Patient perspectives on telehealth access among people experiencing homelessness: A rapid review

Patient perspectives on telehealth access among people experiencing homelessness: A rapid review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Patient perspectives on telehealth access among people experiencing homelessness: A rapid review Claire Doherty, Hayley Pepper, Rebecca Jessup, Jennie Hutton This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5665490/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jan, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background Telehealth services are rapidly expanding across the globe yet under-served populations, particularly people experiencing homelessness (PEH), are at risk of being further marginalised in society if focussed interventions to address telehealth access are not implemented. The aim of this rapid review was to report on the patient experience of PEH when accessing telehealth services. Secondary objectives of the review were to summarise both the patient and health service outcomes that were reported. Methods This rapid review identified peer reviewed literature that explored patient experiences of telehealth for people experiencing homelessness. Databases searched were MEDLINE, Embase, APA PsychINFO and CINAHL. Study characteristics were extracted and during the second-phase, two authors independently extracted data from each paper using a framework for evaluating telehealth outcomes (access to care, cost, experience, effectiveness) with a third author reviewing the extracted data and finalising the results table. Results Twelve eligible studies were identified with publication dates between 2020 and 2024. Two were qualitative, nine were quantitative and one was a mixed-methods study design. A large variation was found across the literature in relation to participant experience of telehealth for PEH. Telehealth was shown to be an acceptable form of healthcare for PEH. It was more acceptable in settings where participants were accessing it with clinician support, in an environment that was familiar to the participant, where the participant was living in at least temporary accommodation. Furthermore, telehealth was accessible where the processes to access telehealth were not prohibitive and where the internet connection was reliable. However, significant adaptions to improve a participant’s experience of telehealth was identified as a need. Conclusion There is limited evidence available that explores the experiences of PEH when accessing telehealth. We have identified a number of simple factors that can be implemented to make telehealth services more accessible for PEH. Acknowledging that telehealth services are an accepted form of healthcare delivery across the globe, future research involving people experiencing primary homelessness and undertaking research utilising a digital inclusion framework would be of value. Registration The review was registered on the International prospective register of systematic reviews, (PROSPERO in October 2023 CRD42023466817). Telehealth homelessness patient experience digital inclusion Figures Figure 1 Background The fundamental human right to housing is universal yet homelessness exists across the globe and disproportionately affects under-served populations. ( 1 ) Ideological and political dimensions shape how homelessness is defined across different countries. Consequently, an agreed global definition by which to measure homelessness by does not exist. ( 2 ) Despite this, it is estimated that 100 million people across the globe do not have access to a home and this number has been growing since 2022. ( 3 ) Throughout Australia the number of people experiencing homelessness (PEH) continues to grow amid a housing crisis. ( 4 ) In 2021, the country recorded one of the highest homelessness rates among OECD countries. ( 5 ) Globally, drivers of homelessness are complex and both individual and structural risk factors contribute to this problem. ( 6 ) It has been established that PEH have poorer health compared to the general population. An Australian study found that people who had experienced insecure housing at least once over a 15 year period were at risk of premature mortality and a younger age of death compared to a population in secure housing. ( 7 ) These people experience high rates of chronic illness and one in four people who experience homelessness are unable to receive the medical care they need. ( 8 ) Homelessness is associated with high-cost healthcare utilisation patterns including emergency department (ED) presentations for non-emergency, primary care conditions. ( 9 , 10 ) PEH have reported stigma in attending primary care and difficulty accessing these services. ( 11 – 13 ) Access to healthcare is also limited by recognised factors such as prioritising physiological needs, lack of resources such as transportation, and barriers related to health literacy. ( 12 ) The Covid-19 pandemic further jeopardised PEH access to healthcare due to the increased pressures on ED’s. ( 14 ) In Australia, as was the case internationally, the Covid-19 pandemic disproportionately affected under-served populations as they were found to have reduced access to quality healthcare compared to the general population. ( 15 ) Amid the global Covid-19 pandemic, the healthcare industry swiftly transformed the way in which healthcare was provided through the widespread adoption of telehealth. Telehealth services, that is, healthcare (including information and education) delivered via audio and visual means ( 16 , 17 ) was adopted in Australia in mid-2000, with mental health telehealth services being one of the first to be established. Telehealth services have grown rapidly across metropolitan, rural and remote settings. ( 17 ) With telehealth becoming widely available across Australia during the pandemic, consumers have reported value in the choice and flexibility which it provided along with an ease of access. ( 18 ) However, consumers also recognised that it should not replace face-to-face health care, particularly when a physical examination is required. ( 18 ) A web-based survey of the Australian population found people who were less likely to engage with telehealth were older and had achieved an education level below that of a Bachelor’s degree. ( 19 ) While telehealth has merit and is widely accepted, there are populations and groups of people who are less engaged with it and the reasons for this require further exploration. There is evidence that a ‘digital divide’ exists in the provision of telehealth care and that this may further increase health inequity. ( 20 – 22 ) Groups that have been shown to have reduced access to telehealth include PEH and without specific interventions aimed at addressing the digital divide, they are at risk of being further marginalised by the expansion of telehealth services and suffering increased disparities in their health. ( 23 ) Relevant telehealth barriers and outcomes are important to identify to improve the design of healthcare services for underserved populations. The aim of this rapid review was to understand the patient experience of PEH when accessing telehealth services. Secondary objectives of the review were to understand what patient outcomes and health service outcomes were reported. Methods Search Strategy A rapid review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA 2020). ( 24 ) A librarian was engaged during the initial stages of the search to assist with identification of search terms. The search strategy was prepared and refined by the authorship team. This comprised of academics and clinicians with experience of providing healthcare to PEH. Search terms Search terms included in the study were (homelessness OR homeless person* OR homeless youth OR ill-housed person* OR homeless* OR homeless mentally ill) AND (telehealth OR telemedicine OR eHealth OR virtual healthcare OR remote consultation OR virtual visit OR online healthcare OR telecare OR digital health). Search inclusion and exclusion criteria To guide development of the eligibility criteria, a PICO framework was used to determine inclusion and exclusion criteria [see Additional file 1]. Synchronous telehealth for PEH was the intervention and population of interest. No limits were placed on the year of publication. The search was limited to papers written in English. Peer reviewed publications, including reviews, were included. Editorials, opinion pieces and commentaries, protocols, reports, conference proceedings, letters to the editor, grey literature and government reports were excluded. Databases searched originally on 25 September 2023 and repeated on 29th July 2024 included: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (Embase), American Psychological Association PsychINFO and Current Index to Nursing and Allied Health Literature (CINAHL). An example of the final search strategy and terms adapted for Medline database has been made available [see Additional file 2]. Search results were exported to Endnote. Covidence, an online systematic review software, was used for authors to screen and assess all papers. Duplicates were automatically removed and all paper titles and abstracts were screened independently by two authors. Any conflicts were resolved by discussion between the two authors. All papers included in the full text review were once again screened independently by two authors with conflicts being resolved between reviewing authors and the broader research team was consulted for any remaining conflicts. Review papers and systematic reviews identified during the screening process were recorded separately and reference lists reviewed for any eligible reference texts. Study quality assessment The Mixed Methods Appraisal Tool ( 25 ) was used to assess the quality of each paper. Two authors appraised each paper with both authors resolving any conflicts. Final quality assessment of each of the included search results has been made available [see Additional file 3]. Data extraction strategy The data extraction process utilised a two-phase approach. During the first phase, one author extracted data into a table describing the study characteristics including author, year of publication, country, title, study design, objective, population, setting, exposure and outcome measures used. A second author completed a full review of all extracted articles and ensured data accuracy. The second phase was guided by the application of Li et al. framework for evaluating telehealth outcomes. ( 26 ) The framework suggested four domains for measuring outcomes of telehealth quality, as guided by the National Quality Forum (USA), which included (i) access to care, (ii) cost, (iii) experience and (iv) effectiveness (Table 1 ). These domains and their related sub-domains were used to meaningfully extract and then code data from each paper. All members of the authorship team participated in this process with at least two authors extracting data against the four domains for each paper, a third author reviewed the extracted data and finalised the results table. Table 1 Telehealth evaluation domains and sub-domains Domain Sub-Domains Experience Patient, family, and/or caregiver experience Care team member experience Community experience Access to care Access for patient, family, and/or caregiver Access for care team Access to information Cost Cost to patient, family and/or caregiver Cost to care team Cost to health system or payer Cost to society Effectiveness System effectiveness Clinical effectiveness Operational effectiveness Technical effectiveness Results and discussion Study Selection Of the 762 studies identified in the database search, twelve studies were included in the final review. The screening and exclusion process is shown in the PRISMA diagram (Fig. 1 ). Study Characteristics Of the 12 studies included in this review, nine were quantitative ( 27 – 35 ), two were qualitative ( 36 , 37 ) and one was a mixed methods ( 38 ) study design (Table 1 ). Most studies were from the USA (n = 10) with the remaining two studies being from the UK and Hungary. All studies were published between 2020 and 2024 (Table 2 ). Table 2 Summary of study characteristics Author, year, country Title Study Design/ Aim Population/ Intervention Outcome Measures Key Findings/ Other learnings Adams, 2021, USA A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness Cross sectional Survey AIM : To describe the demographics and health related needs of PEH and determine the feasibility and the acceptability for patients and providers of telehealth visits as a care delivery method compared to in person visits Population : Needs assessment survey: n = 63 PEH Survey following telehealth consult = 85 PEH & 13 providers Intervention : Telehealth visits - internet based two-way audio/visual system enabling remote stethoscope, ophthalmoscope and dermatoscope with physicians/resident physicians Needs assessment survey, patient and provider clinical survey The survey results demonstrated telehealth is a health care delivery for PEH that is feasible, is accepted by patients and providers, and increases access to health care Leung, 2024, USA Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-10 Pandemic Onset Retrospective Cohort Study AIM: To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterise users before and after the onset of the COVID-19 pandemic. Population : 394 731 veterans with homelessness diagnosis Intervention : The expansion of telehealth (video, phone, secure messaging) in veteran primary care pre, during and post COVID-19 pandemic Frequency and type of telehealth (video, phone, secure messaging) utilised in veteran primary healthcare services for homeless-experienced veterans 1 year prior, 1 year during, and 2 years post COVID-19 Telehealth use in veteran primary care for veterans experiencing homelessness increased significantly during the COVID-19 pandemic with the increase being maintained post COVID-19 and comparable to the general VA population. Other learnings : Disproportionately higher use of telehealth was found among homeless-experienced veterans who were young, female, racial-ethnic minorities, and with multiple comorbidities. Tofighi, 2022, USA A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System's Initiative to Expand Treatment Access During the COVID-19 Pandemic Retrospective cohort study AIM : To assess the feasibility and clinical impact of TBOT with BUP-NX following the COVID-19 pandemic Population : NYC residents with OUD n = 78 (including 52 PEH) Intervention : TBOT with UP-NX using video conferencing and telephonic visits between March 26, 2020 - May 28, 2020 Patient characteristics, clinic attendance, prescription records, program retention, ongoing referrals, number prescribed naloxone during initial visit, adverse