins, & Peters, 2012; Shore, Goranson, Ward, & Lu, 2014). The use of telehealth by VA clinicians escalated dramatically in the early weeks of the pandemic, allowing Veterans widespread access to necessary mental health services during an uncertain time (Cheng, Allison, McSteen, Cattle, & Lo, 2020; Heyworth, Kirsh, Zulman, Ferguson, & Kizer, 2020; Rosen et al., 2020). However, limited internet access remains a barrier to outpatient care for some older Veterans, especially those in rural areas, and telephone visits may be preferred to televideo by some (Padala, Wilson, Gauss, Stovall, & Padala, 2020).

VA geriatric mental health clinicians working in assisted living, senior housing, long-term care, and rehab settings face additional challenges in providing care to Veterans during the pandemic. Residents of these settings are among the highest risk for poor COVID-19 outcomes and experienced sudden restricted contact with others, sometimes involuntarily. Therapeutic support for social isolation and other mental health concerns may have traditionally taken the form of group intervention, which has been demonstrably feasible and welcomed in long-term care settings if presented as part of ongoing community activities to reduce the stigma of receiving mental health care (Strong, Plys, Hartmann, Hinrichs, & McCullough, 2020). However early in the pandemic, many geriatric mental health clinicians did not have prior experience delivering group telehealth interventions and there were no group interventions that specifically targeted anxieties and loneliness related to COVID-19.

In response to the urgent need for tailored mental health treatments for older Veterans during this unprecedented time, the “Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic,” an evidence-based group intervention deliverable over telephone or televideo, was developed that incorporated topics specific to the COVID-19 pandemic and its related mental health challenges. The intervention was compiled in written manual form and disseminated to geriatric mental health clinicians across the VA in March 2020. As the impact of the pandemic was quickly evolving and differentially impacting regions within the US, the manual was intended to be flexibly adapted by clinicians according to their local needs over time. In August 2020, a survey was sent to clinicians across three VA geriatric mental healthcare integrated care team settings (home-based primary care (HBPC), community living centers (CLC), and geriatric primary care (geriPACT)) asking for their feedback on their implementation of this intervention with their patients.

Methods

Implementation framework

Implementation frameworks allow researchers to understand contextual factors affecting implementation, such as facilitators and barriers to implementing their intervention in a particular setting (Nilsen, 2015). While this project was not developed around a research question (the manual was developed and disseminated within a span of three weeks to fill an urgent clinical need), we do find it useful to map onto an implementation and dissemination framework in conceptualizing this work. Selection of an implementation framework from among the many kinds available is driven by a fit between a given framework and the project undertaken (Tabak, Khoong, Chambers, & Brownson, 2012). Because this project involved the dissemination of a novel treatment manual that was based on existing evidence-based geriatric mental health practices, we utilized a Hybrid Type 1 design framework (Curran, Bauer, Mittman, Pyne, & Stetler, 2012), with the primary aims being (1) identifying barriers and facilitators to implementation (Cochrane et al., 2007), and (2) identifying modifications to or future versions of the manual that could support patient needs as the pandemic evolved.

Given the urgent clinical needs brought about by the COVID-19 pandemic, we also aimed for a rapid implementation framework (Smith et al., 2020). In order to encourage use of evidence-based geropsychological interventions, we built the framework of the intervention on therapeutic approaches that would be familiar to these clinicians, while also addressing pandemic-specific clinical needs that we anticipated. We sought to understand factors that supported implementation of this manual by those who chose to use it in clinical practice. It was also important to identify barriers the clinicians faced and augmentations to care they implemented to fit their local needs, adding an element of patient-centered medicine that is a building block of rapid implementation. Consistent with previous applications of these design frameworks we also developed an informal community of practice for VA geriatric mental health clinicians to collaborate with each other around implementation of this manual.

