August 14, 2019, 03:36 pm Sheri Porter – Telehealth is becoming increasingly available and popular across the country as it saves time for overstretched clinicians and provides easy access to care for patients. However, one area that's ripe for exploration is use of this technology with homebound elderly patients.
With that in mind, physicians and researchers affiliated with a home-based primary care program in New York state conducted a telehealth video pilot from June 2018 to December 2018 as part of their ongoing efforts to identify cost-effective ways to provide high-quality long-term care for older adults.
Results of the study were published online ahead of print in the Journal of the American Geriatrics Society in a research letter titled "Not Yet Ready for Prime Time: Video Visits in a Home-based Primary Care Program."
Study coauthor and internist Karen Abrashkin, M.D., medical director for the Northwell Health House Calls program, and her colleagues there, partnered with the West Health Institute in La Jolla, Ca., on this research.
We are constantly looking at ways to expand our services -- expand our footprint -- because there is very big unmet need in our community and across the United States for home-based primary care services for frail elderly folks who want to remain in their home," she told AAFP News.
"We see about 2,000 unique patients per year in downstate New York," said Abrashkin. "And we provide everything in the home, from home-based primary care to urgent and emergent care. We use an interdisciplinary care team, including primary care physicians and clinicians paired with care managers who are nurses and medical social workers."
When it comes to patient care, Abrashkin said family physicians, internists and geriatricians all share similar goals.
"Everyone in primary care wants to do what's best for the patient and honor their wishes at the end of life. Many patients want to age in place, but we don't have enough services around the country to reach all the patients who want to do so," she said.
At an agreed-on time, researchers emailed or texted participation invitations to patients who were assigned to medical social worker care managers in Northwell's home-based primary care program. Researchers then helped participants install the telehealth app.
Of the nearly 500 potentially eligible patients, 56 were enrolled. All had access to the internet and a compatible device such as a smartphone, tablet or computer with a webcam. Patients chosen to participate were cognitively and technologically capable and had a willing family caregiver.
Researchers tracked video success rates and conducted post-visit satisfaction surveys with patients, caregivers and the medical social worker care managers. At the study's conclusion, all five medical social workers provided additional feedback during an informal discussion with researchers.
Abrashkin said researchers expected some level of technological difficulty but were surprised by the number of technical and equipment incompatibility issues.
The overall video success rate was 49% -- just 56 visits out of the 114 attempted. A total of 39 patients completed at least one successful video visit with their medical social worker; the average length of visit was 18 minutes.
"What people don't realize -- and what we came to find out -- is how many barriers there are to setting this up in a traditional telehealth model where the patient has the technology at home," said Abrashkin. "Our average patient is 85 years old, and we encountered numerous problems, including people not remembering their Apple IDs or passwords."
She added that security protocols required users to obtain a code to access the app before they could enter the video conference.
"So the complexity of obtaining a code -- by email or by text -- and installing an app, opening the app and putting in the code to get into this secure video conferencing platform is a lot to ask of people," said Abrashkin. "Even for those who have some technology experience, it's a very complex process," she added.
Among other findings, researchers pointed out that patients and caregivers said the video visit met their needs 74% of the time. However, medical social workers said video visits were complicated by technical issues almost 50% of the time, and they reported high satisfaction levels just 23% of the time.
On the other hand, when video visits were successful, medical social workers said their ability to assess patients was not impaired by the inability to provide hands-on care.
In addition, video visits provided opportunities to contact primary care physicians, generate referrals for additional services, and address labs and new prescriptions.
Importantly, most patients/caregivers (67%) and medical social workers (83%) saw video visits as a better option than long wait times for an in-person visit.
Social workers "expressed an interest in continuing to test video visits, assuming technical issues could be addressed," wrote the authors. "All agreed that video visits allowed for higher-quality contact than phone calls," they added.
Abrashkin said that even though the number of successful visits was extremely low, "it gave us a lot of hope, because when it did work, it was successful. People enjoyed the video visits and they found value in having that face-to-face connection."
She explained that a phone backup was always available, so even when a video attempt failed, "patients never went without care."
Looking ahead, Abrashkin and her colleagues already are working on another pilot project that utilizes a device with a camera that connects directly to a patient's home television. "The patient uses a TV remote to connect to the visit. This new product seems to be more user friendly for older individuals," she said.
Study authors assessed the future of video visits for homebound geriatric patients this way: "Telehealth has the potential to allow for expansion of patient panels, reduced travel and lower costs for home-based care, along with improved access and perceived social support for participants.
"Although the technology is not yet optimal, prime time is coming."