clinical outcomes, difficulties accessing BUP-NX at pharmacy following initial visit Loss to follow up among patients enrolled in TBOT at 8 weeks and not transitioned to community treatment was low (19.2%) and comparable to prior studies of in-person TBOT. Prince, 2022, United States Facing the Digital Divide: Increasing Video Visits Among Veterans Experiencing Homelessness Prospective cohort study AIM : To increase the percentage of video visit among telehealth visits to 10% within 16 weeks amongst VEH Population : n = 3902 VEH Intervention : Video call using patient own phone, tablet or computer or call supported by clinicians A proportion of video visits are post-intervention versus pre-intervention. Association between patient demographics and telehealth use. The proportion of video visits post-intervention doubled from 4.8% pre-intervention to 10.3% post-intervention. Video visit uptake differed by age (19% of patients aged < 60 years vs 10% aged ≥ 60 years) and housing status (19% of patients in long-term supportive housing vs 12% in other settings) Other learnings : Need to address the digital divide for disadvantaged populations accessing healthcare Garvin, 2021, United States Use of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness Service evaluation/ Retrospective cohort AIM : To provide telehealth tablets to increase access for VEH Population : n = 1470 VEH Intervention : Providing a tablet to support VEH to access care Tablet use within 6 months of receipt for mental health, primary or specialty care 45.9% of VEH who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among VEH who were younger, middle-aged, in rural settings; and those with post-traumatic stress disorder, and less common among those who were Black and those with a SUD or persistent housing instability. Other learnings : Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond Iheanacho, 2020, USA Mobile, Community-Based Buprenorphine Treatment for Veterans Experiencing Homelessness with Opioid Use Disorder: A Pilot, Feasibility Study Retrospective cohort study AIM : To pilot test a mobile, community-based BUP treatment for VEH with OUD Population : VEH with OUD. Mobile Intervention (N = 12) Clinic (N = 24) Intervention : FaceTime video conferencing to evaluate and prescribe BUP using existing case managers; Mobile community assessment team; community follow up visits were planned Treatment retention and healthcare utilisation Twelve veterans were enrolled in M-CAT and 24 were enrolled in BUP clinic. Mean retention in treatment was 19.2 months (standard deviation [SD] = 10.2) in M-CAT and 36 months (SD = 27.6) in BUP clinic. At the endpoint, 66.7% (n = 8) in M-CAT and 100% (n = 24) in BUP clinic remained on BUP. Other learnings : Successfully engaged and retained a small subset of 'difficult-to-engage' veterans struggling with homelessness and OUD in care on BUP. Reduced emergency visits but increased psychiatric admissions. Bekasi, 2022, Hungary Telemedicine in community shelters: possibilities to improve chronic care among people experiencing homelessness in Hungary Cross sectional survey AIM : To determine the feasibility, patient experience, and medical relevance of a telehealth service focusing on care continuity of chronic conditions among PEH Population : PEH (in mid- and long-term accommodation): n = 75 Intervention : Six online video calls with a physician delivered weekly by WhatsApp or Facebook Messenger Physician and patient satisfaction measured on a 5-point Likert scale Both the patients’ and physicians’ overall satisfaction was very high (4.52 and 4.79, respectively, on a 5-point Likert scale) Other learnings : Study provided evidence of a feasible telecare setup in shelters offering accommodation to PEH Zahir, 2023, United States I Needed for You to See What I'm Talking About': Experiences with Telehealth Among Homeless-Experienced Older Adults Qualitative interview study AIM : To examine the perceptions and use of Telehealth in older adults experiencing homelessness Population : Purposive sampling from previous study participants: HOPE HOME Cohort n = 37 (23 PEH) Participants > 50 yrs old Previously recruited for HOPE HOME study: Rough sleeper = 1, Shelter = 12, Hotel = 11, Housed = 14. Intervention : Participants had accessed healthcare during the COVID-19 pandemic N/A Clinicians interacting with homeless experienced older adults should address the potential skepticism of audio only telehealth patients, and assess their access to, and knowledge of, video conferencing technology Legha, 2020, USA Telemental health in an Alaska Native residential substance abuse treatment program Retrospective cohort study AIM : To describe diagnostic status, socioeconomic and demographic characteristics, treatment patterns of patients receiving services at a residential substance abuse treatment program for Alaska Native people Population : Participants of a residential inpatient substance abuse treatment program n = 206 (170 PEH) Intervention : Telemental health clinic; teleconferencing system with psychiatrist LOS, DC plans, ED visits, and hospital admissions; clinical hx, including suicide attempts, hx violence, and trauma hx; social stressors including legal, unemployment, housing; mental health, medical, substance abuse diagnoses; number & nature of telemental health contacts Both groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telemental health group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete Howells, 2022, UK Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study Qualitative interview study AIM : To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to healthcare for PEH Population : PEH, n = 21 Clinicians and support workers, n = 22 Intervention : Telephone primary care services. N/A Findings emphasised the importance of addressing practical and technological barriers as well as supporting communication and choice for mode of consultation. Telephone consultations were used. Experience of consultation as transactional and with less empathy, harder to negotiate triage/booking system as compared with "dropping in". Ferguson, 2021, USA Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization Retrospective cohort study AIM : To describe the shift from in person to virtual care within VA during the early phase of the COVID-19 pandemic and to identify at risk patient populations who require greater resources to overcome access barriers to virtual care. Population : Veterans, n = 5400878 (VEH, = 216,035 (4%)) Intervention : Expansion of virtual care services - either phone or video based - during COVID-19 pandemic A proportion of video visits post intervention versus pre-intervention. Association between patient demographics and telehealth use. 58% of VA care was provided virtually compared to only 14% prior. Veterans aged 45–64 and 65 + were less likely to use video care compared to those aged 18–44. Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban and non-homeless veterans. Other learnings : No exploration of quality of care or clinical outcomes, did not account for patient preferences or knowledge Mehtani, 2021, USA COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management Prospective cohort study AIM : To describe the development and feasibility of the ATP, a telephone-based program to reduce treatment access barriers for people with SUD staying at San Francisco's COVID-19 Isolation and Quarantine (I&Q) sites Population : San Francisco COVID-19 I&Q sites n = 12 PEH with OUD, all received referral for ATP, 1 left prior to & 3 after initiating BUP Intervention : ATP; external provider refers at I&Q admission, pt screened for risky SU, + screen referred to ATP provider/on-site I&Q nurse informed, I&Q nurse discuss with ATP provider, ATP conducts intake & schedules phone visits through clinic, phone visit(s) via hotel phone/mobile, prescribed meds requested for delivery, pt provided option to fu at clinic (in-person) post dc, ATP provided & clinic continue outreach if pt interested via phone Telehealth encounters, Patient demographics ATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I&Q site guests. Twelve patients were identified with untreated OUD and newly prescribed BUP. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I&Q-1 prior to and 3 after initiating BUP. Of the remaining 8 patients, 7 reported continuing to take BUP at the time of I&Q discharge and 1 discontinued. No patients started on BUP sustained significant adverse effects, required emergency care, or experienced overdose. Other learnings : Limited generalisability, ATP provided with numerous resources which may not be available elsewhere, i.e. under-insured patients able to be enrolled. Table 2 . Summary of study characteristics [INSERT Table 2 HERE] Seven studies focused on telehealth care initiatives or the way in which telehealth was accessed by PEH in response to the COVID-19 pandemic. ( 30 , 31 , 33 , 35 – 38 ) All other studies sought to understand how telehealth care services were either reaching or could better reach PEH prior to the global pandemic. ( 27 – 29 , 32 , 34 ) Five of the studies ( 27 , 28 , 35 , 36 , 38 ) focused on telehealth services in the primary care setting with an additional three ( 29 , 30 , 37 ) describing the general uptake of telehealth care across a range of health care settings by PEH. Three papers investigated the management of opioid use disorder by telehealth ( 31 – 33 ) and the final paper ( 34 ) explored the use of telemental health for a population accessing a drug and alcohol rehabilitation facility. Five of the nine studies from the USA focussed on the veteran population. ( 27 , 29 , 30 , 32 , 35 ) The size of study populations varied between studies with the number of people experiencing any form of homelessness ranging from 12 through to 394,731. While all studies had a focus or sub-group focus on PEH, four of them described the level of homelessness that the study population were experiencing ( 31 , 33 , 37 , 38 ) enabling the identification of primary, secondary and tertiary homelessness ( 39 ) at a glance. Six of the remaining studies ( 27 , 28 , 30 , 32 , 34 , 36 ) did not define homelessness. Leung et al ( 35 ) and Garvin et al ( 29 ) defined homelessness as the assignment of the homelessness diagnostic code from the International Classification of Diseases (ICD-9 or ICD-10) with Garvin et al ( 29 ) also including those with one of the Veteran’s Affairs Department of Social Services codes in the 12 months prior to study in the participants Veterans Administrative profile. However, confirmation of housing status was not obtained nor a delineation between primary, secondary or tertiary homelessness of the study population in both of these studies. There was no consistent definition of homelessness used across the 12 studies. Of those studies which did delineate between primary, secondary and tertiary homelessness, a total of 32 people experienced primary homelessness from the total of 202 participants (combined study population of the four studies). Zahir et al ( 37 ) and Howells et al ( 36 ) utilised semi-structured interviews to examine patient experience when reflecting on the shift to telehealth care services during the COVID-19 global pandemic; one in the context of primary care ( 36 ), the other focussing on a cohort over the age of 50 across all types of healthcare provision. ( 37 ) Bekasi et al ( 38 ) explored patient and clinician satisfaction when using video-telehealth calls to manage chronic health conditions across a three-month period (fortnightly appointments) for people experiencing homelessness in mid- to long-term housing. Six quantitative studies undertook a retrospective analysis approach to examine variation in study populations related to the uptake of telehealth services across generalised healthcare ( 29 , 30 ), primary healthcare ( 35 ), telemental health ( 34 ) and alcohol and other drug services. ( 32 , 33 ) Adams et al ( 28 ) explored the acceptability of telehealth in a primary care setting for patients and providers through a quality improvement lens by collating survey responses. Likewise, Prince et al ( 27 ), through a quality improvement lens aimed to increase the use of video-telehealth among veterans by 10% by implementing streamlined pathways and education packages to staff to enable video-technology access over the 16-week period. Lastly, Mehtani et al ( 31 ) undertook a case series approach to examine the implementation and uptake of an addiction telehealth program used across Covid-19 Isolation and Quarantine sites in San Francisco. Synthesis of results The framework for evaluating telehealth outcomes ( 26 ) was used to extract results from each of the study papers across the four domains of the framework. Experience Experience was reported in three studies, all of which used a qualitative methods. ( 36 – 38 ) Participants described telehealth as being valuable in the context of chronic disease management noting that this cohort were described as living in mid- to long-term accommodation and with support to access the telehealth service. ( 38 ) Higher satisfaction rates were reported by participants who could effectively use their devices and explain their symptoms. In their experience, these participants felt that the doctor understood their health concerns. In contrast, some patients described a less than optimum experience of telehealth with some reporting having less trust in a telephone consultation compared to a face-to-face appointment. ( 36 ) This was echoed by Zahir et al ( 37 ) where participants, all over the age of 50, felt the lack of ‘a visual’ being very confronting and problematic. Participants reported a decrease in empathy from treating providers leading to participants feeling they should withhold complex or sensitive issues during their telehealth appointment and viewing them more as a ‘transactional’ appointment. ( 36 ) A lack of feeling safe during telehealth appointments was reported ( 36 ) with a sense of concern elicited when no blood pressure was taken, yet a script was prescribed. ( 37 ) Telehealth providers had variable experiences with providing telehealth across the studies. Adams et al ( 28 ) reported providers were likely to agree, or strongly agree, that telehealth had a positive impact on a participant’s health compared to an in-person consult. In contrast, Howells et al ( 36 ) found providers felt that without good quality and adequate Wi-Fi the telehealth experience was hindered. Providers also felt that telehealth, at times, compromised patient safety with the opportunity to discuss other issues impacting their health seldom available. By standardising video visit workflows and providing sustained, ongoing staff education, Prince et al ( 27 ) reported that this contributed to an increase in the uptake of