Occupational Therapists’ Insights on Family Involvement in Videoconferencing-Based Home Assessments and Modifications in the Veterans Health Administration: A Descriptive Qualitative Study

Abstract

Importance: Collaboration between occupational therapists and family caregivers is essential during home assessments and modifications. The shift to videoconferencing-based assessments suggests increased family caregiver involvement, but the specifics of this change are unclear.

Objective: To investigate family caregiver involvement during videoconferencing-based home assessments and subsequent modifications from the perspective of occupational therapists.

Design: This descriptive qualitative study involved virtual, semistructured individual interviews with participants who were recruited through purposeful and snowball sampling. Data analysis followed a descriptive thematic analysis methodology with an inductive approach.

Setting: All interviews were conducted virtually at each participant’s preferred time and location.

Participants: Fifteen occupational therapists from the Veterans Health Administration (VHA) with experience in videoconferencing-based home assessments and subsequent modifications for rural veterans.

Results: Four key themes were identified: (1) increased active involvement of family caregivers during the home assessment process, (2) circumstances that require family caregiver involvement for videoconferencing, (3) family caregiver–related factors affecting outcomes, and (4) strategies for effective family caregiver involvement.

Conclusions and Relevance: The findings suggest that veterans’ family caregivers play a more active role during videoconferencing-based home assessments than they do during traditional in-person assessments. This increased involvement may lead to a higher workload for VHA occupational therapists, who should now train caregivers, and for family caregivers themselves, who need to perform tasks previously handled by occupational therapists during home visits. To address this challenge, occupational therapists can leverage the insights extracted from this study.

Plain-Language Summary: Occupational therapists often collaborate with family caregivers to assess the safety and accessibility of clients in their homes, recommending changes to the home environment accordingly. However, occupational therapy practitioners do not fully understand how much family caregivers are involved in videoconferencing-based home assessments, which is a new remote method, and subsequent modifications to client interventions. In this study, we explored, through interviews with 15 occupational therapists from the Veterans Health Administration (VHA), how family caregivers are involved in videoconferencing-based home assessments and subsequent modifications that are made to client interventions. We found that family caregivers have a greater responsibility for additional tasks during videoconferencing compared with traditional in-person assessments, including conducting measurements typically handled by occupational therapists. This understanding will help VHA occupational therapists adjust their practices to improve service delivery and reduce the workload for both occupational therapists and family caregivers.

Through interviews with occupational therapists from the Veterans Health Administration with experience in videoconferencing-based home assessments, this study explored family involvement in the assessments and subsequent home modifications.

Incorporating caregivers into the home assessment and modification process is crucial for a client-centered collaborative approach (Struckmeyer & Pickens, 2016). Given that clients often share their homes with other family members, it is important to discuss and ensure that home modifications meet the needs of all residents (Stark et al., 2015). In addition, clients with cognitive impairments, such as Alzheimer’s dementia, may need family caregivers to help identify safety hazards, accept necessary changes, and implement those changes effectively (Horvath et al., 2005). In this regard, family caregivers can play a vital role in various aspects of home assessments and modifications.

Occupational therapists can collaborate with clients and their family caregivers to assess potential environmental hazards in the home (American Occupational Therapy Association, 2017). After the assessment, they can work together to create a list of prioritized home modifications (Goldhammer et al., 2022). This client-centered collaborative approach can leverage the unique insights provided by both clients and their family caregivers into the clients’ functional independence and home environment, along with the occupational therapists’ expertise and clinical reasoning skills, to develop optimal solutions for the clients (Chen et al., 2000). In addition to clients, family caregivers—in particular, spouses, who typically share the living environment with clients—often play an important role in deciding whether to implement the recommended home modifications (Bayer & Harper, 2000). Therefore, the involvement of family caregivers from intervention planning to implementation is essential for the success of the interventions (Chen et al., 2000).

Occupational therapists are the primary health care providers of home assessments and modifications (Blanchet & Edwards, 2018), and therefore they play a critical role in facilitating family caregiver involvement in the interventions. Home assessments have traditionally been conducted through in-person visits by occupational therapists. However, Kang et al. (2024) reported that the coronavirus 2019 (COVID-19) pandemic changed this practice, leading to the adoption of videoconferencing for home assessments in the Veterans Health Administration (VHA). This change has been particularly beneficial for veterans living in rural and remote areas because it more effectively overcomes geographic and systematic barriers to in-person service delivery (Day et al., 2021; Kang et al., 2024). Despite this change, there is limited information on how VHA occupational therapists perceive the involvement of family caregivers during videoconferencing-based home assessments and subsequent home modifications. The purpose of this study was to investigate these perceptions and answer the following research questions:

1. What is the typical involvement of family caregivers during videoconferencing-based home assessments?

2. How do VHA occupational therapists view the influence of family caregiver participation on the process and success of videoconferencing-based home assessments and subsequent modifications?

Method

Study Design

In this study, we used a qualitative descriptive approach to explore VHA occupational therapists’ perceptions of family caregivers’ involvement in videoconferencing-based home assessments and subsequent modifications.

