Can telemedicine reach rural, older veterans on the edge of or caught in the digital divide? - Unique considerations for two distinct populations.

GRECC Connect, a national program with interprofessional teams at urban-based VA medical facilities, partner with VA community-based outpatient clinics (CBOCs) to provide geriatric specialty care via telemedicine to rural, older Veterans. Our QI project explored factors affecting program uptake. February-May 2020 we conducted 50 interviews with CBOC staff across the US; 60-80% of patients were rural/highly rural older Veterans. CBOC staff described social determinants of health negatively impacting telemedicine access. Patients on the edge of the digital divide were at risk of diminished access due to changes in physical, cognitive or emotional health and/or socio-economic status. CBOC staff also described highly rural Veterans caught in the digital divide, without access to reliable internet, devices or computer knowledge/skills; included in this subgroup were Veterans staff described as 'off the grid' due to histories of trauma resulting in mental/physical health challenges, distrust of institutions and technology, and desire for geographic/social isolation. This work differentiated rural, older Veterans GRECC Connect served through telemedicine, from those CBOC partners struggled to reach, even by phone. This digital divide may grow given the aging population. Unique contextual factors influencing telemedicine use among older adult populations are important to elucidate to inform structural supports for enhanced access.