Factors Informing High-Risk Primary Care Patient Choice around Telehealth Use: a Framework

Background: While telehealth's presence in post-pandemic primary care appears assured, its exact role remains unknown. Value-based care's expansion has heightened interest in telehealth's potential to improve uptake of preventive and chronic disease care, especially among high-risk primary care populations. Despite this, the pandemic underscored patients' diverse preferences around using telehealth. Understanding the factors underlying this population's preferences can inform future telehealth strategies.

Objective: To describe the factors informing high-risk primary care patient choice of whether to pursue primary care via telehealth, in-office or to defer care altogether.

Design: Qualitative, cross-sectional study utilizing semi-structured telephone interviews of a convenience sample of 29 primary care patients between July 13 and September 30, 2020.

Participants: Primary care patients at high risk of poor health outcomes and/or acute care utilization who were offered a follow-up primary care visit via audiovisual, audio-only or in-office modalities.

Approach: Responses were analyzed via grounded theory, using a constant comparison method to refine emerging categories, distinguish codes, and synthesize evolving themes.

Key results: Of the 29 participants, 16 (55.2%) were female and 19 (65.5%) were Black; the mean age (SD) was 64.6 (11.1). Participants identified four themes influencing their choice of visit type: perceived utility (encapsulating clinical and non-clinical utility), underlying costs (in terms of time, money, effort, and safety), modifiers (e.g., participants' clinical situation, choice availability, decision phenotype), and drivers (inclusive of their background experiences and digital environment). The relationship of these themes is depicted in a novel framework of patient choice around telehealth use.

Conclusions: While visit utility and cost considerations are foundational to participants' decisions around whether to pursue care via telehealth, underappreciated modifiers and drivers often magnify or mitigate these considerations. Policymakers, payers, and health systems can leverage these factors to anticipate and enhance equitable high-value telehealth use in primary care settings among high-risk individuals.