Recruitment and Setting

Study invitations were emailed to occupational therapists at both the local and national levels within the VHA, targeting those in the Physical Medicine and Rehabilitation Service at the U.S. Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (local level) and the TeleRehabilitation Enterprise Wide Initiative program (national level). The three inclusion criteria for this study were as follows: (1) VHA occupational therapist (2) who self-identified as having experience in conducting home assessments and modifications for rural veterans (3) within the past 5 yr. Those without videoconferencing experience for these assessments were excluded. Participants were selected through purposeful sampling from diverse settings, with additional participants from varied settings recruited via snowball sampling.

This study aimed to recruit 15 VHA occupational therapists to reach data saturation. The sample size was determined on the basis of Hennink and Kaiser’s (2022) recommendation that data saturation can typically be achieved with 9–17 participants when in-depth interviews for qualitative research are being used. This study was approved by the institutional review boards (IRBs) of the University of Florida (IRB No. 202200035), the University of Texas Medical Branch at Galveston (IRB No. 22–0245), and the VA Research and Development Program at the North Florida/South Georgia Veterans Health System (IRBNet No. 1673845).

Materials

A semistructured interview guide, which included open-ended questions to explore VHA occupational therapists’ experience in conducting videoconferencing-based home assessments and subsequent modifications, was created for this study. We iteratively modified the questions to facilitate better data exploration. Examples include “How would you describe your overall experience with regard to technology use specific to providing remote home assessments?”; “Can you please describe your clinical decision-making process as to whether to use telehealth technologies, which could be an alternative to in-home assessments?”; and “Aside from connectivity, what are some challenges or potential shortcomings when conducting videoconferencing-based assessments and subsequent modifications?”

Data Collection

Participants virtually took part in an individual semistructured interview through Microsoft Teams; each interview was conducted once for each participant between June and September 2022. During the interviews, the primary moderator, who has a background in occupational therapy, led the session, while the co-moderators provided support by asking follow-up questions or offering technology assistance. Participants were asked to provide demographic information regarding their age, gender, years of clinical experience as an occupational therapist, and length of time conducting home assessments and modifications. All interviews were audio and video recorded with the participant’s verbal consent and subsequently transcribed verbatim.

Data Analysis

This study followed Braun and Clarke’s (2006) methodology for thematically analyzing qualitative data. We began by repeatedly reading all the transcripts, to gain familiarity with the data and identify meaningful sentences related to VHA occupational therapists’ perceptions of family caregiver involvement during videoconferencing-based home assessments and subsequent modifications. These identified sentences were then summarized into short phrases through descriptive coding (Saldaña, 2013). The next step was to investigate the relationships between the initial descriptive codes. We merged conceptually similar codes using a pattern coding approach to develop overarching themes and subthemes (Saldaña, 2013). Each potential theme and subtheme was then reviewed and refined to ensure that it had a coherent pattern and was distinct from all other themes (Braun & Clarke, 2006). Finally, clear definitions and names were created for each theme and subtheme.

To increase the credibility of the study, we used two strategies. First, we implemented investigator triangulation by involving two members of the research team (Jaewon Kang and Consuelo Kreider) in the data analysis process (Carter et al., 2014). Second, we used peer debriefing, during which we presented emerging concepts to an external researcher for discussion and feedback (Ohman, 2005). We analyzed participants’ demographic information using descriptive statistics, including mean, range, standard deviation, frequency, and percentage. We managed all data using NVivo and Microsoft Excel.

Results

This study involved 15 participants, with an average age of 44.7 yr (SD = 10.9). Most participants (n = 10) were female. Participants were from eight states across the country, with the majority of them being from Florida (n = 6), Massachusetts (n = 2), or Wisconsin (n = 2). On average, participants had 15.9 yr (SD = 10.6) of experience as occupational therapists, with an average of 7.5 yr (SD = 7.6) of experience in conducting home assessments and modifications (Table 1). The length of the interview ranged from approximately 37 min to 57 min, with an average duration of 49 min.

Table 1.

Participant Demographic Characteristics

Variable	n (%)
Age, yr, M (SD)	44.7 (10.9)
Years in occupational therapy, M (SD)	15.9 (10.6)
Years in home assessments and modifications, M (SD)	7.5 (7.6)
Gender
Male	5 (33.3)
Female	10 (66.7)
State
Florida	6 (40.0)
Massachusetts	2 (13.3)
Wisconsin	2 (13.3)
California	1 (6.7)
Minnesota	1 (6.7)
North Carolina	1 (6.7)
Washington	1 (6.7)
West Virginia	1 (6.7)

Note. N = 15.

We identified four key themes related to VHA occupational therapists’ perceptions of family caregiver involvement during videoconferencing-based home assessments and subsequent modifications: (1) increased active involvement of family caregivers during the home assessment process, (2) circumstances that require family caregiver involvement for videoconferencing, (3) family caregiver–related factors affecting outcomes, and (4) strategies for effective family caregiver involvement. Each of the themes consists of several subthemes, which are summarized in Table 2.

Table 2.