video-telehealth and staff felt more capable of providing it. Access to care Access to care was reported in all 12 studies. Access to care for participants was generally enhanced across all studies that involved an intervention that provided additional support through the form of a clinician or service, provision of a technology device ( 29 , 30 , 33 ) and/or provision of temporary-type accommodation. ( 31 , 34 ) Clinician-supported interventions ( 28 , 31 – 34 , 38 ) all reported an improvement in access to primary care, psychiatry and alcohol and other drug services for PEH. Participants residing at a mid- to long-term accommodation rated their likelihood of using telehealth again as very high (mean score of 4.34 on a 5-point Likert scale) four to six months after initially using the service for chronic disease management. ( 38 ) Likewise, a participant cohort based at a 12-month rehabilitation clinic who were provided with access to telemental health were less likely to discharge against medical advice and more likely to complete their rehabilitation program compared to those who did not have access to telemental health. ( 34 ) A mobile community-based team that provided telehealth to access buprenorphine treatment was embedded into an existing case management service for veterans. This service successfully engaged a ‘harder-to-reach' sub-group of the veteran population on buprenorphine treatment and, at the same time, noticed a reduction in emergency department presentations. ( 32 ) Tofighi et al ( 33 ) reported loss to follow-up rates (19.2%) in a telemedicine-based opioid treatment service provided to people experiencing homelessness as comparable to prior studies of in-person clinics. A technology device was prescribed at commencement of treatment to enable greater ongoing access to the program. Technology devices were likewise prescribed in two additional studies ( 29 , 30 ) with analysis describing PEH that were younger or middle age, located in rural settings or who had a diagnosis of post-traumatic stress disorder, were more likely to access telehealth when provided with a means to access healthcare via technology. In the primary-care setting, telehealth use increased significantly among veterans experiencing homelessness across the year and year following the COVID-19 pandemic and rates of use were similar to the general veteran population. ( 35 ) Participants experiencing homelessness accessing temporary accommodation to isolate during the Covid-19 pandemic were provided with immediate access to an addiction telehealth program to manage their opioid use disorder via telehealth removing the need for an in-person initial consult which was normally required by state law. ( 31 ) Of the 12 participants identified as having opioid use disorder, 58% had never been prescribed medication for it. The provision of temporary shelter enabled access to required medication, and at the point of discharge, seven continued on treatment. The provision of telehealth services, at times, was observed to reduce access to care and increase barriers. For example, Howells et al ( 36 ) found that some study participants experiencing homelessness preferred the flexibility of being able to drop-in for a same-day face-to-face appointment. It was also recognised that not all PEH have access to community support or an outreach worker to facilitate access to telehealth. Wait times to get through to telehealth and complex triage services were also perceived as barriers to access. Zahir et al ( 37 ) found that the majority of the study population didn’t access telehealth despite it being available. Of those who did use telehealth, the majority utilised audio technology as a lack of knowledge and capacity to access videoconferencing was a barrier. Telehealth was perceived as inadequate for the management of physical health issues. To ensure access to care for participants, findings across the studies emphasised the need of addressing both practical and technological barriers. There are cohorts of PEH identified as experiencing more significant barriers to accessing telehealth, namely veterans between the ages of 45 and 64, people over the age of 65, and those living in rural locations. ( 30 ) In addition, a lack of access to technology, high rates of smart device turn-over, a lack of stable internet connection and persistent housing instability were variables commonly reported to contribute to reducing access to telehealth services for PEH. ( 29 , 33 ) Those veterans experiencing homelessness who experienced less barriers to accessing telehealth in the primary care setting, Leung et al ( 35 ) identified as younger, female, from a racial-ethnic minority and with a high rate of comorbidities. Cost Cost was the least assessed variable across the studies. It was indirectly reported in six studies. ( 28 , 29 , 33 , 34 , 36 , 37 ) Howells et al ( 36 ) reported participants were concerned about the cost of the phone call to access telehealth and the subsequent cost of waiting on the telephone line until a clinician was available. In contrast, Zahir et al ( 37 ) found that telehealth relieved the burden of cost to the participant through not having to pay for transport to get to an appointment. Some study participants who were prescribed buprenorphine during their initial visit to a virtual buprenorphine clinic were unable to access it from the pharmacy which was attributed to a variety of reasons, one being insurance coverage issues. ( 33 ) In contrast, when video-enabled tablets were distributed to a large cohort of veterans, removing the burden of the cost from the participant, less than half (45.9%) of PEH had used it for telehealth within the 6 months of receiving it ( 29 ) indicating that cost may not be the only prohibiting factor to accessing telehealth for this population. In a trial of telehealth delivered to a drop-in centre, participants reported that they would have sought care through the ED or not at all if the telehealth service wasn’t available. ( 28 ) Only 2.2% of participants were referred to the hospital as an outcome of the telehealth intervention. ( 28 ) Treatment retention, leading to a decrease use in emergency care services, was much higher for participants receiving telemental health in a drug and alcohol rehabilitation setting despite this cohort experiencing more significant health and social disparities than the control group. ( 34 ) Effectiveness Effectiveness was reported in all 12 studies with all areas of effectiveness being covered to some degree across all of the studies. It was highlighted that system level preparedness for the move to telehealth in the event of future pandemics is pertinent for PEH. ( 30 ) Concern was raised about the reduction in face-to-face consults leading to increasing inequity, however, telehealth was seen to promote community partnerships and encourage connection between health professionals. ( 36 ) Studies suggested the provision of telehealth led to a reduction in the use of expensive emergency healthcare ( 28 ) and improved retention in healthcare programs for complex cohorts leading to decreased pressure on stretched healthcare systems. ( 34 ) Mixed results were found by Iheanacho et al ( 32 ) who described a decrease in ED psychiatry visits yet an increase in psychiatric inpatient admissions. Providers of telehealth to PEH had varying views on its clinical effectiveness. Doctors providing chronic disease management by telehealth felt they could rate the participant’s issues and make an adequate diagnosis. ( 38 ) Telehealth providers also were likely to agree and strongly agree that telehealth had a positive impact on a participant’s health compared to an in-person consult in the setting of a drop-in centre and the provision of primary care. ( 28 ) Telemental health was reported in multiple studies to be an effective mode of health care provision. ( 29 , 34 , 37 ) Telemental health was the telehealth service most utilised in the 6 months after being provided with a tablet ( 29 ) by veterans experiencing homelessness. Telemental health was more widely accepted by participants who had an existing relationship with a mental health provider prior to accessing telemental health ( 37 ) and showed high levels of retention in a complex cohort during their stay at a rehabilitation clinic ( 34 ) compared to the control group who did not receive telemental health. In contrast, some telehealth providers were concerned that it compromised patient safety and the opportunity to discuss other health or psychosocial issues lost. ( 36 ) At times the telehealth consult felt more transactional than personal. Participants also were reluctant to explain their story again and felt less safe communicating over a phone without knowing the person at the other end. ( 36 ) Clinically, telehealth in the context of pharmacotherapy service provision showed some clinical effectiveness particularly for those in quarantine facilities where access to this type of therapy was essential given the risk of opioid withdrawal if not prescribed. ( 31 ) Operational effectiveness was variable across and within studies, often hindered by participant’s access to technology and stable Wi-Fi connection as well as operational knowledge. Where access to technology and stable Wi-Fi were not problematic, studies showed high levels of comfort with utilising telehealth as a means to accessing appropriate healthcare provision. ( 28 , 38 ) Telehealth services requiring formal enrolment exhibited lower uptake in the primary care setting when compared with telehealth that was readily accessible. ( 35 ) To enable operational effectiveness, relationships with community services was essential and sometimes lacking, prohibiting the participant from being able to access scripts or medication. ( 33 ) Operational effectiveness was hindered in one study by the provider’s lack of knowledge and awareness of how to use video-conferencing. The development of standardised workflows and sustained staff education was essential to enable the operationalisation of telehealth in the first instance. ( 27 ) Awareness of how to use smart technology impacted technical effectiveness in some studies. When reflecting on their use of telehealth during the global pandemic, PEH over the age of 50 described tending not to use it at all, or, if they did, they would rely on audio-only telehealth. ( 37 ) This was due to not having access to a smartphone or a computer capable of videoconferencing alongside a lack of stable internet connection. ( 37 ) A lack of stable internet access was also described by Tofighi et al ( 33 ) as a limitation to technical effectiveness with fixing this issue described as a low priority given the complex psychosocial issues exhibited by the study population. Summary of results across the four domains The studies included in the review showed a large variation in the participant’s experience of telehealth services. The two qualitative studies ( 36 , 37 ) indicated that the provision of telehealth services to PEH requires significant adaptations to improve participant experience. Participant experience of telehealth was shown to be more acceptable in settings where participants were accessing it with clinician support, in a place that was familiar to the participant, when access to telehealth technology was provided and not prohibited by identification verification processes and where a participant's accommodation was considered at least temporary. Participant and provider experience were reported in the literature, however family and caregiver and community experience were not. Access to care for participants was reported in the literature with family, and/or caregiver and access to information not being reported. Cost was not adequately addressed in the literature with limited evidence available to draw any significant conclusions about the patient, system or society level cost impacts of telehealth service provision. Finally, all areas of effectiveness were reported to some degree in the literature. Discussion People experiencing homelessness are greatly under-represented in literature reporting on experiences of telehealth services, with the voice of those experiencing primary homelessness seldom represented. Through asking participants about their experience of the shift toward telehealth in various healthcare settings, three studies were able to elicit the voice of PEH and speak to the conditions that enable a positive experience. ( 36 – 38 ) Conditions for successful engagement that were identified included having access to a stable internet connection, having a support person involved before, during and after the consult, using telehealth for chronic disease management and, in most cases, when accessing telehealth for the management of mental health conditions. Conversely, patient experience was less than optimal for PEH accessing telehealth who were older, and in the situation where technology and systems available to participants prevented easy access. Our findings are similar to the international literature which identifies that telehealth in the setting of chronic disease management and telemental health is an accepted form of healthcare provision. ( 40 – 43 ) Chronic disease management via telehealth was acceptable particularly when it was considered easy to use. ( 41 ) This finding was similar to the veteran populations experiencing homelessness who described a preference for using face-to-face consult when there was a perceived barrier to accessing telehealth, for example, when there was a need to register for the telehealth service with multiple steps involved. Included studies demonstrated that telemental health is generally accepted among population groups as a means of mental health support delivery. This is in agreement with a systematic review and meta-analysis of tele-mental health services which found that they were a highly accepted form of health service delivery. ( 42 ) Consideration of the needs of both the end-user and service provider were emphasised in the findings. Likewise, a systematic review exploring the acceptability of telemental health support for patients post stroke showed high levels of acceptability though noted that technical difficulties were cited as a primary barrier to patient access. ( 44 ) Truong et al ( 40 ) found that among people from diverse backgrounds, preconditions that enabled use of telehealth included addressing barriers specific to cost as well as digital health literacy. Likewise, a scoping review of the use of telehealth in the primary care setting ( 45 ) found that for telehealth services to be fully integrated, all aspects of digital inclusion need to be addressed particularly for under-served populations. These findings are similar to the literature, particularly literature focussing on veterans