In 2012, the Office of Telehealth Services completed its Conditions of Participation review of all VISN 20 Telehealth programs and in their final report commended the practices of the HBTMH program, highlighting the associated peer-to-peer volunteer program.4
Discussion
The number of technical issues addressed by the PTC demonstrates the versatility and potential impact of this role. In each case, the PTC accommodates the specific needs of the veteran and any factors that might impact their technology use (eg, low cognitive functioning, hyperarousal, slowed processing speed, low frustration tolerance, or paranoia). This model could be expanded within or outside the VA, although due to the limited scope of the evaluation and the unique qualifications of the individual who filled the PTC role, generalizability remains to be established.
By providing direct support, the PTC attempts to meet veterans where they are and helps them become comfortable with the technology so they are not preoccupied with technical problems while receiving health care. In doing so, engagement in telehealth care is enhanced for patients and providers, and dropouts due to technologic problems may be prevented. Initial program evaluation of this role also suggests considerable provider and veteran satisfaction.
The PTC’s interactions help minimize potential frustrations related to technology use for the delivery of mental health care. Frequently, veterans using in-home telehealth have little experience with technology. Moreover, technology use has been found to be lower for rural dwelling adults.5 Other populations (eg, geriatric) may have greater technology challenges and need additional support.6 When patients start CVT services, there is a potential for dropout if there are initial connection problems, particularly among patients who may have low stress tolerance. The PTC can develop an ongoing relationship with veterans who have a history of technologic difficulties and help monitor them.
Technology barriers and limited support are also a documented barrier to provider engagement.7 Given the inherent limitations and reported provider discouragement with the NTTHD model, more directed technical support may enhance provider engagement and efficiency. With the immediate and one-on-one support given by the PTC, this concern has been assertively addressed. In VISN 20 some mental health care providers elected not to use the CVT-IH program technical support system of the and chose instead to work with the Innovation PTC.
Programmatically, the PTC role is consistent with the VA Office of Mental Health Services and the VA Central Office initiative to increase involvement of peer support programs. From a recovery model perspective, the role of the PTC goes beyond technical support in connecting veterans to other veterans who are encouraged to take control of their health care by making self-directed choices. They can experience empowerment through interactions with another veteran who may share some of their experiences. Further investigation into the effects of using a peer technical support system on veterans, providers, and PTCs compared with the existing national VA technical support help desk system might be useful, particularly with regard to rates of initiation of care or dropouts.
Integration of this role should be done in a purposeful and direct manner, defining peer roles and establishing clear policies and practices. Logistically, the transition of the PTC from a volunteer to a contract employee afforded increased credentialing to allow for improved integration with the other HBTMH team members. The PTC was able to effectively coordinate with clinical, support and administrative staff to share information, resolve issues collaboratively, and bridge gaps in technology knowledge.
Conclusion
Between the HBTMH pilot and the Innovation program, the authors have demonstrated the growing need for personalized and attentive technical support for patients enrolled in home-based telehealth services. Under a current call center help desk model, satisfaction and services may be inadequate for some veterans’ needs. The authors contend that the PTC is an effective way to deliver the necessary specialized technical assistance to veterans and providers and encourage further implementation and evaluation of this approach.
There is preliminary evidence suggesting that this support can have a beneficial impact on provider and veteran engagement in telehealth services. The PTC offers much needed support to providers who frequently do not have the time or knowledge to address all the technical issues that arise during telehealth care. Veterans helping veterans is a powerful alternative deserving of national resources and policy change. Although this case developed in a very VA-specific context, peer technical support may be applicable to other organizations as well.
Acknowledgements
Being the first to do anything in the VA takes courage, tenacity, and luck. The following individuals greatly assisted with the HBTMH pilot and the subsequent Innovation: William “Bear” Cannon, David Greaves, Tracy Dekelboum, William Minium, Sean O’Connor, Joe Ronzio, Kit Teague, and Mark Ward. For assistance with data entry and analysis, the authors thank Athalia White. For help with administrative approvals, the authors thank Bradford Felker and Carol Simons.
This article is dedicated to William “Bear” Cannon, who reinvented himself while serving as the PTC and saved his life along the way. His unwavering commitment to serve his fellow veterans is unheralded. May he be the shining light to those who follow him.