Group materials and format

The “Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic” manual and its associated patient handouts are housed on the official webpage of “GeroCentral.org,” a collaborative catalog of essential geriatric mental health resources, (https://gerocentral.org/clinical-toolbox/covid-19-resources/), alongside a regularly updated list of additional geriatric mental health resources related to COVID-19. The manual and its handouts are also available in full as a supplemental online appendix to this article. The contents of this manual were compiled as a rapid response to emergent COVID-19 pandemic realities in March 2020, during which many locations in the United States called for immediate self-quarantine measures for unknown durations. As such, the manual is a rapidly developed compilation of evidence-based psychotherapy interventions for older adults designed for group administration by televideo or telephone in an effort to overcome emerging barriers to care. The manual drew from three commonly used evidence-based treatments for older adults: Acceptance and Commitment Therapy (ACT) approaches to facilitate anxiety management, Problem-Solving Therapy (PST) to address social connectedness tactics, and Cognitive Behavioral Therapy (CBT) to promote behavioral change.

ACT is an evidence-based psychotherapy that focuses on acceptance as a process resulting in increased psychological flexibility that works as a buffer against experiential avoidance and ineffective coping (Luoma, Hayes, & Walser, 2007). Research supports the relationship between ACT and quality-of-life factors among older adults, particularly for addressing generalized anxiety disorder (Wetherell et al., 2011). ACT tenets of value-based acceptance of environmental and logistical limitations within the context of the pandemic were incorporated into the manual. Studies of PST in older adults have revealed significant reduction in symptoms of late-life major depression (e.g., Crabb & Arean, 2015) at greater rates than supportive therapy and reminiscence therapy (Kiosses & Alexopoulos, 2014). Thus, approaches of PST were applied within the manual to help participants address social isolation and circumvent situational barriers to interpersonal connection. CBT, pioneered by Beck (1970) and Ellis (1971), is an effective treatment recommended for depression in adults of all ages and is one of the most systematically researched psychosocial treatments for depression in later life (e.g., Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). CBT’s efficacy in alleviation of depressive symptoms among older adults is consistently concluded by comprehensive meta-analysis of randomized controlled trials (e.g., Cuijpers, Van Straten, & Smit, 2006). Tenets of CBT, such as identifying unhelpful thinking patterns and formulating behavioral strategies, were incorporated into the manual.

We used the principle of user-centered design (Lyon & Koerner, 2016) to gear the manual to the needs of VA geriatric mental health clinicians. Because many clinicians may have been new to telephone and virtual groups, the group was designed to be easy and efficient to implement quickly as the pandemic unfolded. For example, to help familiarize clinicians new to telemental health, information on the ethical and practical considerations of geriatric telehealth is included, drawn from sources such as the APA’s guidelines for the practice of telepsychology (Joint Task Force for the Development of Telepsychology Guidelines, 2013). The manual also included educational information on mental health impacts of the COVID-19 outbreak and geriatric-specific considerations of the outbreak (e.g., Inter-Agency Standing Committee, 2020).

Similarly, educational information on COVID-19 was incorporated into the group treatment, with aims of addressing anxieties associated with ambiguity or misinformation about the pandemics’ contagiousness, prevalence and risk (Qiu et al., 2020). Another focus of the intervention specific to the pandemic was social connection. Suggested homework for participants to complete between sessions centered on creative ways to connect with loved ones such as writing letters or exploring technology-based methods for sharing experiences with others. This was an advantageous avenue for introducing these social outlets, as research indicates that clinicians in geriatric mental health settings are well-positioned to address barriers to older patients’ technology use, such as unfamiliarity with how technology can facilitate and augment their care (Gould & Hantke, 2020). Indeed, this group intervention was designed specifically for older adults whose social isolation was exacerbated by COVID-19 or for those experiencing isolation for the first time because of COVID-19.

The group manual is a finite series of eight sessions. Each session was tightly structured to allow for effortless implementation and support of clinician self-efficacy in delivering these types of groups, as described in Table 1. Clinicians were also encouraged to utilize the manual flexibly in accordance with local needs, as those could not be fully anticipated at the time of dissemination. Within each session, time was allotted to address specific patient concerns that emerged over time as the pandemic situation unfolded. In response to Veteran feedback, handouts were created and disseminated that coincided with each group session to support Veterans’ mastery and retention. Table 2 lists the topics, skill building exercises, summary description, and social engagement homework for each group session.

Table 1.

Group session structure.