Themes and Subthemes Representing the Involvement of Family Caregivers During Home Assessments and Modifications

Themes and Subthemes	Definitions	Representative Quotation
1. Increased active involvement of family caregivers during the home assessment process	Identification by OTs of the activities or tasks performed by family caregivers during videoconferencing-based assessments
Displaying the home environment	Giving a virtual tour of the home to OTs via videoconferencing	“We’ll use the caregivers, and they’ll hold the phone. . . . Most of the time when I’ve done [remote assessments], it’s been with [caregivers] with a smartphone. So just trying to get them to hold the phone in the right place . . . trying to see a home.” (OT7)
Describing or demonstrating Veterans’ presenting issues	Showing the Veterans’ activities of daily living and potential challenges in their home environment	“I like [caregivers] to show me how the Veteran gets in and out of the house. . . . I also ask [caregivers] to demonstrate [Veterans’] hand function. I can ask [caregivers] to pick something up for me or show me how [Veterans] hold up a coffee cup.” (OT4)
Conducting measurements	Act of determining the size of objects or the available space to evaluate accessibility and judge the feasibility of modifying or installing equipment	“You can tell [caregivers] to go get that measuring tape and tell me how wide . . . or how tall . . . that step [is].” (OT14)
2. Circumstances that require family caregiver involvement for videoconferencing	Circumstances that could make it difficult for OTs to complete the assessments successfully without caregiver assistance
Consideration of health conditions	Illnesses or injuries that impede assessments conducted without the assistance of family caregivers	“Especially thinking about [veterans] with cognitive deficits, we see dementia very frequently. Can the person retain information learned in one visit and carry that over to the next? Umm, when you don’t have [caregivers] in place, I think it’s okay to give yourself grace or permission to say, you know this, ‘It actually just may not work, and we just need to do the traditional format of in-person visits,’ and I personally feel like that’s okay versus forcing something that’s not gonna work because that leads to frustration.” (OT3)
Lack of essential technical skills	Limited ability to effectively operate technological devices and software, such as cameras, cell phones, and videoconferencing software	“Most [veterans] are impoverished, elderly, and lack knowledge as well as technology to engage in [videoconferencing]. . . . The ones that do participate heavily rely on younger family members to sort of guide them through doing a [VA Video Connect].” (OT1)
3. Family caregiver–related factors affecting outcomes	Factors related to family caregivers that may affect the clinical decision-making process of OTs
Proficiency in videoconferencing technology	Family caregivers’ ability to proficiently use and operate technological devices and software, such as cameras, cell phones, and videoconferencing software	“I had a caregiver once trying to show me . . . the bathroom. However, I kept seeing the ceiling, and I was like, ‘No, put the camera down.’ To me, it’s just too challenging. . . . As far as doing [an initial] full home assessment, I can’t do it. I have never been able to successfully do one.” (OT7)
Precision in environmental representation and measurement	The extent to which the measurements and visual details provided by family caregivers accurately represent the actual physical environment	“I’ve had a wife that brought out one of the little plastic tape measures. Also, I’ve had a wife that brought out a yardstick that was folding, and she had to try to measure doorways by unfolding the yardstick and then, like angling it and taking measurements. And in that instance, she wants what’s best for her husband, but that’s . . . such a stressful experience.” (OT10)
Acceptance of assistive technology	Family caregivers’ embracing of the installation of assistive technology in the home environment without hesitation or resistance	“Unfortunately, if they do get modifications done, it’s kind of hard sometimes sitting there and being like, when you hear someone saying about their parents that they don’t want their house to become a nursing home. Unfortunately, that’s a sad thing.” (OT13)
Consideration of inclusive design	Creating a home environment that can be effectively and efficiently used by both Veterans and family caregivers	“We need to make sure that whatever we’re recommending is gonna work for both the veteran but also the caregiver that’s helping the veteran.” (OT11)
Willingness to learn and use technology	Positive attitude toward providing assistance or support to OTs to conduct videoconferencing	“I’ve had great results with family and caregiver[s] just wanting to help out because usually that means if we’re doing this, it’s gonna help make their job a little bit easier. So, they’re more than willing.” (OT2)
4. Strategies for effective family caregiver involvement	Approaches used by OTs to effectively engage family caregivers
Requesting photographs or taking a snapshot	The use of still images captured by a camera to observe and document specific details of the home environment	“We used to have them taking us around and it was like we would see feet, we would see ceilings, we would see everything we didn’t want to see. So, we sort of changed that to where we would just request photos. . . . A picture speaks a thousand words.” (OT2)
Delivering caregiver education	Providing family caregivers with the necessary knowledge and training to effectively engage in the interventions	“YouTube has been a lifesaver. . . . Sharing my screen and showing the person a YouTube video, saying, ‘This is what I want you to do.’ It has been more successful than me just trying to tell them and talk them through it.” (OT11)
Building rapport	Establishing favorable and trustworthy relationships between family caregivers and OTs to facilitate effective collaboration	“When you have a good relationship, it gives me some cushion for offending people. I don’t try to offend anyone but sometimes like ‘No, Miss Mary, I don’t want you to measure top to bottom. It’s side to side.’ So, I think that having good rapport helps overcome a lot of barriers.” (OT10)
Demonstrating the use of assistive technology	Using visual aids or representations to clearly illustrate the location or purpose of assistive technology or structural modifications that will be installed or conducted in the home environment	“When I’m making recommendations in a [veteran’s] home environment and I’m thinking about adding a piece of equipment or how it might look visually. . . . It has been really helpful for me that I can use my technology to show examples. [This way,] I can give choices to veterans and families when we’re talking about adding potential things to their homes to improve the safety. I can give a visual [demonstration that] allows a [caregiver] to have a better choice versus just using my more descriptive abilities. So, I’ve found that [visual demonstration] is very helpful.” (OT3)

Note. OT = occupational therapist.

