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

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?

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.

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).

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?”

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.

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.

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.

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.

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.

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.”

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:

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.”

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.

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:

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.”

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

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:

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:

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).

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).

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:

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.

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:

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:

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,

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.”

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:

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.

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.

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.

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.

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.