	ACTIVITY	DESCRIPTION	TIME
1	Check-in	Group members share updates from the week. Review successes and barriers to previous session’s goals.	15 minutes
2	Teaching	Clinician presents on the topic of the week.	15 minutes
3	Skill Building	Clinician leads group members in an exercise to practice the skills they are learning.	10 minutes
4	Discussion	Group members are asked to answer a question, describe a specific experience, or discuss a topic with other group members.	10 minutes
5	Wrap Up & Homework	Summarize session themes. Group members plan one concrete step to take in the next week to reduce social isolation	10 minutes

Table 2.

Group session topics, skill building exercises, and homework.

Session	Teaching	Skill Building Exercise	Summary description	Social Engagement Homework
1	COVID-19 Facts vs. Fiction	FACE COVID mindfulness exercise	Introductions, group norm setting	Where to get your info from
2	Noticing, Checking & Worry	Identifying Automatic Thoughts	Coping with worry, recognizing thoughts aren’t facts	Pleasant Activities (What are you already doing)
3	Challenging Automatic Thoughts	Thoughts as Changeable	Develop a positive self-statement or mantra to say	Pleasant Activities (Try Something New)
4	Anxiety: Approach vs. Avoidance	Identify Behavioral Strategies for Anxiety	Basic Mindfulness Exercises	Calling an old friend
5	Attention & Mindfulness	Mindfulness Exercise	Practice additional mindfulness strategies	Writing a letter
6	Dealing with Difficult Emotions	Naming emotions, identify triggers	Emotions are neither good nor bad, our responses to our emotions are what hurt/help us	Sharing something emotional with someone
7	Emotional Barriers to Problem Solving	Emotion-Focused vs. Problem-Focused Coping	Emotion regulation strategies	Grieving a Loss
8	Mobilizing Resources and Giving Thanks	Gratitude Exercise	Recap the group members’ experiences. Revisit social goals and discuss the future. Discuss mobilizing supports. Review local resources for emerging member needs.	Giving Thanks to Someone Important to Me

Several studies have captured unintended negative consequences of societal responses to the pandemic in relation to older adults. For example, Monahan et al. (2020) reviewed both positive and negative impacts from protective policies aimed at limiting older adults’ exposure to COVID-19. The authors noted that designated senior shopping hours and home delivery services have exemplified how older adults are valued and appreciated. The flip side is the perpetuation of a pre-pandemic negative stereotype that all older adults are fragile, dependent, and sickly; this is then argued to negatively impact self-esteem and well-being. A deeper look into the paternal messaging geared to help older adults reveals instances of undermined autonomy and internalized negative self-perceptions.

Relatedly, some have argued that various media outlets initially portrayed COVID-19 as an “old people” disease, alongside perceptions of older adults as being irresponsible (Colenda et al., 2020). “Boomer removers” emerged as a trending term that suggests a different societal impact than if younger adults were perceived as equally vulnerable to the virus. Given harmful portrayals of older adults in the media before and during the pandemic, this group was also designed to provide an opportunity for members to share wisdom and strengths with each other. Counteracting negative views of aging may help to reinforce resilience, as a recent study of COVID-19 self-isolating adults in Spain suggested those with more optimistic views of aging fared better than others in the face of the outbreak (Losada-Baltar et al., 2020).

Procedures

In late March 2020, approximately two weeks after the United States declared a national emergency due to the pandemic, the manual was disseminated across three national VA e-mail listservs, each of which targets a distinct geriatric mental health clinician community: 1) Mental Health Providers within Home-Based Primary Care Clinics (n = 360); 2) Mental Health Providers for VA’s long-term care facilities (Community Living Centers; n = 275); and 3) Mental Health Providers in Geriatric Primary Care (“GeriPACT,” n = 217). A web-based clinician feedback survey was created via Qualtrics and in August 2020 was disseminated across the three listservs inviting recipients to complete it if they had implemented a support group using the manual.

Measures

The clinician feedback survey was developed for the purpose of this study as a program evaluation and quality improvement tool. The survey included questions regarding utilization characteristics, implementation outcomes, and characteristics of the group participants. The survey also asked clinicians to rate the effectiveness of the group’s session structure and topics via likert scales (1 = not effective, 2 = slightly effective, 3 = moderately effective, 4 = very effective, and 5 = extremely effective).