where people over 45 years or who live more rural experience greater issues with digital inclusion. Implications for practice Digital inclusion means that people have access to technology and stable Wi-Fi, can afford to pay for technology and Wi-Fi relative to their income and have the ability, or required digital health literacy, to navigate the technology. ( 46 ) While telehealth appears to be of some value to PEH, and there is a willingness from PEH to engage with it, all areas of digital inclusion need to be addressed at a local health service level through to national policy. With video-telehealth being more accepted as a means of telehealth delivery, consideration of how this can be made reliably possible for PEH to access is essential. Having a clinician known to the PEH present to support access to telehealth is an example of digital inclusion. The presence of a clinician enables access to Wi-Fi and technology while simultaneously providing support to navigate complex multi-step telehealth services. Furthermore, the support of a known clinician contributes to enhancing a relationship of trust between the PEH and the telehealth service. Support clinicians play an important role in bridging the gap that exists with health literacy and facilitating effective communication between the patient and the telehealth clinician. There are many ways in which PEH can access telehealth services if all areas of digital inclusion are addressed. This becomes more challenging for PEH who are experiencing primary homelessness, but not an impossible task. The frequent movement of this cohort means that they are less visible across the literature, however a nuanced approach to digital inclusion for this cohort needs to be considered. Health services committed to providing telehealth for all members of our society need to be committed to addressing funding models, strategic policies, operational workflows and staff education to ensure they promote digital inclusion. ( 47 ) Strengths and limitations A strength of the study is that no limitations were set on the publication year. A comprehensive evaluation framework specific to telehealth was used to categorise and sort the findings. There were some limitations in this review including the high heterogeneity in study designs and countries in which the studies were conducted. Only studies published in English were included and study populations didn’t represent the vast living situations of PEH, with those experiencing primary homelessness being seldom represented. The interventions and outcomes across the studies were also limited. Conclusion This rapid review found limited evidence exploring the experiences of PEH when accessing telehealth with the literature mostly limited to the USA and veteran populations. Existing literature provides some insights into the individual and system conditions that enable PEH access to telehealth services which support positive experiences. Telehealth can be accessed successfully by PEH and improvements in their experience are gained when a support worker is present. It is clear that telehealth services are an accepted form of healthcare delivery for PEH and future research should further explore an individual’s perspective about the enablers and barriers to digital telehealth. Abbreviations ATP Addiction telehealth program BUP Buprenorphine BUP-NX Buprenorphine-naloxone DC Discharge ED Emergency department Hx History I&Q Isolation and quarantine LOS Length of stay NYC New York City OUD Opioid use disorder PEH People experiencing homelessness Pt Patient PWID People who inject drugs SUD Substance use disorder TBOT Telemedicine-based opioid treatment VA Veterans Affairs VEH Veterans experiencing homelessness Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding A grant from the Victorian Medical Rapid Acceleration Fund was received to the value of $45,290. The grant is to fund the research component of a broader project which is to improve the accessibility of telehealth to people experiencing homelessness. Authors’ contributions All authors conceived the study, search strategy and methodology. All authors analysed the data. CD was the lead author with substantial contribution and editing from all listed authors. All authors read and approved the final manuscript. Acknowledgements Not applicable References Hugh S, Fox MS. Homelessness and open city data: Addressing a global challenge: Springer; 2020 [cited 2024 May 01]. Available from: https://link.springer.com/chapter/10.1007/978-981-13-6605-5_2. Treglia D, Culhane D. Defining and counting homelessness. 2023 [cited 2024 May 01]. In: The Routledge Handbook of Homelessness [Internet]. Routledge, [cited 2024 May 01]; [35-47]. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9781351113113-5/defining-counting-homelessness-dan-treglia-dennis-culhane. UN-Habitat. 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Acceptability of tele-mental health services among users: A systematic review and meta-analysis. BMC Public Health. 2024;24(1):1143. Omboni S, Ballatore T, Rizzi F, Tomassini F, Panzeri E, Campolo L. Telehealth at scale can improve chronic disease management in the community during a pandemic: An experience at the time of COVID-19. PLoS One [Internet]. 2021 [cited 2024 September 25]; 16(9):[e0258015 p.]. Available from: https://pubmed.ncbi.nlm.nih.gov/34587198/. Lombardo C, Islam MS. Stroke survivors’ acceptance and satisfaction of telerehabilitation delivery of physiotherapy services: a systematic review. Physical Therapy Reviews. 2023;28(4-6):261-77. Beheshti L, Kalankesh LR, Doshmangir L, Farahbakhsh M. Telehealth in primary health care: a scoping review of the literature. Perspectives in Health Information Management. 2022;19(1). Barraket J. The digital divide in telepractice service delivery: Australian Institute of Family Studies; 2021 [cited 2024 September 25]. Available from: https://aifs.gov.au/resources/short-articles/digital-divide-telepractice-service-delivery. Banbury A, Smith AC, Mehrotra A, Page M, Caffery LJ. A comparison study between metropolitan and rural hospital-based telehealth activity to inform adoption and expansion. Journal of Telemedicine and Telecare. 2023;29(7):540-51. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.pdf Additional Files File name: Additional file 1 File format: .pdf Title of data: PICO Framework Description of data: PICO description of inclusion and exclusion criteria based on population, intervention and outcomes Additionalfile2.pdf File name: Additional file 2 File format: .pdf Title of data: Search Strategy Description of data: Example of search strategy used for MEDLINE Additionalfile3.pdf File name: Additional file 3 File format: .pdf Title of data: Quality Assessment Table Description of data: Table detailing the quality of each paper, as agreed by the authors, using the Mixed Methods Appraisal Tool (MMAT) Cite Share Download PDF Status: Published Journal Publication published 22 Jan, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 14 Sep, 2025 Reviews received at journal 12 Sep, 2025 Reviews received at journal 25 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 18 Jul, 2025 Editor assigned by journal 23 Dec, 2024 Submission checks completed at journal 18 Dec, 2024 First submitted to journal 17 Dec, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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under-served populations. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Ideological and political dimensions shape how homelessness is defined across different countries. Consequently, an agreed global definition by which to measure homelessness by does not exist. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Despite this, it is estimated that 100\u0026nbsp;million people across the globe do not have access to a home and this number has been growing since 2022. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThroughout Australia the number of people experiencing homelessness (PEH) continues to grow amid a housing crisis. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) In 2021, the country recorded one of the highest homelessness rates among OECD countries. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Globally, drivers of homelessness are complex and both individual and structural risk factors contribute to this problem. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) It has been established that PEH have poorer health compared to the general population. An Australian study found that people who had experienced insecure housing at least once over a 15 year period were at risk of premature mortality and a younger age of death compared to a population in secure housing. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) These people experience high rates of chronic illness and one in four people who experience homelessness are unable to receive the medical care they need. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHomelessness is associated with high-cost healthcare utilisation patterns including emergency department (ED) presentations for non-emergency, primary care conditions. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) PEH have reported stigma in attending primary care and difficulty accessing these services. (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Access to healthcare is also limited by recognised factors such as prioritising physiological needs, lack of resources such as transportation, and barriers related to health literacy. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe Covid-19 pandemic further jeopardised PEH access to healthcare due to the increased pressures on ED’s. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) In Australia, as was the case internationally, the Covid-19 pandemic disproportionately affected under-served populations as they were found to have reduced access to quality healthcare compared to the general population. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAmid the global Covid-19 pandemic, the healthcare industry swiftly transformed the way in which healthcare was provided through the widespread adoption of telehealth. Telehealth services, that is, healthcare (including information and education) delivered via audio and visual means (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) was adopted in Australia in mid-2000, with mental health telehealth services being one of the first to be established. Telehealth services have grown rapidly across metropolitan, rural and remote settings. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) With telehealth becoming widely available across Australia during the pandemic, consumers have reported value in the choice and flexibility which it provided along with an ease of access. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) However, consumers also recognised that it should not replace face-to-face health care, particularly when a physical examination is required. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) A web-based survey of the Australian population found people who were less likely to engage with telehealth were older and had achieved an education level below that of a Bachelor’s degree. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) While telehealth has merit and is widely accepted, there are populations and groups of people who are less engaged with it and the reasons for this require further exploration.\u003c/p\u003e \u003cp\u003eThere is evidence that a ‘digital divide’ exists in the provision of telehealth care and that this may further increase health inequity. (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Groups that have been shown to have reduced access to telehealth include PEH and without specific interventions aimed at addressing the digital divide, they are at risk of being further marginalised by the expansion of telehealth services and suffering increased disparities in their health. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Relevant telehealth barriers and outcomes are important to identify to improve the design of healthcare services for underserved populations.\u003c/p\u003e \u003cp\u003eThe aim of this rapid review was to understand the patient experience of PEH when accessing telehealth services. Secondary objectives of the review were to understand what patient outcomes and health service outcomes were reported.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSearch Strategy\u003c/p\u003e\u003cp\u003e A rapid review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA 2020). (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) A librarian was engaged during the initial stages of the search to assist with identification of search terms. The search strategy was prepared and refined by the authorship team. This comprised of academics and clinicians with experience of providing healthcare to PEH.\u003c/p\u003e\u003cp\u003eSearch terms\u003c/p\u003e\u003cp\u003eSearch terms included in the study were (homelessness OR homeless person* OR homeless youth OR ill-housed person* OR homeless* OR homeless mentally ill) AND (telehealth OR telemedicine OR eHealth OR virtual healthcare OR remote consultation OR virtual visit OR online healthcare OR telecare OR digital health).\u003c/p\u003e\u003cp\u003eSearch inclusion and exclusion criteria\u003c/p\u003e\u003cp\u003eTo guide development of the eligibility criteria, a PICO framework was used to determine inclusion and exclusion criteria [see Additional file 1]. Synchronous telehealth for PEH was the intervention and population of interest. No limits were placed on the year of publication. The search was limited to papers written in English. Peer reviewed publications, including reviews, were included. Editorials, opinion pieces and commentaries, protocols, reports, conference proceedings, letters to the editor, grey literature and government reports were excluded.\u003c/p\u003e\u003cp\u003eDatabases searched originally on 25 September 2023 and repeated on 29th July 2024 included: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (Embase), American Psychological Association PsychINFO and Current Index to Nursing and Allied Health Literature (CINAHL). An example of the final search strategy and terms adapted for Medline database has been made available [see Additional file 2].\u003c/p\u003e\u003cp\u003eSearch results were exported to Endnote. Covidence, an online systematic review software, was used for authors to screen and assess all papers. Duplicates were automatically removed and all paper titles and abstracts were screened independently by two authors. Any conflicts were resolved by discussion between the two authors. All papers included in the full text review were once again screened independently by two authors with conflicts being resolved between reviewing authors and the broader research team was consulted for any remaining conflicts. Review papers and systematic reviews identified during the screening process were recorded separately and reference lists reviewed for any eligible reference texts.