Increased Active Involvement of Family Caregivers During the Home Assessment Process

Participants highlighted that the COVID-19 pandemic brought a significant change to home assessments, making videoconferencing a viable option that was previously considered impractical. This shift has transformed the role of family caregivers from being passive observers during in-person assessments to becoming active participants, now crucial in facilitating videoconferencing-based assessments.

Displaying the Home Environment

Participants noted that during videoconferencing-based home assessments, family caregivers use mobile devices, such as cell phones and laptops, along with the VA’s secure app, VA Video Connect (VVC), to give VHA occupational therapists a virtual view of the home environment. Occupational Therapist 12 (OT12) stated, “If we are doing telehealth, we typically require . . . [that] a caregiver or family member be present to take charge of the camera or the tablet and walk us around.”

Describing or Demonstrating Veterans’ Presenting Issues

Participants described another aspect of family caregivers’ involvement, emphasizing their understanding of the chronic or acute challenges that veterans encounter in their home environment. Some participants noted that family caregivers—in particular, those who live with veterans—may have a deeper understanding of the veterans’ specific needs and limitations, so they can describe or demonstrate the challenges to VHA occupational therapists more thoroughly:

We could either use VVC or just use a FaceTime call, and they could take their camera through the house and show me, like, saying, “Dad’s having a new issue,” and generally, my initial assessment will have a super descript[ive] area about the bathroom, but they can take that camera back there and sort of show me and let him try to stand up from the toilet or something if there’s [an] issue. (OT1)

Conducting Measurements

When discussing the importance of family caregivers during videoconferencing-based home assessments, most participants emphasized the role of family caregivers in measuring objects within the home environment. Participants noted that because they cannot measure objects themselves during videoconferencing, they often rely on family caregivers to take measurements. Participants reported that they provided the family caregivers with a list of objects needing measurement. Family caregivers then take the measurements and send the results back to the VHA occupational therapists. A comment made by OT2 describes this: “We would tell [family caregivers] the different areas of the home that we want measurements of because we couldn’t do those measurements ourselves.” OT7 added, “You would have to have [family caregivers] do it because there’s no way you could measure it.”

Circumstances That Require Family Caregiver Involvement for Videoconferencing

During discussions about the involvement of family caregivers during videoconferencing-based home assessments, some participants noted that veterans could perform certain family caregiver responsibilities. However, they also mentioned that there are instances when involving family caregivers is irreplaceable for conducting effective videoconferencing.

Consideration of Health Conditions

Participants reported that certain veterans’ illnesses or injuries make it difficult to conduct videoconferencing without family caregivers. These health conditions, identified by participants, include severe cognitive or mobility impairments, blindness, hearing loss, multiple medical diagnoses, and inpatient status:

Let’s say [veterans] don’t have a caregiver that can come and show us the upstairs, and that’s really where we need to be able to see, and the veteran isn’t able to physically get themselves up there to show us. We consider all of those different things. (OT5)

Blindness can be an issue . . . legally blind or just visually impaired. I think sometimes family members do help a lot with [videoconferencing], but even without it, it’s almost like I can’t really do a whole lot there, ‘cause if the veterans can’t see and they’re trying to use [a laptop or smartphone] to show me things . . . it makes [the assessment] quite cumbersome, and sometimes it’s just not appropriate for telehealth. (OT6)

Lack of Essential Technical Skills

Participants highlighted that conducting videoconferencing-based home assessments often requires family caregivers, especially when veterans had limited familiarity with technology. They noted that although some rural veterans, who are generally older than their urban counterparts, are proficient with digital tools, many rely on caregivers for technical assistance. Several participants observed that younger family members are often more comfortable and familiar with videoconferencing technology, making them valuable resources in facilitating these assessments. This was supported by OT7, who stated, “We have a few [veterans] who are real tech-savvy and have a computer . . . but most of the time, you have to have a reliable caregiver.”

Family Caregiver–Related Factors Affecting Outcomes

Participants illustrated how family caregivers can influence their clinical decision-making for videoconferencing-based home assessments and subsequent modifications.

Proficiency in Videoconferencing Technology

The ability of family caregivers to effectively use videoconferencing technology for displaying the home environment and conducting virtual meetings is crucial for determining both the feasibility of videoconferencing-based home assessments and their outcomes. Participants emphasized the importance of ensuring that family caregivers have adequate technical skills before involving them in these assessments. For example, OT13 said, “If [veterans] have a caregiver that’s able to do the camera, I would have no problem with that.” Participants further explained that if family caregivers lack proficiency in using or operating mobile devices and videoconferencing software, occupational therapists might struggle to identify environmental hazards and make appropriate recommendations for home modifications. This difficulty arises because occupational therapists cannot clearly and comprehensively observe the home environment when they need to spend time teaching family caregivers how to use these technologies or fix technical issues:

I think that could be a huge challenge when caregivers who are not familiar with technology can’t get it to work. . . . If you keep trying to push them to figure it out, they’re just emotionally spent, and they don’t want to even participate because you just spent 30 min trying to fix it. (OT2)

Precision in Environmental Representation and Measurement

For videoconferencing-based home assessments to be effective and successful, family caregivers should clearly display the home environment. However, there are occasions when VHA occupational therapists may find it difficult to fully complete the assessments: “We don’t get the correct angles we want, and then they’re moving and shaking and going all around and I’m like, ‘Oh my goodness, just stay still for one second,’ [it’s] just getting a little crazy on this end” (OT 9).