Clinicians were asked open-ended questions regarding their group implementation and suggestions for future application. Qualitative responses were analyzed using a strategy based on a conventional content analysis (Hsieh & Shannon, 2005). Categorizing was completed via an inductive approach by three research team members. Keywords and phrases from responses were highlighted and similar concepts across responses were grouped together. Themes and subthemes were generated based on these grouped concepts.

Results

Clinician and site characteristics

Twenty-one clinicians who implemented the group manual filled out the survey. Study analyses were conducted on the 18 (86%) respondents who completed the survey in full. The majority of respondents (83.3%, n = 15) were clinical psychologists, one (5.6%) was a social worker, and two (11.1%) were psychology trainees (one pre-doctoral intern and one postdoctoral fellow) who co-ran the group with a clinical psychologist. Twelve respondents (66.7%) reported that they co-ran the group with another clinician, one (5.5%) ran it alone, and two (11.1%) co-ran the group with two other clinicians; both trio teams consisted of a clinical psychologist, psychology trainee, and social worker.

VA Clinics in which the manualized group was delivered included HBPC (n = 11, 61.1%), Community Living Centers (n = 2, 11.1%), Primary Care Mental Health Integration Clinics (n = 1, 5.5%), Outpatient Geriatric Mental Health Clinics (n = 1, 5.5%) and Other (n = 2, 11.1%). Respondents described the urbanity/rurality of their groups’ participant make-up in a multiple response format, as many HBPC clinicians (for example) cover large geographic catchment areas (see Figure 1). Eleven (61.1%) respondents reported their groups included members from areas that are rural or highly rural. Eleven (61.1%) respondents reported including group members from suburban areas. Six (33.3%) respondents reported including group members from urban areas.

Figure 1.

Veteran population distribution by site.

COVID-19 experiences

Respondents were asked about the impact of COVID-19 on themselves and on their group participants. Twelve (66.7%) reported that at least one of their group participants mentioned that someone they knew had been diagnosed with COVID-19. Five (27.8%) reported that at least one of their group participants mentioned that a friend or acquaintance had been diagnosed with COVID-19. Five (27.8%) reported that at least one of their group participants mentioned that a loved one had died due to COVID-19. Three (16.7%) experienced the death of a loved one due to COVID-19 while facilitating the group. No respondents reported that a participant had been diagnosed with or passed away from COVID-19. No respondents reported that they had been diagnosed with COVID-19 while running the group.

Group administration characteristics

Eleven respondents (61.1%) ran the group once, five (27.7%) ran it twice and two (11.1%) ran it four or more times. Eight sites began their first (or only) iteration of the group in April 2020, nine (50%) began in May 2020 and one (5.5%) began in June 2020. Nearly all respondents (n = 16, 88.9%) ran the groups for Veteran participants, while two (11.1%) had both Veteran and caregiver participants in the same groups. According to respondents’ report, an average of 6.2 (SD = 1.76) Veterans attended at least one group session and an average of 3.6 (SD = 1.61) Veterans attended half or more group sessions. Thirteen (72.2%) respondents reported they had enough time each session to cover group material. No respondents reported administering measures to participants.

Sixteen respondents (88.9%) ran the group over telephone and two (11.1%) used a video conferencing platform. Fourteen respondents (77.8%) reported experiencing technical difficulties at least once during the group. Technical difficulties occurred during an average of 3.29 sessions (SD = 2.43) for the fourteen respondents who experienced them at least once. Eleven (61.1%) endorsed user errors (trouble navigating platform or device), seven (38.9%) endorsed technology errors (dropped calls, lost internet service) and four (22.2%) endorsed both.

Perceived program effectiveness evaluation

Respondents were asked to rank the perceived effectiveness of both structured session components (see Table 3) and of session topics (see Table 4). They also rated how the overall group on how well they felt it addressed COVID-related worry (M = 3.56, SD = 0.86) and social isolation in Veterans who participated (M = 3.61 SD = 2.04), with 10 (55.6%) respondents describing the group as very or extremely effective in addressing social isolation, and 10 (55.6%) describing the group as very or extremely effective in addressing COVID-related worry. Twelve (66.7%) reported they would “definitely” run this group again, four (22.2%) reported they would “likely” run the group again, and two (11.1%) stated they “might or might not” run the group again. All (100%) respondents reported that they would be interested in a modified version of the manual for telehealth services post-COVID.

Table 3.