\u003c/p\u003e\u003cp\u003eStudy quality assessment\u003c/p\u003e\u003cp\u003eThe Mixed Methods Appraisal Tool (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) was used to assess the quality of each paper. Two authors appraised each paper with both authors resolving any conflicts. Final quality assessment of each of the included search results has been made available [see Additional file 3].\u003c/p\u003e\u003cp\u003eData extraction strategy\u003c/p\u003e\u003cp\u003eThe data extraction process utilised a two-phase approach. During the first phase, one author extracted data into a table describing the study characteristics including author, year of publication, country, title, study design, objective, population, setting, exposure and outcome measures used. A second author completed a full review of all extracted articles and ensured data accuracy.\u003c/p\u003e\u003cp\u003eThe second phase was guided by the application of Li et al. framework for evaluating telehealth outcomes. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The framework suggested four domains for measuring outcomes of telehealth quality, as guided by the National Quality Forum (USA), which included (i) access to care, (ii) cost, (iii) experience and (iv) effectiveness (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These domains and their related sub-domains were used to meaningfully extract and then code data from each paper. All members of the authorship team participated in this process with at least two authors extracting data against the four domains for each paper, a third author reviewed the extracted data and finalised the results table.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTelehealth evaluation domains and sub-domains\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-Domains\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient, family, and/or caregiver experience\u003c/p\u003e \u003cp\u003eCare team member experience\u003c/p\u003e \u003cp\u003eCommunity experience\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess to care\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccess for patient, family, and/or caregiver\u003c/p\u003e \u003cp\u003eAccess for care team\u003c/p\u003e \u003cp\u003eAccess to information\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost to patient, family and/or caregiver\u003c/p\u003e \u003cp\u003eCost to care team\u003c/p\u003e \u003cp\u003eCost to health system or payer\u003c/p\u003e \u003cp\u003eCost to society\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystem effectiveness\u003c/p\u003e \u003cp\u003eClinical effectiveness\u003c/p\u003e \u003cp\u003eOperational effectiveness\u003c/p\u003e \u003cp\u003eTechnical effectiveness\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Results and discussion","content":"\u003cp\u003eStudy Selection\u003c/p\u003e\n\u003cp\u003eOf the 762 studies identified in the database search, twelve studies were included in the final review. The screening and exclusion process is shown in the PRISMA diagram (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eStudy Characteristics\u003c/p\u003e\n\u003cp\u003eOf the 12 studies included in this review, nine were quantitative (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), two were qualitative (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) and one was a mixed methods (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) study design (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Most studies were from the USA (n\u0026thinsp;=\u0026thinsp;10) with the remaining two studies being from the UK and Hungary. All studies were published between 2020 and 2024 (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of study characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAuthor, year, country\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTitle\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy Design/ Aim\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation/ Intervention\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome Measures\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKey Findings/\u003c/p\u003e\n \u003cp\u003eOther learnings\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdams, 2021, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCross sectional Survey\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To describe the demographics and health related needs of PEH and determine the feasibility and the acceptability for patients and providers of telehealth visits as a care delivery method compared to in person visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eNeeds assessment survey: n\u0026thinsp;=\u0026thinsp;63 PEH\u003c/p\u003e\n \u003cp\u003eSurvey following telehealth consult\u0026thinsp;=\u0026thinsp;85 PEH \u0026amp; 13 providers\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eTelehealth visits - internet based two-way audio/visual system enabling remote stethoscope, ophthalmoscope and dermatoscope with physicians/resident physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeeds assessment survey, patient and provider clinical survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe survey results demonstrated telehealth is a health care delivery for PEH that is feasible, is accepted by patients and providers, and increases access to health care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeung, 2024, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCharacteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-10 Pandemic Onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRetrospective Cohort Study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eAIM: To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterise users before and after the onset of the COVID-19 pandemic.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003e394 731 veterans with homelessness diagnosis\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: The expansion of telehealth (video, phone, secure messaging) in veteran primary care pre, during and post COVID-19 pandemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFrequency and type of telehealth (video, phone, secure messaging) utilised in veteran primary healthcare services for homeless-experienced veterans 1 year prior, 1 year during, and 2 years post COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelehealth use in veteran primary care for veterans experiencing homelessness increased significantly during the COVID-19 pandemic with the increase being maintained post COVID-19 and comparable to the general VA population.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Disproportionately higher use of telehealth was found among homeless-experienced veterans who were young, female, racial-ethnic minorities, and with multiple comorbidities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTofighi, 2022,\u003c/p\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System\u0026apos;s Initiative to Expand Treatment Access During the COVID-19 Pandemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRetrospective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To assess the feasibility and clinical impact of TBOT with BUP-NX following the COVID-19 pandemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eNYC residents with OUD n\u0026thinsp;=\u0026thinsp;78 (including 52 PEH)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: TBOT with UP-NX using video conferencing and telephonic visits between March 26, 2020 - May 28, 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient characteristics, clinic attendance, prescription records, program retention, ongoing referrals, number prescribed naloxone during initial visit, adverse clinical outcomes, difficulties accessing BUP-NX at pharmacy following initial visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLoss to follow up among patients enrolled in TBOT at 8 weeks and not transitioned to community treatment was low (19.2%) and comparable to prior studies of in-person TBOT.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrince, 2022, United States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacing the Digital Divide: Increasing Video Visits Among Veterans Experiencing Homelessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProspective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To increase the percentage of video visit among telehealth visits to 10% within 16 weeks amongst VEH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;3902 VEH\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eVideo call using patient own phone, tablet or computer or call supported by clinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA proportion of video visits are post-intervention versus pre-intervention. Association between patient demographics and telehealth use.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe proportion of video visits post-intervention doubled from 4.8% pre-intervention to 10.3% post-intervention. Video visit uptake differed by age (19% of patients\u003c/p\u003e\n \u003cp\u003eaged\u0026thinsp;\u0026lt;\u0026thinsp;60 years vs 10% aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years) and housing status (19% of patients in long-term supportive housing vs 12% in other\u003c/p\u003e\n \u003cp\u003esettings)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Need to address the digital divide for disadvantaged populations accessing healthcare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGarvin, 2021, United States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse of Video Telehealth Tablets to Increase Access for Veterans Experiencing Homelessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eService evaluation/ Retrospective cohort\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To provide telehealth tablets to increase access for VEH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;1470 VEH\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: Providing a tablet to support VEH to access care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTablet use within 6 months of receipt for mental health, primary or specialty care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.9% of VEH who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among VEH who were younger, middle-aged, in rural settings; and those with post-traumatic stress disorder, and less common among those who were Black and those with a SUD or persistent housing instability.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIheanacho, 2020, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMobile, Community-Based Buprenorphine Treatment for Veterans Experiencing Homelessness with Opioid Use Disorder: A Pilot, Feasibility Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRetrospective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To pilot test a mobile, community-based BUP treatment for VEH with OUD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eVEH with OUD. Mobile Intervention (N\u0026thinsp;=\u0026thinsp;12) Clinic (N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: FaceTime video conferencing to evaluate and prescribe BUP using existing case managers; Mobile community assessment team; community follow up visits were planned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTreatment retention and healthcare utilisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwelve veterans were enrolled in M-CAT and 24 were enrolled in BUP clinic. Mean retention in treatment was 19.2 months (standard deviation [SD]\u0026thinsp;=\u0026thinsp;10.2) in M-CAT and 36 months (SD\u0026thinsp;=\u0026thinsp;27.6) in BUP clinic. At the endpoint, 66.7% (n\u0026thinsp;=\u0026thinsp;8) in M-CAT and 100% (n\u0026thinsp;=\u0026thinsp;24) in BUP clinic remained on BUP.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Successfully engaged and retained a small subset of \u0026apos;difficult-to-engage\u0026apos; veterans struggling with homelessness and OUD in care on BUP. Reduced emergency visits but increased psychiatric admissions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBekasi, 2022, Hungary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelemedicine in community shelters: possibilities to improve chronic care among people experiencing homelessness in Hungary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCross sectional survey\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To determine the feasibility, patient experience, and medical relevance of a telehealth service focusing on care continuity of chronic conditions among PEH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003ePEH (in mid- and long-term accommodation): n\u0026thinsp;=\u0026thinsp;75\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eSix online video calls with a physician delivered weekly by WhatsApp or Facebook Messenger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysician and patient satisfaction measured on a 5-point Likert scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth the patients\u0026rsquo; and physicians\u0026rsquo; overall satisfaction was very high (4.52 and 4.79, respectively, on a 5-point Likert scale)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Study provided evidence of a feasible telecare setup in shelters offering accommodation to PEH\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZahir, 2023, United States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Needed for You to See What I\u0026apos;m Talking About\u0026apos;: Experiences with Telehealth Among Homeless-Experienced Older Adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eQualitative interview study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To examine the perceptions and use of Telehealth in older adults experiencing homelessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003ePurposive sampling from previous study participants: HOPE HOME Cohort n\u0026thinsp;=\u0026thinsp;37 (23 PEH)\u003c/p\u003e\n \u003cp\u003eParticipants\u0026thinsp;\u0026gt;\u0026thinsp;50 yrs old Previously recruited for HOPE HOME study: Rough sleeper\u0026thinsp;=\u0026thinsp;1, Shelter\u0026thinsp;=\u0026thinsp;12, Hotel\u0026thinsp;=\u0026thinsp;11, Housed\u0026thinsp;=\u0026thinsp;14.