It is also crucial for occupational therapists to receive accurate information about objects and spaces, as they would during in-person visits. Some participants expressed concern regarding the reliability of measurements taken by family caregivers. They shared instances when family caregivers had used incorrect tools or lacked measuring tools, which led to inaccurate measurements and reliance on guesswork:

There’s a big difference when you’re talking about a front door threshold that’s 4 inches and 6 inches. If the caregiver tells me it’s a 4-inch ramp, and then I’ll order a 4-inch ramp, then we have a 4-inch ramp in a 6-inch space and then we have a problem. (OT10)

A lot of [caregivers] don’t have measuring sticks or measuring tape. . . . [I tell them] “Put your feet right in front of the other, take so many steps, and let me figure out how many feet that might be. . . . Sit on that toilet, reach your arm over there.” I get the gist of how much it is . . . and try to judge the distances. (OT15)

Acceptance of Assistive Technology

With respect to the implementation of home modifications, participants emphasized the importance of both veterans’ and family caregivers’ acceptance of assistive technology in the home environment. For example, OT14 shared that family caregivers usually accept the installation of assistive technology, saying, “I guess I don’t run into that issue a lot that the caregiver can’t use or doesn’t wanna use the equipment. . . . They’re pretty excited that the veteran’s getting this equipment ’cause they can use it too.” On the other hand, other participants mentioned that some caregivers were unwilling to approve the suggested modifications, which prevented VHA occupational therapists from proceeding: “The reasons [for declining home modifications] range from ‘It makes my house look ugly’ to ‘We don’t have room for that. I don’t need that.’ Some of the wives don’t want it making their house look ugly or cluttered” (OT1). Another participant said, “There have been situations where I haven’t been able to issue something as simple as a grab bar because the caregiver feels that it doesn’t match the decor of the rest of the bathroom” (OT11).

Consideration of Inclusive Design

During the discussion on the implementation of home modifications, participants noted that it is crucial to consider whether the modified environment is safe and accessible for not only veterans but also family caregivers. When making adjustments for veterans, VHA occupational therapists need to consider how that change could affect the caregivers: “Sometimes I’ve made adjustments to make sure that they’re both able to get in and out of the shower safely because obviously, it affects my patients if their caregiver gets hurt” (OT 13).

Willingness to Learn and Use Technology

The cooperation and positive attitude of family caregivers play a crucial role in the success of videoconferencing-based home assessments. Participants noted that the effectiveness of these assessments can vary on the basis of family caregivers’ level of willingness to assist occupational therapists. Interestingly, this willingness and capability to engage with technology were seen as more influenced by individual motivation than by age. In addition, having a second caregiver available could be beneficial because it allows multiple caregivers to support each other and increases their willingness to try new technology:

If there is a motivation for caregivers to know how to use [technology], age has almost nothing to do with it. I’ve had as much trouble with 35-year-olds as with 82-year-olds. Because a 35-year-old might be like, “Well, this is how I always do it. Why do I have to do something different?” (OT4)

I feel like the caregivers are usually a little bit more willing to give it a try. I think just in general when there are two people involved, they feel more supported. So, they feel like two heads are better than one. . . . They can solve problems more easily than when it’s just one single person. (OT11)

Strategies for Effective Family Caregiver Involvement

With the newly emerged challenges associated with videoconferencing-based home assessments and the enduring nature of modification implementation, the use of effective strategies becomes imperative.

Requesting Photographs or Taking a Snapshot

Many participants highlighted the value of asking family caregivers to take pictures of the home environment when they need additional observation after a videoconferencing session. OT2 noted, “We would send them an email telling them the different areas of the home that we want photos [of].” Participants also noted that photographs could complement videoconferencing, especially in cases where audio and video connection quality may be poor because of family caregivers’ technical skills or limited internet speed, especially in remote and rural areas. However, clear instructions about what should be included in the photographs are essential. As OT4 described, “[The] caregiver sent me photographs that were adequate, but people again don’t tend to take pictures of the flooring.” Another strategy involves capturing snapshots during the videoconferencing session to facilitate subsequent reobservation of the environment if needed:

One of the strategies I have for that is I ask people’s permission to take screenshots of the VVC while we’re going, so I’ll say, “Okay, hold the camera really still.” . . . I take a screenshot, and I copy and paste it into a Word doc really fast, and I can write some notes on there really fast if I just need to remind myself something about where we are, and what we’re looking at. (OT12)

Delivering Caregiver Education

Family caregiver education is essential for successful caregiver involvement in videoconferencing-based home assessments and subsequent modifications. Participants noted that providing education to family caregivers enhances their ability to follow instructions for camera movements or measurements, which helps VHA occupational therapists effectively observe the home environment during videoconferencing. Some participants recommended informing caregivers about what is expected before the videoconferencing session:

[Videoconferencing] doesn’t give you a 360-degree view, but you know if we tell them “Okay, go to the left a little bit, bring it down a little bit,” they’re able to follow those commands and let us have a good idea of what the bathroom or a room looks like. (OT9)

[I have instructed caregivers by saying,] “We’re gonna need pictures of these places, and we’re gonna need measurements. So when you come to us, make sure you bring this information.”. . . So, we gather that information before we do a video assessment with them. (OT2)

Some participants mentioned the use of digital media as an efficient and effective way to deliver caregiver education. OT12 stated, “I have some YouTube videos about how to use tape measures.” OT11 added,

YouTube has been a lifesaver. I hate to say it, but for whatever reason, sharing my screen and showing the person a YouTube video of “This is what I want you to do” has been more successful than me just trying to tell them and talk them through it.