Perceived effectiveness of structured session components.

	M (SD)
Check-in	3.89 (0.90)
Teaching	3.50 (0.924)
Skill Building	3.61 (0.92)
Discussion	4.28 (0.75)
Wrap Up & Homework	3.00 (1.14)

Notes: Perceived Effectiveness Likert Scale: 1 = not effective, 2 = slightly effective, 3 = moderately effective, 4 = very effective, and 5 = extremely effective.

Table 4.

Perceived effectiveness of session topics.

	M (SD)
Session 1 – COVID Facts vs. Fiction	3.78 (0.94)
Session 2 – Noticing, Checking & Worry	3.83 (0.92)
Session 3 – Challenging Automatic Thoughts	3.50 (1.10)
Session 4 – Anxiety: Approach vs. Avoidance	3.44 (0.86)
Session 5 – Attention & Mindfulness	3.78 (1.17)
Session 6 – Dealing with Difficult Emotions	3.44 (0.86)
Session 7 – Emotional Barriers to Problem-Solving	3.39 (0.85)
Session 8 – Consolidation, Mobilization & Termination	3.28 (1.07)

Notes: Perceived Effectiveness Likert Scale: 1 = not effective, 2 = slightly effective, 3 = moderately effective, 4 = very effective, and 5 = extremely effective.

Qualitative data

Table 5 provides a list of themes, subthemes, and a summary of the qualitative findings. The five main themes that emerged included: clinicians’ satisfaction; utility/effectiveness; Veterans’ engagement; implementation; opportunities for future modification. Respondents generally indicated that Veterans enjoyed the groups and desired to participate again in the future. The responses indicated the manual was a valuable guide for conducting group teletherapy with the complex older Veterans served in these settings. Respondents noted the group was helpful for skill-building, led to social connections between Veterans, and demonstrated feasibility for use in geriatric mental health care.

Table 5.

Qualitative themes emerging from open-ended survey responses.

Themes/Subthemes	Summary of Findings
Clinician Satisfaction	-Desire to offer group again   -Well-written protocol
Utility/Effectiveness Helpful to Veterans	-Useful for skill-building   -Veterans benefited
Connections among Veterans	-Cohesion and social connections formed
Feasibility	-Feasible in a geriatric mental health setting
Veterans’ Engagement	-Inconsistent attendance   -Desire for additional sessions
Implementation	-Opportunity for wellness check-in   -Clinicians added content   -Shifted content focus toward post-COVID
Opportunities for Future Modification
Technological challenges	-Difficulty adapting to videoconferencing   - Challenges related to telephone usage due to   -Veterans’ functional impairment
Suggested content changes	-More time for discussion   -Adaptation for cognitive challenges   -Additional topics: reminiscence, grief/loss, finding community/online supports

Comments were also made about Veterans’ engagement. Some respondents suggested participation in their groups was inconsistent across sessions. They attributed the variable attendance to technology complications, a brief recruitment period due to clinical urgency, and the level of functional impairment their Veterans faced. Despite these hurdles, respondents consistently reported their Veterans wanted the group to continue past the final session. Multiple respondents indicated a plan or desire to run the group again within their clinical setting. Respondents also commented on implementation strategies. The group content appeared to be applied flexibly; for example, one clinician added a teaching module on coping with grief during the pandemic. Another clinician indicated their group focused more on general anxiety rather than COVID-related anxiety, in alignment with the request of group members.

Responses indicated that technology challenges arose and sometimes led to disruption during sessions. The telephone modality was described as challenging when Veterans were more functionally impaired, but was preferred over having no intervention at all, as face-to-face visits were not occurring in most or all cases. Some responses suggested modifications to session format, such as dedicating more time to the discussion component. Several conflicting comments were noted, perhaps as a reflection of diverse Veteran needs. For example, one respondent suggested that an open group format may improve participants’ social connections and resources more than a closed group, whereas another respondents indicated that their group’s open format may have limited group cohesion and expressed preference for running the group in a closed format.

Discussion

A rapid response manual titled “Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic” was developed and disseminated in March 2020 to VA geriatric mental health clinicians. Utilizing an implementation science framework, the current study examined the group intervention’s feasibility and identified barriers that arose during implementation. Findings from this clinician feedback survey demonstrate the utility of a manualized intervention aimed at improving socialization and worry reduction in older adults during the early months of the COVID-19 pandemic in the United States.