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: Participants had accessed healthcare during the COVID-19 pandemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinicians interacting with homeless experienced older adults should address the potential skepticism of audio only telehealth patients, and assess their access to, and knowledge of, video conferencing technology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLegha, 2020, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelemental health in an Alaska Native residential substance abuse treatment program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRetrospective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To describe diagnostic status, socioeconomic and demographic characteristics, treatment patterns of patients receiving services at a residential substance abuse treatment program for Alaska Native people\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e: Participants of a residential inpatient substance abuse treatment program n\u0026thinsp;=\u0026thinsp;206 (170 PEH)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: Telemental health clinic; teleconferencing system with psychiatrist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLOS, DC plans, ED visits, and hospital admissions; clinical hx, including suicide attempts, hx violence, and trauma hx; social stressors including legal, unemployment, housing; mental health, medical, substance abuse diagnoses; number \u0026amp; nature of telemental health contacts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth groups exhibited high rates of mental and medical illness, socioeconomic challenges, and substance abuse. However, the telemental health group demonstrated a significantly higher rate of post-traumatic stress disorder, history of violence, ongoing legal issues, and children in outside custody. It also remained engaged in treatment longer, had fewer discharges against medical advice, and was more likely to complete\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHowells, 2022, UK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRemote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eQualitative interview study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to healthcare for PEH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e: PEH, n\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e\n \u003cp\u003eClinicians and support workers, n\u0026thinsp;=\u0026thinsp;22\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: Telephone primary care services.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFindings emphasised the importance of addressing practical and technological barriers as well as supporting communication and choice for mode of consultation. Telephone consultations were used. Experience of consultation as transactional and with less empathy, harder to negotiate triage/booking system as compared with \u0026quot;dropping in\u0026quot;.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFerguson, 2021, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVirtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRetrospective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To describe the shift from in person to virtual care within VA during the early phase of the COVID-19 pandemic and to identify at risk patient populations who require greater resources to overcome access barriers to virtual care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eVeterans, n\u0026thinsp;=\u0026thinsp;5400878 (VEH, = 216,035 (4%))\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eExpansion of virtual care services - either phone or video based - during COVID-19 pandemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA proportion of video visits post intervention versus pre-intervention. Association between patient demographics and telehealth use.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58% of VA care was provided virtually compared to only 14% prior. Veterans aged 45\u0026ndash;64 and 65\u0026thinsp;+\u0026thinsp;were less likely to use video care compared to those aged 18\u0026ndash;44. Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban and non-homeless veterans.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: No exploration of quality of care or clinical outcomes, did not account for patient preferences or knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMehtani, 2021, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProspective cohort study\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAIM\u003c/em\u003e: To describe the development and feasibility of the ATP, a telephone-based program to reduce treatment access barriers for people with SUD staying at San Francisco\u0026apos;s COVID-19 Isolation and Quarantine (I\u0026amp;Q) sites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eSan Francisco COVID-19 I\u0026amp;Q sites n\u0026thinsp;=\u0026thinsp;12 PEH with OUD, all received referral for ATP, 1 left prior to \u0026amp; 3 after initiating BUP\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e:\u003c/p\u003e\n \u003cp\u003eATP; external provider refers at I\u0026amp;Q admission, pt screened for risky SU, + screen referred to ATP provider/on-site I\u0026amp;Q nurse informed, I\u0026amp;Q nurse discuss with ATP provider, ATP conducts intake \u0026amp; schedules phone visits through clinic, phone visit(s) via hotel phone/mobile, prescribed meds requested for delivery, pt provided option to fu at clinic (in-person) post dc, ATP provided \u0026amp; clinic continue outreach if pt interested via phone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTelehealth encounters, Patient demographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I\u0026amp;Q site guests. Twelve patients were identified with untreated OUD and newly prescribed BUP. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I\u0026amp;Q-1 prior to and 3 after initiating BUP. Of the remaining 8 patients, 7 reported continuing to take BUP at the time of I\u0026amp;Q discharge and 1 discontinued. No patients started on BUP sustained significant adverse effects, required emergency care, or experienced overdose.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOther learnings\u003c/em\u003e: Limited generalisability, ATP provided with numerous resources which may not be available elsewhere, i.e. under-insured patients able to be enrolled.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Summary of study characteristics\u003c/p\u003e\n\u003cp\u003e[INSERT Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e HERE]\u003c/p\u003e\n\u003cp\u003eSeven studies focused on telehealth care initiatives or the way in which telehealth was accessed by PEH in response to the COVID-19 pandemic. (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) All other studies sought to understand how telehealth care services were either reaching or could better reach PEH prior to the global pandemic. (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eFive of the studies (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) focused on telehealth services in the primary care setting with an additional three (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) describing the general uptake of telehealth care across a range of health care settings by PEH. Three papers investigated the management of opioid use disorder by telehealth (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) and the final paper (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) explored the use of telemental health for a population accessing a drug and alcohol rehabilitation facility. Five of the nine studies from the USA focussed on the veteran population. (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eThe size of study populations varied between studies with the number of people experiencing any form of homelessness ranging from 12 through to 394,731. While all studies had a focus or sub-group focus on PEH, four of them described the level of homelessness that the study population were experiencing (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) enabling the identification of primary, secondary and tertiary homelessness (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) at a glance. Six of the remaining studies (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) did not define homelessness. Leung et al (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) and Garvin et al (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) defined homelessness as the assignment of the homelessness diagnostic code from the International Classification of Diseases (ICD-9 or ICD-10) with Garvin et al (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) also including those with one of the Veteran\u0026rsquo;s Affairs Department of Social Services codes in the 12 months prior to study in the participants Veterans Administrative profile. However, confirmation of housing status was not obtained nor a delineation between primary, secondary or tertiary homelessness of the study population in both of these studies. There was no consistent definition of homelessness used across the 12 studies.\u003c/p\u003e\n\u003cp\u003eOf those studies which did delineate between primary, secondary and tertiary homelessness, a total of 32 people experienced primary homelessness from the total of 202 participants (combined study population of the four studies).\u003c/p\u003e\n\u003cp\u003eZahir et al (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) and Howells et al (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) utilised semi-structured interviews to examine patient experience when reflecting on the shift to telehealth care services during the COVID-19 global pandemic; one in the context of primary care (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e), the other focussing on a cohort over the age of 50 across all types of healthcare provision. (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) Bekasi et al (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) explored patient and clinician satisfaction when using video-telehealth calls to manage chronic health conditions across a three-month period (fortnightly appointments) for people experiencing homelessness in mid- to long-term housing. Six quantitative studies undertook a retrospective analysis approach to examine variation in study populations related to the uptake of telehealth services across generalised healthcare (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e), primary healthcare (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), telemental health (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) and alcohol and other drug services. (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) Adams et al (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) explored the acceptability of telehealth in a primary care setting for patients and providers through a quality improvement lens by collating survey responses. Likewise, Prince et al (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e), through a quality improvement lens aimed to increase the use of video-telehealth among veterans by 10% by implementing streamlined pathways and education packages to staff to enable video-technology access over the 16-week period. Lastly, Mehtani et al (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) undertook a case series approach to examine the implementation and uptake of an addiction telehealth program used across Covid-19 Isolation and Quarantine sites in San Francisco.\u003c/p\u003e\n\u003cp\u003eSynthesis of results\u003c/p\u003e\n\u003cp\u003eThe framework for evaluating telehealth outcomes (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) was used to extract results from each of the study papers across the four domains of the framework.\u003c/p\u003e\n\u003cp\u003eExperience\u003c/p\u003e\n\u003cp\u003eExperience was reported in three studies, all of which used a qualitative methods. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eParticipants described telehealth as being valuable in the context of chronic disease management noting that this cohort were described as living in mid- to long-term accommodation and with support to access the telehealth service. (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) Higher satisfaction rates were reported by participants who could effectively use their devices and explain their symptoms. In their experience, these participants felt that the doctor understood their health concerns.\u003c/p\u003e\n\u003cp\u003eIn contrast, some patients described a less than optimum experience of telehealth with some reporting having less trust in a telephone consultation compared to a face-to-face appointment. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) This was echoed by Zahir et al (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) where participants, all over the age of 50, felt the lack of \u0026lsquo;a visual\u0026rsquo; being very confronting and problematic. Participants reported a decrease in empathy from treating providers leading to participants feeling they should withhold complex or sensitive issues during their telehealth appointment and viewing them more as a \u0026lsquo;transactional\u0026rsquo; appointment. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) A lack of feeling safe during telehealth appointments was reported (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) with a sense of concern elicited when no blood pressure was taken, yet a script was prescribed. (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eTelehealth providers had variable experiences with providing telehealth across the studies. Adams et al (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) reported providers were likely to agree, or strongly agree, that telehealth had a positive impact on a participant\u0026rsquo;s health compared to an in-person consult. In contrast, Howells et al (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) found providers felt that without good quality and adequate Wi-Fi the telehealth experience was hindered. Providers also felt that telehealth, at times, compromised patient safety with the opportunity to discuss other issues impacting their health seldom available. By standardising video visit workflows and providing sustained, ongoing staff education, Prince et al (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e) reported that this contributed to an increase in the uptake of video-telehealth and staff felt more capable of providing it.\u003c/p\u003e\n\u003cp\u003eAccess to care\u003c/p\u003e\n\u003cp\u003eAccess to care was reported in all 12 studies.