Teleheath and Housing Insecurity in the Upper Valley

This study seeks to answer the question, "How can we optimize the delivery of telehealth to improve the health of people experiencing homelessness (PEH) in the Upper Valley?" The question is presented by the Upper Valley Haven's (UVH) Executive Director Michael Redmond as part of the organization's Rural Health Equity Grant funded by the Centers for Disease Control and Prevention. The literature on telehealth portrays it as a promising mode of healthcare delivery, especially in rural areas, where clients often face large burdens related to transportation and inadequate access to specialized care. This study addresses a lack of evidence about the accessibility and quality of telehealth
for PEH in rural areas and examines the experiences of telehealth providers and beneficiaries in the Upper Valley.

The research team conducted and analyzed interviews with 15 individuals representing 11 healthcare and social service providers in the Upper Valley. Almost all had little or no experience providing services via telehealth before the institution of restrictions related to the COVID-19 pandemic in the Upper Valley. At the time of the interviews—late 2022 and early 2023—most organizations had shifted to a hybrid of in-person and remote service delivery. Some findings from this analysis are consistent with the literature on the impacts of telehealth on access to healthcare. For example, reduced transportation burden was widely cited as a beneficial impact of telehealth, especially for PEH. Healthcare providers also described mental health services as activities well-suited to the telehealth format. Telehealth has also alleviated barriers to accessing healthcare, including stigma associated with medical conditions and treatments. However, PEH in the Upper Valley face several obstacles to obtaining access to healthcare via telehealth. These include a lack of access to necessary technology, technological literacy, and confidential spaces, as well as mistrust in communication technology. Providers also described activities they found ill-suited to telehealth, such as initial visits (many of which involve complex medical and legal paperwork) and treatments that involve physically bringing clients into their communities. During the period of strict pandemic-related restrictions, organizations in the Upper Valley implemented supports to combat these barriers, including the provision of internet devices and, in some cases, wireless hotspots, as well as the designation of physical spaces for confidential visits and the use of workflows in which nurses assisted clients with examinations and technological issues in-person.

Four primary insights can be drawn from this study: (1) comprehensive assistance with technology— which comprises assurance of a device, a connection, and technological literacy—is essential to ensuring access to telehealth; (2) effective telehealth visits require clients to trust both the confidentiality of secure communication technology and the relevant health system or system. Some interviewees commented that clients experiencing homelessness and housing insecurity often found trust in one or either to be a barrier to accessing care; (3) safe, confidential spaces in which to take telehealth visits are essential for open communication between clients and providers, and often not available for PEH; and (4) in-person assistance—including assistance with technology and physical examination—from nurses during telehealth visits is often necessary to ensure the quality of telehealth visits. These insights may serve to guide programs seeking to optimize the delivery of telehealth services for PEH in the Upper Valley. Future studies should obtain and analyze data on the personal experiences of PEH in the Upper Valley with respect to telehealth. These would engender a more comprehensive evaluation of telehealth services in the region and steps necessary to optimize them.