Abstract
This study reports on the quality of mental healthcare delivered to rural and urban Department of Veterans Affairs (VA) patients across COVID-19 pandemic. This is a retrospective study using VA medical records between 3/10/2019 and 9/22/2022. This study divided the COVID-19 pandemic into Eras based on significant historical events. Quality metrics represented core mental health services. Delivery modalities included on-site, telephone, and video. The study calculated the percentage of patients, by rural and urban strata, who met each quality metric throughout defined COVID Eras. This research used logistic regression to identify predictors of receiving quality mental healthcare. During the pre-COVID Era, primary care (PC) and mental health (MH) encounters using remote video were rare making up a fraction of all care (Rural PC = 0.1%, Urban PC = 0.1%; Rural MH = 0.2%, Urban MH = 0.3%). There was a dramatic increase in remote video encounters during the Early COVID Era, but urban patients experienced a much larger increase versus rural counterparts (Rural PC = 0.9%, Urban PC = 2.0%; Rural MH = 1.3%, Urban MH = 2.8%). The effect of COVID Eras on quality was mixed depending on the metric examined. Across all Eras, rural patients and patients receiving remote care only received substantially lower quality mental health care compared to urban patients and patients who received a combination of remote and on-site care. Overall, there were dramatic changes to service delivery modalities across the COVID-19 pandemic. Quality of mental health care remained persistently lower among rural patients.