\u003c/p\u003e\n\u003cp\u003eAccess to care for participants was generally enhanced across all studies that involved an intervention that provided additional support through the form of a clinician or service, provision of a technology device (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) and/or provision of temporary-type accommodation. (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eClinician-supported interventions (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) all reported an improvement in access to primary care, psychiatry and alcohol and other drug services for PEH. Participants residing at a mid- to long-term accommodation rated their likelihood of using telehealth again as very high (mean score of 4.34 on a 5-point Likert scale) four to six months after initially using the service for chronic disease management. (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) Likewise, a participant cohort based at a 12-month rehabilitation clinic who were provided with access to telemental health were less likely to discharge against medical advice and more likely to complete their rehabilitation program compared to those who did not have access to telemental health. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) A mobile community-based team that provided telehealth to access buprenorphine treatment was embedded into an existing case management service for veterans. This service successfully engaged a \u0026lsquo;harder-to-reach\u0026apos; sub-group of the veteran population on buprenorphine treatment and, at the same time, noticed a reduction in emergency department presentations. (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eTofighi et al (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) reported loss to follow-up rates (19.2%) in a telemedicine-based opioid treatment service provided to people experiencing homelessness as comparable to prior studies of in-person clinics. A technology device was prescribed at commencement of treatment to enable greater ongoing access to the program. Technology devices were likewise prescribed in two additional studies (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) with analysis describing PEH that were younger or middle age, located in rural settings or who had a diagnosis of post-traumatic stress disorder, were more likely to access telehealth when provided with a means to access healthcare via technology. In the primary-care setting, telehealth use increased significantly among veterans experiencing homelessness across the year and year following the COVID-19 pandemic and rates of use were similar to the general veteran population. (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eParticipants experiencing homelessness accessing temporary accommodation to isolate during the Covid-19 pandemic were provided with immediate access to an addiction telehealth program to manage their opioid use disorder via telehealth removing the need for an in-person initial consult which was normally required by state law. (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) Of the 12 participants identified as having opioid use disorder, 58% had never been prescribed medication for it. The provision of temporary shelter enabled access to required medication, and at the point of discharge, seven continued on treatment.\u003c/p\u003e\n\u003cp\u003eThe provision of telehealth services, at times, was observed to reduce access to care and increase barriers. For example, Howells et al (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) found that some study participants experiencing homelessness preferred the flexibility of being able to drop-in for a same-day face-to-face appointment. It was also recognised that not all PEH have access to community support or an outreach worker to facilitate access to telehealth. Wait times to get through to telehealth and complex triage services were also perceived as barriers to access.\u003c/p\u003e\n\u003cp\u003eZahir et al (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) found that the majority of the study population didn\u0026rsquo;t access telehealth despite it being available. Of those who did use telehealth, the majority utilised audio technology as a lack of knowledge and capacity to access videoconferencing was a barrier. Telehealth was perceived as inadequate for the management of physical health issues.\u003c/p\u003e\n\u003cp\u003eTo ensure access to care for participants, findings across the studies emphasised the need of addressing both practical and technological barriers. There are cohorts of PEH identified as experiencing more significant barriers to accessing telehealth, namely veterans between the ages of 45 and 64, people over the age of 65, and those living in rural locations. (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) In addition, a lack of access to technology, high rates of smart device turn-over, a lack of stable internet connection and persistent housing instability were variables commonly reported to contribute to reducing access to telehealth services for PEH. (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) Those veterans experiencing homelessness who experienced less barriers to accessing telehealth in the primary care setting, Leung et al (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) identified as younger, female, from a racial-ethnic minority and with a high rate of comorbidities.\u003c/p\u003e\n\u003cp\u003eCost\u003c/p\u003e\n\u003cp\u003eCost was the least assessed variable across the studies. It was indirectly reported in six studies. (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eHowells et al (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) reported participants were concerned about the cost of the phone call to access telehealth and the subsequent cost of waiting on the telephone line until a clinician was available. In contrast, Zahir et al (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) found that telehealth relieved the burden of cost to the participant through not having to pay for transport to get to an appointment. Some study participants who were prescribed buprenorphine during their initial visit to a virtual buprenorphine clinic were unable to access it from the pharmacy which was attributed to a variety of reasons, one being insurance coverage issues. (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) In contrast, when video-enabled tablets were distributed to a large cohort of veterans, removing the burden of the cost from the participant, less than half (45.9%) of PEH had used it for telehealth within the 6 months of receiving it (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) indicating that cost may not be the only prohibiting factor to accessing telehealth for this population.\u003c/p\u003e\n\u003cp\u003eIn a trial of telehealth delivered to a drop-in centre, participants reported that they would have sought care through the ED or not at all if the telehealth service wasn\u0026rsquo;t available. (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) Only 2.2% of participants were referred to the hospital as an outcome of the telehealth intervention. (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) Treatment retention, leading to a decrease use in emergency care services, was much higher for participants receiving telemental health in a drug and alcohol rehabilitation setting despite this cohort experiencing more significant health and social disparities than the control group. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eEffectiveness\u003c/p\u003e\n\u003cp\u003eEffectiveness was reported in all 12 studies with all areas of effectiveness being covered to some degree across all of the studies.\u003c/p\u003e\n\u003cp\u003eIt was highlighted that system level preparedness for the move to telehealth in the event of future pandemics is pertinent for PEH. (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) Concern was raised about the reduction in face-to-face consults leading to increasing inequity, however, telehealth was seen to promote community partnerships and encourage connection between health professionals. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) Studies suggested the provision of telehealth led to a reduction in the use of expensive emergency healthcare (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) and improved retention in healthcare programs for complex cohorts leading to decreased pressure on stretched healthcare systems. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) Mixed results were found by Iheanacho et al (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) who described a decrease in ED psychiatry visits yet an increase in psychiatric inpatient admissions.\u003c/p\u003e\n\u003cp\u003eProviders of telehealth to PEH had varying views on its clinical effectiveness. Doctors providing chronic disease management by telehealth felt they could rate the participant\u0026rsquo;s issues and make an adequate diagnosis. (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) Telehealth providers also were likely to agree and strongly agree that telehealth had a positive impact on a participant\u0026rsquo;s health compared to an in-person consult in the setting of a drop-in centre and the provision of primary care. (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eTelemental health was reported in multiple studies to be an effective mode of health care provision. (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) Telemental health was the telehealth service most utilised in the 6 months after being provided with a tablet (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) by veterans experiencing homelessness. Telemental health was more widely accepted by participants who had an existing relationship with a mental health provider prior to accessing telemental health (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) and showed high levels of retention in a complex cohort during their stay at a rehabilitation clinic (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) compared to the control group who did not receive telemental health.\u003c/p\u003e\n\u003cp\u003eIn contrast, some telehealth providers were concerned that it compromised patient safety and the opportunity to discuss other health or psychosocial issues lost. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) At times the telehealth consult felt more transactional than personal. Participants also were reluctant to explain their story again and felt less safe communicating over a phone without knowing the person at the other end. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eClinically, telehealth in the context of pharmacotherapy service provision showed some clinical effectiveness particularly for those in quarantine facilities where access to this type of therapy was essential given the risk of opioid withdrawal if not prescribed. (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eOperational effectiveness was variable across and within studies, often hindered by participant\u0026rsquo;s access to technology and stable Wi-Fi connection as well as operational knowledge. Where access to technology and stable Wi-Fi were not problematic, studies showed high levels of comfort with utilising telehealth as a means to accessing appropriate healthcare provision. (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) Telehealth services requiring formal enrolment exhibited lower uptake in the primary care setting when compared with telehealth that was readily accessible. (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) To enable operational effectiveness, relationships with community services was essential and sometimes lacking, prohibiting the participant from being able to access scripts or medication. (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eOperational effectiveness was hindered in one study by the provider\u0026rsquo;s lack of knowledge and awareness of how to use video-conferencing. The development of standardised workflows and sustained staff education was essential to enable the operationalisation of telehealth in the first instance. (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eAwareness of how to use smart technology impacted technical effectiveness in some studies. When reflecting on their use of telehealth during the global pandemic, PEH over the age of 50 described tending not to use it at all, or, if they did, they would rely on audio-only telehealth. (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) This was due to not having access to a smartphone or a computer capable of videoconferencing alongside a lack of stable internet connection. (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) A lack of stable internet access was also described by Tofighi et al (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) as a limitation to technical effectiveness with fixing this issue described as a low priority given the complex psychosocial issues exhibited by the study population.\u003c/p\u003e\n\u003cp\u003eSummary of results across the four domains\u003c/p\u003e\n\u003cp\u003eThe studies included in the review showed a large variation in the participant\u0026rsquo;s experience of telehealth services. The two qualitative studies (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) indicated that the provision of telehealth services to PEH requires significant adaptations to improve participant experience. Participant experience of telehealth was shown to be more acceptable in settings where participants were accessing it with clinician support, in a place that was familiar to the participant, when access to telehealth technology was provided and not prohibited by identification verification processes and where a participant\u0026apos;s accommodation was considered at least temporary.\u003c/p\u003e\n\u003cp\u003eParticipant and provider experience were reported in the literature, however family and caregiver and community experience were not. Access to care for participants was reported in the literature with family, and/or caregiver and access to information not being reported. Cost was not adequately addressed in the literature with limited evidence available to draw any significant conclusions about the patient, system or society level cost impacts of telehealth service provision. Finally, all areas of effectiveness were reported to some degree in the literature.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeople experiencing homelessness are greatly under-represented in literature reporting on experiences of telehealth services, with the voice of those experiencing primary homelessness seldom represented. Through asking participants about their experience of the shift toward telehealth in various healthcare settings, three studies were able to elicit the voice of PEH and speak to the conditions that enable a positive experience. (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Conditions for successful engagement that were identified included having access to a stable internet connection, having a support person involved before, during and after the consult, using telehealth for chronic disease management and, in most cases, when accessing telehealth for the management of mental health conditions. Conversely, patient experience was less than optimal for PEH accessing telehealth who were older, and in the situation where technology and systems available to participants prevented easy access.