Our findings suggest this group intervention is a feasible group telehealth intervention to implement in an otherwise challenging healthcare landscape. Results of the clinician feedback survey indicate that groups were successfully delivered by clinical psychologists, social workers, and varying levels of trainees with high reported ratings of effectiveness on treatment goals. The group was implemented nationwide across a broad spectrum of geographic regions and geriatric mental health settings.

The manual was feasible across telehealth modalities. Respondents delivered the intervention in full via video conferencing and telephone, though the majority of respondents opted to conduct the group over telephone. Technical difficulties were experienced at least once by most respondents regardless of modality. At least one respondent switched to telephone format after their participants had challenges navigating the video conferencing platform. Occasional technological glitches in telehealth are not uncommon, but the frequency with which respondents endorsed technological complications might reflect the time period in which the groups were delivered. Most respondents began their groups in April 2020, in the earlier stages of the pandemic in the United States. During this time, video communication platforms were overwhelmed with the sudden and unprecedented reliance on telecommunication and were underperforming. Infrastructural and user design improvements in technologies that were made in response to the pandemic’s surge in telehealth may yield different outcomes if current group clinicians were surveyed today.

In addition to feasibility, the acceptability of this group telehealth intervention was supported. Results found that Veterans frequently requested group continuation past the original eight sessions. The treatment’s focus on social connection and targeted topical relevance of a shared stressor may have facilitated the group’s high acceptability. Camaraderie is a significant component of Veteran identity (Davison et al., 2020); peer-based group support for a health threat with shared risk factors may have facilitated the comradely connection this group offered. This group also demonstrated acceptability from the clinicians’ perspective. Most respondents reported having repeated or continued offering groups using the manual. All respondents expressed interest in receiving further modifications to the manual (e.g., post-pandemic version, caregiver-focused version) and all reported that they would be interested in a modified version of the manual for telehealth services post-COVID.

Qualitative data of the survey provide further support for the group’s feasibility and acceptability. Responses indicate the group manual was administered adaptively to address each cohort’s needs. For example, one respondent reported that they adjusted session topics on COVID-19-specific worries toward general anxiety management to reflect one group cohort’s more mild concerns toward the pandemic. Identified challenges included themes of inconsistent participation and technology problems. Respondents offered suggestions for how to modify the treatment’s structure to meet Veterans’ needs.

The application of this manual via telephone or videoconference modality may differ depending on population density and availability of social resources. Populations in rural areas are on average older (Pender, Hertz, Cromartie, & Farrigan, 2019) and have more underlying health conditions than populations of suburban and urban communities (National Center for Health Statistics, 2018). Evidence shows that rurality impacts mental health service delivery, but this association is weaker for telehealth rather than outpatient treatments. In this way, telehealth improves access to mental health support for rural and homebound patients. However, systemic challenges, such as limited internet access and bandwidth coverage, present barriers to telehealth delivery in rural settings (Padala et al., 2020).

Limitations

The sample of the present study poses a limitation to generalizability. For instance, all respondents were Veteran Affairs Medical Center employees or trainees. The technology infrastructure for group telehealth is potentially different compared to non-VA care settings. Being in a national health system, VA clinicians and Veterans also had access to pandemic-focused infrastructure (e.g., COVID-19 testing, system-wide infection control measures), which may not have been as readily available in other health systems or care settings. This may have impacted group perceptions of the impact of the pandemic and the severity of COVID-related anxieties.

Another limitation to the generalizability of the present study is that survey responses reflect a historical snapshot of time during the early months of the pandemic (Spring/Summer 2020). Mid to later pandemic issues (e.g., inequitable COVID-19 health outcomes, economic strains, vaccine availability and coordination) and post-pandemic issues (e.g., complicated and cumulative bereavement or trauma due to COVID-19, lasting changes to healthcare delivery, physical, cognitive, and emotional sequelae of people recovering from COVID-19 infection) had not yet come to fruition and were unaddressed during clinicians’ group implementation. These presenting concerns could be incorporated into future iterations of the group. Time, geographic location, and local pandemic severity are all potential covariates of group outcomes. Given this was a project that was a rapid response to an emerging clinical dilemma, formal evaluations of group members were left to the discretion of the clinicians to implement. Future applications of this intervention could include pre-/post-evaluative assessments and measurement-based care.