Building Rapport

Most participants pointed out that establishing favorable and trustworthy relationships between family caregivers and VHA occupational therapists can facilitate effective collaboration, which may increase the effectiveness of videoconferencing-based home assessments and subsequent modifications. The effectiveness of building rapport with family caregivers is not limited to in-person communication; participants reported that talking to family caregivers over the phone was equally effective in building rapport. As OT7 stated, “I don’t really see a difference. I mean, it’s easier to get to know [caregivers] if you’re talking to them in person, obviously . . . but I don’t really see a big difference.” OT6 added, “It’s actually quite easy to build a rapport when I’m on the phone kind of explaining what I do and why we’re doing it this way.”

Demonstrating the Use of Assistive Technology

While discussing home modifications, some participants mentioned that they provided family caregivers with an opportunity to try out certain forms of assistive technology to demonstrate potential modifications that could be made in the home environment:

I try to make sure the veteran and the caregiver are able to try things before we recommend them or before we issue them. Obviously, if there’s something like a ramp or ceiling lift, they can’t really try that in their home before it’s there, but they could maybe come to the clinic and try something similar or see something similar. (OT12)

Discussion

In this study, we conducted individual in-depth interviews with 15 VHA occupational therapists to investigate family caregiver involvement during videoconferencing-based home assessments and subsequent modifications. The findings offer insights into the crucial role played by family caregivers and provide practical strategies for effectively involving them in these processes.

Videoconferencing has become a commonly adopted technology for occupational therapists to conduct home assessments remotely (Gately et al., 2020; Kang et al., 2024; Kreider et al., 2023; Latulippe et al., 2022; Lee et al., 2020). We found that family caregivers play a much larger role in videoconferencing-based home assessments, leading to more active participation compared with in-person assessments. Family caregivers often need to be present during videoconferencing-based home assessments, especially to offer technical support, such as operating mobile devices to show the home environment. In addition, family caregivers now handle tasks, such as taking measurements, that were traditionally performed by occupational therapists during home visits.

A recent study highlighted that although videoconferencing-based assessments facilitate real-time feedback between occupational therapists and caregivers, they also increase stress and require extra time for training (Latulippe et al., 2022). Occupational therapists may encounter difficulties in effectively training caregivers and need to find ways to support them without adding to their burden (Abbott-Gaffney et al., 2022). In addition, given the increased role of family caregivers in these assessments, there is a risk that occupational therapists will become overly dependent on them. Caregivers should not be expected to perform tasks that require professional expertise but should be equipped with the knowledge and resources to assist occupational therapists effectively within their capacity. This approach helps maintain the integrity of the assessment and intervention process while leveraging the valuable input caregivers can provide.

To address these challenges, occupational therapists should offer detailed, easy-to-follow instructions for using videoconferencing technology and taking measurements, specifying clear aims without expecting caregivers to perform professional tasks. Our findings suggest that providing this education before the videoconferencing sessions would be beneficial because it sets clear expectations for what is needed. This approach is consistent with those noted in recent research, which identified presession education as a key factor in facilitating caregiver participation (Gately et al., 2024). In addition, creating instructional videos for caregiver education could further enhance support and effectiveness.

Occupational therapists should be aware that veterans with severe cognitive, visual, or hearing impairments may need caregivers present during videoconferencing-based home assessments. Our study supports previous findings indicating that these conditions can hinder effective interaction during telehealth sessions (Choi et al., 2014; Isautier et al., 2020). Limited technology knowledge may also add complexity to the remote assessment process, but fortunately most older veterans may have access to caregivers who can assist with the process. According to one study (Freedman & Spillman, 2014), community-dwelling older adults in the United States have an average of four potential caregivers, including spouses, children, and other household members. Moreover, a recent study reported that in the majority (73%) of geriatric specialty telemedicine sessions for rural veterans, both the veterans and their caregivers participated together (Dryden et al., 2023). Therefore, including family caregivers as a part of the health care service delivery may be a feasible solution for addressing these challenges.

Our findings suggest several strategies to facilitate family caregiver involvement during videoconferencing-based home assessments. Participants frequently mentioned using photographs as a strategy, especially when they cannot fully observe the environment during videoconferencing and need additional visual information. However, it is important to note that photographs could still have limitations similar to those of videoconferencing; for example, they may not capture the entire room. To address this issue, occupational therapists should provide specific instructions to caregivers or encourage them to take multiple photographs. Occupational therapists also can use advanced technology (Guay et al., 2024; Kang et al., 2024). For example, Kang et al. (2024) tested 360° immersive technology for remote home assessments, which allows VHA occupational therapists to perform remote measurements and view the home environment from various angles, including zooming in for detailed observation. Continuously exploring the use of state-of-the-art technologies can considerably enhance the involvement of family caregivers and improve the effectiveness of remote home assessments.