\u003c/p\u003e \u003cp\u003eOur findings are similar to the international literature which identifies that telehealth in the setting of chronic disease management and telemental health is an accepted form of healthcare provision. (\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) Chronic disease management via telehealth was acceptable particularly when it was considered easy to use. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) This finding was similar to the veteran populations experiencing homelessness who described a preference for using face-to-face consult when there was a perceived barrier to accessing telehealth, for example, when there was a need to register for the telehealth service with multiple steps involved. Included studies demonstrated that telemental health is generally accepted among population groups as a means of mental health support delivery. This is in agreement with a systematic review and meta-analysis of tele-mental health services which found that they were a highly accepted form of health service delivery. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) Consideration of the needs of both the end-user and service provider were emphasised in the findings. Likewise, a systematic review exploring the acceptability of telemental health support for patients post stroke showed high levels of acceptability though noted that technical difficulties were cited as a primary barrier to patient access. (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTruong et al (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) found that among people from diverse backgrounds, preconditions that enabled use of telehealth included addressing barriers specific to cost as well as digital health literacy. Likewise, a scoping review of the use of telehealth in the primary care setting (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) found that for telehealth services to be fully integrated, all aspects of digital inclusion need to be addressed particularly for under-served populations. These findings are similar to the literature, particularly literature focussing on veterans where people over 45 years or who live more rural experience greater issues with digital inclusion.\u003c/p\u003e \u003cp\u003eImplications for practice\u003c/p\u003e \u003cp\u003eDigital inclusion means that people have access to technology and stable Wi-Fi, can afford to pay for technology and Wi-Fi relative to their income and have the ability, or required digital health literacy, to navigate the technology. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) While telehealth appears to be of some value to PEH, and there is a willingness from PEH to engage with it, all areas of digital inclusion need to be addressed at a local health service level through to national policy. With video-telehealth being more accepted as a means of telehealth delivery, consideration of how this can be made reliably possible for PEH to access is essential.\u003c/p\u003e \u003cp\u003eHaving a clinician known to the PEH present to support access to telehealth is an example of digital inclusion. The presence of a clinician enables access to Wi-Fi and technology while simultaneously providing support to navigate complex multi-step telehealth services. Furthermore, the support of a known clinician contributes to enhancing a relationship of trust between the PEH and the telehealth service. Support clinicians play an important role in bridging the gap that exists with health literacy and facilitating effective communication between the patient and the telehealth clinician.\u003c/p\u003e \u003cp\u003eThere are many ways in which PEH can access telehealth services if all areas of digital inclusion are addressed. This becomes more challenging for PEH who are experiencing primary homelessness, but not an impossible task. The frequent movement of this cohort means that they are less visible across the literature, however a nuanced approach to digital inclusion for this cohort needs to be considered.\u003c/p\u003e \u003cp\u003eHealth services committed to providing telehealth for all members of our society need to be committed to addressing funding models, strategic policies, operational workflows and staff education to ensure they promote digital inclusion. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eA strength of the study is that no limitations were set on the publication year. A comprehensive evaluation framework specific to telehealth was used to categorise and sort the findings.\u003c/p\u003e \u003cp\u003eThere were some limitations in this review including the high heterogeneity in study designs and countries in which the studies were conducted. Only studies published in English were included and study populations didn\u0026rsquo;t represent the vast living situations of PEH, with those experiencing primary homelessness being seldom represented. The interventions and outcomes across the studies were also limited.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis rapid review found limited evidence exploring the experiences of PEH when accessing telehealth with the literature mostly limited to the USA and veteran populations. Existing literature provides some insights into the individual and system conditions that enable PEH access to telehealth services which support positive experiences. Telehealth can be accessed successfully by PEH and improvements in their experience are gained when a support worker is present. It is clear that telehealth services are an accepted form of healthcare delivery for PEH and future research should further explore an individual\u0026rsquo;s perspective about the enablers and barriers to digital telehealth.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eATP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Addiction telehealth program\u003c/p\u003e\n\u003cp\u003eBUP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Buprenorphine\u003c/p\u003e\n\u003cp\u003eBUP-NX\u0026nbsp;Buprenorphine-naloxone\u003c/p\u003e\n\u003cp\u003eDC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Discharge\u003c/p\u003e\n\u003cp\u003eED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Emergency department\u003c/p\u003e\n\u003cp\u003eHx\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;History\u003c/p\u003e\n\u003cp\u003eI\u0026amp;Q\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Isolation and quarantine\u003c/p\u003e\n\u003cp\u003eLOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Length of stay\u003c/p\u003e\n\u003cp\u003eNYC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;New York City\u003c/p\u003e\n\u003cp\u003eOUD\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Opioid use disorder\u003c/p\u003e\n\u003cp\u003ePEH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;People experiencing homelessness\u003c/p\u003e\n\u003cp\u003ePt\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Patient\u003c/p\u003e\n\u003cp\u003ePWID\u0026nbsp; \u0026nbsp; \u0026nbsp;People who inject drugs\u003c/p\u003e\n\u003cp\u003eSUD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Substance use disorder\u003c/p\u003e\n\u003cp\u003eTBOT\u0026nbsp; \u0026nbsp; \u0026nbsp;Telemedicine-based opioid treatment\u003c/p\u003e\n\u003cp\u003eVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Veterans Affairs\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVEH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Veterans experiencing homelessness\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eA grant from the Victorian Medical Rapid Acceleration Fund was received to the value of $45,290. The grant is to fund the research component of a broader project which is to improve the accessibility of telehealth to people experiencing homelessness.\u003c/p\u003e\n\u003ch2\u003eAuthors’ contributions\u003c/h2\u003e\n\u003cp\u003eAll authors conceived the study, search strategy and methodology. All authors analysed the data. CD was the lead author with substantial contribution and editing from all listed authors. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHugh S, Fox MS. Homelessness and open city data: Addressing a global challenge: Springer; 2020 [cited 2024 May 01]. Available from: https://link.springer.com/chapter/10.1007/978-981-13-6605-5_2.\u003c/li\u003e\n\u003cli\u003eTreglia D, Culhane D. Defining and counting homelessness. 2023 [cited 2024 May 01]. 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BMC Public Health. 2024;24(1):1143.\u003c/li\u003e\n\u003cli\u003eOmboni S, Ballatore T, Rizzi F, Tomassini F, Panzeri E, Campolo L. Telehealth at scale can improve chronic disease management in the community during a pandemic: An experience at the time of COVID-19. PLoS One [Internet]. 2021 [cited 2024 September 25]; 16(9):[e0258015 p.]. Available from: https://pubmed.ncbi.nlm.nih.gov/34587198/.\u003c/li\u003e\n\u003cli\u003eLombardo C, Islam MS. Stroke survivors\u0026rsquo; acceptance and satisfaction of telerehabilitation delivery of physiotherapy services: a systematic review. Physical Therapy Reviews. 2023;28(4-6):261-77.\u003c/li\u003e\n\u003cli\u003eBeheshti L, Kalankesh LR, Doshmangir L, Farahbakhsh M. Telehealth in primary health care: a scoping review of the literature. Perspectives in Health Information Management. 2022;19(1).\u003c/li\u003e\n\u003cli\u003eBarraket J. The digital divide in telepractice service delivery: Australian Institute of Family Studies; 2021 [cited 2024 September 25]. Available from: https://aifs.gov.au/resources/short-articles/digital-divide-telepractice-service-delivery.\u003c/li\u003e\n\u003cli\u003eBanbury A, Smith AC, Mehrotra A, Page M, Caffery LJ. A comparison study between metropolitan and rural hospital-based telehealth activity to inform adoption and expansion. Journal of Telemedicine and Telecare. 2023;29(7):540-51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telehealth, homelessness, patient experience, digital inclusion","lastPublishedDoi":"10.21203/rs.3.rs-5665490/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5665490/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\n\u003cp\u003eTelehealth services are rapidly expanding across the globe yet under-served populations, particularly people experiencing homelessness (PEH), are at risk of being further marginalised in society if focussed interventions to address telehealth access are not implemented.\u003c/p\u003e\n\u003cp\u003eThe aim of this rapid review was to report on the patient experience of PEH when accessing telehealth services. Secondary objectives of the review were to summarise both the patient and health service outcomes that were reported.\u003c/p\u003e\n\u003ch2\u003eMethods\u003c/h2\u003e\n\u003cp\u003eThis rapid review identified peer reviewed literature that explored patient experiences of telehealth for people experiencing homelessness. Databases searched were MEDLINE, Embase, APA PsychINFO and CINAHL. Study characteristics were extracted and during the second-phase, two authors independently extracted data from each paper using a framework for evaluating telehealth outcomes (access to care, cost, experience, effectiveness) with a third author reviewing the extracted data and finalising the results table.\u003c/p\u003e\n\u003ch2\u003eResults\u003c/h2\u003e\n\u003cp\u003eTwelve eligible studies were identified with publication dates between 2020 and 2024. Two were qualitative, nine were quantitative and one was a mixed-methods study design. A large variation was found across the literature in relation to participant experience of telehealth for PEH. Telehealth was shown to be an acceptable form of healthcare for PEH. It was more acceptable in settings where participants were accessing it with clinician support, in an environment that was familiar to the participant, where the participant was living in at least temporary accommodation. Furthermore, telehealth was accessible where the processes to access telehealth were not prohibitive and where the internet connection was reliable. However, significant adaptions to improve a participant’s experience of telehealth was identified as a need.\u003c/p\u003e\n\u003ch2\u003eConclusion\u003c/h2\u003e\n\u003cp\u003eThere is limited evidence available that explores the experiences of PEH when accessing telehealth. We have identified a number of simple factors that can be implemented to make telehealth services more accessible for PEH. Acknowledging that telehealth services are an accepted form of healthcare delivery across the globe, future research involving people experiencing primary homelessness and undertaking research utilising a digital inclusion framework would be of value.\u003c/p\u003e\n\u003ch2\u003eRegistration\u003c/h2\u003e\n\u003cp\u003eThe review was registered on the International prospective register of systematic reviews, (PROSPERO in October 2023 CRD42023466817).\u003c/p\u003e","manuscriptTitle":"Patient perspectives on telehealth access among people experiencing homelessness: A rapid review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-26 06:08:11","doi":"10.21203/rs.3.rs-5665490/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-14T17:08:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T13:36:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T19:41:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57414933404309275744786508410409089682","date":"2025-08-17T23:14:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70170362604239680666841637079372169860","date":"2025-07-28T14:35:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-18T08:02:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-23T08:01:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-18T12:59:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2024-12-18T02:51:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c14796a-0e18-4ab9-b1f2-bff5b38a3a80","owner":[],"postedDate":"December 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:15+00:00","versionOfRecord":{"articleIdentity":"rs-5665490","link":"https://doi.org/10.1186/s12939-025-02749-z","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2026-01-22 15:58:52","publishedOnDateReadable":"January 22nd, 2026"},"versionCreatedAt":"2024-12-26 06:08:11","video":"","vorDoi":"10.1186/s12939-025-02749-z","vorDoiUrl":"https://doi.org/10.1186/s12939-025-02749-z","workflowStages":[]},"version":"v1","identity":"rs-5665490","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5665490","identity":"rs-5665490","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}