Future directions

This telehealth group manual was a clinical innovation developed in crisis early in the pandemic when it was clear that traditional mental health practice required rapid change to address the older adult community’s mental health needs. As the pandemic continues to unfold, pursuing novel approaches for addressing social isolation in older adults remains critical. Several recent studies suggest the decrease of social interaction in light of public health restrictions negatively impacts quality of life and healthcare provision (Moreno et al., 2020; Nguyen et al., 2020). Moreover, emergent literature indicates a risk of speeded disease progression among older adults with chronic and co-occurring diseases, including but not limited to cardiovascular, hepatic, renal, and neurological illnesses (Ferini-Strambi & Salsone, 2021; Napoli, Tritto, Benincasa, Mansueto, & Ambrosio, 2020; Neumann-Podczaska et al., 2020; Shahid et al., 2020). Recent articles have also begun to highlight increasing reports of stress, anxiety, and depression among older adults as the pandemic continues (Baker & Clark, 2020). Aging Veterans present a unique subset of individuals who are particularly vulnerable to social isolation, worry, and other disruptions in mood and anxiety. Supporting social connectedness is an important suicide prevention strategy and this is salient with Veterans as part of VA’s broader mission for reducing Veteran suicide (Carroll, Kearney, & Miller, 2020; Van Orden et al., 2020). While the manual’s impact on Veteran care is not yet known, we are hopeful that positive implications will be observed across mental health, physical illnesses, and overall quality of life.

Remotely delivered interventions targeting anxieties related to health remain relevant amidst the pandemic and beyond. Group-based support via telehealth continues to serve as a viable and important implementation modality. Recent research indicates that a majority of older adults are interested in completing telehealth visits, but fewer report access to necessary technology or confidence they could participate (Hawley et al., 2020). However, pilot trainings for overcoming these perceived barriers have been efficacious, with all older adult participants successfully completing a telehealth visit (Hawley et al., 2020).

Incorporating quantitative measures of treatment outcomes in future delivery of this group will illuminate its efficacy and effectiveness. New empirically validated scales tailored to COVID-19 related mental health issues may have higher clinical utility during the pandemic than traditional assessment tools (e.g., PHQ-9, GAD-7) due to psychometric properties such as face validity (Ransing et al., 2020). Preliminary psychometric reports have suggested that the Coronavirus Anxiety Scale (Lee, 2020a), Obsession with COVID Scale (Lee, 2020b), and the COVID Perceived Stress Scale (Pedrozo-Pupo, Pedrozo-Cortés, & Campo-Arias, 2020) are uniquely discriminative and may be more useful for measuring outcomes related to COVID-19 distress (Ransing et al., 2020). The De Jong Gierveld Loneliness Scale (De Jong Gierveld & Van Tilburg, 2010) and the 11-item UCLA Loneliness Scale (Lee & Cagle, 2017) are also reliable and valid measures that have been used in studies of loneliness in older adults during the pandemic (e.g., Heidinger & Richter, 2020; Luchetti et al., 2020).

Summary

The COVID-19 pandemic has caused clinical care to dramatically shift from face-to-face to technology-driven treatment, including video and telephone modalities. Many older adults prefer face-to-face interactions and are less adept at using smartphone and tablet technology (Fortuna et al., 2019). Despite data that 53% of older adults own smartphones (Pew Research Center, 2018), a recent review highlights the discrepancies in digital literacy and the availability of evidence-based mental health apps (Figueroa & Aguilera, 2020). The Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic manual helps bridge this digital divide. Clinicians and their group participants can opt for either telephone or video meetings based on their local needs. Such flexibility is especially useful for providing care to older adults living in locations with limited resources.

Clinical implications.

• Group teletherapies are a feasible and acceptable clinical resource for treating Veterans in integrated geriatric healthcare settings.

• Clinicians found this group manual to be an effective tool in addressing COVID-related worry and social isolation despite technical challenges and functional limitations experienced by older Veterans.

• This rapid response group manual has remained clinically useful in geriatric mental health care settings past the initial weeks of the pandemic unfolding in the United States.