Last, family caregivers are essential for a client-centered collaborative approach to home modifications (Struckmeyer & Pickens, 2016). However, our participants reported that some family caregivers hold negative views of home modifications, hindering their implementation. Previous research has also identified several factors that contribute to nonadherence to home modifications, such as disbelief in their effectiveness, feelings of embarrassment, fear of stigma related to the use of assistive technology (Cumming et al., 2001), and distaste related to perceived unappealing aesthetics of the living environment (Aplin et al., 2013; Stark et al., 2015). Therefore, it is crucial to improve attitudes toward home modifications by providing caregiver education, which can improve the overall acceptance of recommended modifications.

Limitations and Future Research Directions

Although this study provides valuable insights into family caregiver involvement, it has several limitations. First, we may not have fully captured the range of perceptions held by diverse professionals. Although occupational therapists are the primary health care providers of holistic home assessments and modifications, other health care providers, such as physical therapists and kinesiotherapists, offer these services (Kreider et al., 2023; Struckmeyer et al., 2022). Contractors can also be involved in implementing home modifications (Struckmeyer et al., 2022) and may offer unique insights into family caregivers’ involvement. Therefore, to capture a more comprehensive understanding, future research should include diverse perspectives from various professionals.

Second, it is crucial to consider the caregivers’ perspectives to gain a more holistic understanding of their involvement during the interventions. Gaining insights from both health care providers and caregivers would facilitate effective collaboration between the two groups and improve outcomes. By exploring caregiver perspectives, we can better understand how the increased workload affects them.

Finally, it is important to note that this study exclusively focused on family caregivers because they were the primary type of caregiver mentioned during the interviews. Other types of caregivers, including friends, community members, and paid helpers, were not discussed in this study. Further research is needed to examine and compare the involvement of these different types of caregivers.

Implications for Occupational Therapy Practice

This study provides insights into VHA occupational therapists’ views on involving family caregivers during videoconferencing-based home assessments and subsequent modifications—an emerging practice in the field. On the basis of our findings, we recommend the following for occupational therapy practitioners:

▪ Use telehealth technologies, such as videoconferencing, to enhance the efficiency of home assessments, in particular when occupational therapists face constraints on home visits because of organizational restrictions.

▪ Ensure that family caregivers comprehend their role in remote home assessments and possess the necessary technological skills by providing clear guidance and training in the use of telehealth technologies.

Conclusion

Involving family caregivers throughout the videoconferencing-based home assessment and subsequent modification process could provide valuable insights into the specific needs of veterans to maintain independence at home. In this study, we aimed to explore VHA occupational therapists’ perceptions of the involvement of family caregivers during videoconferencing-based home assessments and subsequent modifications. We found that with the postpandemic rise in videoconferencing-based home assessments, family caregivers play an active role in assisting VHA occupational therapists who would not be physically present in the home. However, during videoconferencing-based home assessments, a new service delivery method, VHA occupational therapists should clearly educate family caregivers about their expected roles. It is essential to minimize the burden on caregivers, ensuring they are not expected to perform tasks that require professional expertise. In addition, because family caregivers often live with clients and share the same living environment, occupational therapists should consider home modifications that ensure the safety of all residents.

Footnotes

Acknowledgments

This study was supported by the U.S. Department of Veterans Affairs Office of Rural Health’s Veterans Rural Health Resource Center in Gainesville, Florida (Grant PROJ-03773). We extend our gratitude to the participating Veterans Health Administration occupational therapists.

References

Abbott-Gaffney

C. R.

Gafni-Lachter

Cason

Sheaffer

Harasink

Donehower

, & Jacobs

(2022). Toward successful future use of telehealth in occupational therapy practice: What the COVID-19 rapid shift revealed. Work, 71, 385–394. https://doi.org/10.3233/WOR-210789

American Occupational Therapy Association. (2017). Occupational therapy’s role with fall prevention [Fact sheet]. https://www.aota.org/∼/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Falls.pdf

Aplin

de Jonge

, & Gustafsson

(2013). Understanding the dimensions of home that impact on home modification decision making. Australian Occupational Therapy Journal, 60, 101–109. https://doi.org/10.1111/1440-1630.12022

Bayer

A.-H.

, & Harper

(2000). Fixing to stay: A national survey of housing and home modification issues. AARP.

Blanchet

, & Edwards

(2018). A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: Results of a scoping review. BMC Geriatrics, 18, 272. https://doi.org/10.1186/s12877-018-0958-1

Braun

, & Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. https://doi.org/10.1191/1478088706qp063oa

Carter

Bryant-Lukosius

DiCenso

Blythe

, & Neville

A. J.

(2014). The use of triangulation in qualitative research. Oncology Nursing Forum, 41, 545–547. https://doi.org/10.1188/14.ONF.545-547

Chen

T.-Y.

Mann

W. C.

Tomita

, & Nochajski

(2000). Caregiver involvement in the use of assistive devices by frail older persons. OTJR: Occupational Therapy Journal of Research, 20, 179–199. https://doi.org/10.1177/153944920002000303

Choi

N. G.

Hegel

M. T.

Marti

C. N.

Marinucci

M. L.

Sirrianni

, & Bruce

M. L.

(2014). Telehealth problem-solving therapy for depressed low-income homebound older adults. American Journal of Geriatric Psychiatry, 22, 263–271. https://doi.org/10.1016/j.jagp.2013.01.037

10.

Cumming

R. G.

Thomas

Szonyi

Frampton

Salkeld

, & Clemson

(2001). Adherence to occupational therapist recommendations for home modifications for falls prevention. American Journal of Occupational Therapy, 55, 641–648. https://doi.org/10.5014/ajot.55.6.641

11.

Day

S. C.

Day

Keller

Touchett

Amspoker

A. B.

Martin

, & Lindsay

J. A.

(2021). Personalized Implementation of Video Telehealth for Rural Veterans (PIVOT-R). mHealth, 7, 24–24. https://doi.org/10.21037/mhealth.2020.03.02

12.

Dryden

E. M.

Kennedy

M. A.

Conti

Boudreau

J. H.

Anwar

C. P.

Nearing

, … Moo

L. R.

(2023). Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers. Health Services Research, 58(Suppl. 1), 26–35. https://doi.org/10.1111/1475-6773.14055

13.

Freedman

V. A.

, & Spillman

B. C.

(2014). Disability and care needs among older Americans. Milbank Quarterly, 92, 509–541. https://doi.org/10.1111/1468-0009.12076

14.

Gately

M. E.

Tickle-Degnen

Trudeau

S. A.

Ward

Ladin

, & Moo

L. R.

(2020). Caregiver satisfaction with a video telehealth home safety evaluation for dementia. International Journal of Telerehabilitation, 12, 35–42. https://doi.org/10.5195/ijt.2020.6337

15.

Gately

M. E.

Waller

D. E.

Metcalf

E. E.

, & Moo

L. R.

(2024). Caregivers’ role in in-home video telehealth: National survey of occupational therapy practitioners. JMIR Rehabilitation and Assistive Technologies, 11, e52049. https://doi.org/10.2196/52049

16.

Goldhammer

Scott

Waugh-Quasebarth

, & Wickel

(2022). Safe at home: A community based approach for home modification implementation. OT Practice, 27(6), 30–33.

17.

Guay

Auger

Séguin‐Tremblay

Michaud

Labbé

Chevalier

, … Polgar

(2024). Utility of 3D modelling of the patient’s living environment as perceived by occupational therapists. Australian Occupational Therapy Journal, 71, 925–939. https://doi.org/10.1111/1440-1630.12975

18.

Hennink

, & Kaiser

B. N.

(2022). Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Social Science and Medicine, 292, 114523. https://doi.org/10.1016/j.socscimed.2021.114523

19.

Horvath

K. J.

Hurley

A. C.

Duffy

M. E.

Gauthier

M. A.

Harvey

R. M.

Trudeau

S. A.

, … Smith

S. J.

(2005). Caregiver competence to prevent home injury to the care recipient with dementia. Rehabilitation Nursing, 30, 189–196. https://doi.org/10.1002/j.2048-7940.2005.tb00109.x

20.

Isautier

J. M.

Copp

Ayre

Cvejic

Meyerowitz-Katz

Batcup

, … McCaffery

K. J.

(2020). People’s experiences and satisfaction with telehealth during the COVID-19 pandemic in Australia: Cross-sectional survey study. Journal of Medical Internet Research, 22, e24531. https://doi.org/10.2196/24531

21.

Kang

Lee

M. J.

Kreider

C. M.

LeBeau

Findley

Myers

K. J.

, & Romero

(2024). Beyond videoconferencing: enhancing remote home assessments with 3D modeling technology. Disability and Rehabilitation: Assistive Technology, 1–11. https://doi.org/10.1080/17483107.2024.2424873

22.

Kreider

Kang

LeBeau

Mburu

Lee

M. J.

Findley

, … Romero

(2023). Home assessments and modifications within the VHA: Preliminary analysis of providers’ experiences—Rural focus. Archives of Physical Medicine and Rehabilitation, 104, e32. https://doi.org/10.1016/j.apmr.2022.12.091

23.

Latulippe

Giroux

Guay

Kairy

Vincent

Boivin

, … Provencher

(2022). Mobile videoconferencing for occupational therapists’ assessments of patients’ home environments prior to hospital discharge: Mixed methods feasibility and comparative study. JMIR Aging, 5, e24376. https://doi.org/10.2196/24376

24.

Lee

M. J.

Poulin

Castañeda

, & Romero

(2020). Use of telepresence robots for home safety evaluations: A feasibility study. Annals of International Occupational Therapy, 3, 119–126. https://doi.org/10.3928/24761222-20200116-01

25.

Ohman

(2005). Qualitative methodology for rehabilitation research. Journal of Rehabilitation Medicine, 37, 273–280. https://doi.org/10.1080/16501970510040056

26.

Saldaña

(2013). The coding manual for qualitative researchers (2nd ed.). Sage.

27.

Stark

S. L.

Somerville

Keglovits

Smason

, & Bigham

(2015). Clinical reasoning guideline for home modification interventions. American Journal of Occupational Therapy, 69, 6902290030. https://doi.org/10.5014/ajot.2015.014266

28.

Struckmeyer

L. R.

Campbell

Ellison

Ahrentzen

, & Classen

(2022). Home modifications and repurposing: Perspectives on the accessibility, affordability, and attractiveness. Disability and Rehabilitation, 44, 4619–4628. https://doi.org/10.1080/09638288.2021.1910866

29.

Struckmeyer

L. R.

, & Pickens

N. D.

(2016). Home modifications for people with Alzheimer’s disease: A scoping review. American Journal of Occupational Therapy, 70, 7001270020. https://doi.org/10.5014/ajot.2015.016089