Telehealth was beneficial during COVID-19 for older Americans: A qualitative study with physicians

Racial and ethnic differences in telemedicine use among community-dwelling older adults with dementia

BACKGROUND

Routine ambulatory care is essential for older adults with Alzheimer's disease and related dementias (ADRD) to manage their health conditions. The federal government expanded telemedicine coverage to mitigate the impact of the COVID-19 pandemic on ambulatory services, which may provide an opportunity to improve access to care. This study aims to examine differences in telemedicine use for ambulatory services by race, ethnicity, and community-level socioeconomic status among community-dwelling older adults with ADRD.

METHODS

This retrospective cohort study used Medicare claims data between April 01, 2020 and December 31, 2021. We included community-dwelling Medicare fee-for-service beneficiaries aged 65 years and older with ADRD. The outcome variable is individual's use (yes/no) of telemedicine evaluation and management (tele-EM) visits in each quarter. The key independent variables are race, ethnicity, and community-level socioeconomic status.

RESULTS

The analytical sample size of the study was 2,068,937, including 9.9% Black, 82.7% White, and 7.4% Hispanic individuals. In general, we observed a decreasing trend of tele-EM use, and the average rate of quarterly tele-EM use was 23.0%. Tele-EM utilization varied by individual race, ethnicity, and community-level socioeconomic status. On average, White and Black individuals in deprived communities were 3.5 and 2.4 percentage-points less likely to use tele-EM compared with their counterparts in less-deprived communities (p < 0.001). However, Hispanic individuals in deprived communities were 2.4 percentage-points more likely to utilize tele-EM compared with those in less-deprived communities (p < 0.001). Additionally, we observed various racial and ethnic differences in telemedicine use in deprived communities versus less-deprived communities.

CONCLUSIONS

We observed various racial and ethnic differences in telemedicine use, both within and between communities by socioeconomic status. Telemedicine is a viable healthcare delivery option that may influence healthcare access for racial and ethnic minorities and for individuals in socioeconomically deprived communities. Further policies or interventions may be needed to ensure all individuals have equal access to newly available care delivery models.

Review article: Telehealth in Emergency Medicine in Australasia: Advantages and barriers

The COVID-19 pandemic catapulted Telehealth to the forefront of Emergency Medicine (EM) as an alternative way of assessing and managing patients. This challenged the traditional idea that EM can only be practised within brick-and-mortar EDs. Many Emergency Physicians may find the idea of practising Telehealth in Emergency Medicine (TEM) confronting, particularly in the absence of training and clear practice guidelines. The purpose of the present paper is to describe the current use of TEM in Australasia, and outline the advantages and barriers in adopting this practice domain.

An Exploration of Dutch Dermatologists' Experience and Satisfaction With Teledermatology: Sociotechnical and Complex Adaptive System Perspective

BACKGROUND

Despite the global upscale of teledermatology during the COVID-19 pandemic, persistent barriers, such as the poor anamnesis and photo quality, hinder its effective use in practice. Understanding Dutch dermatologists' experiences and satisfaction with using the teledermatology system in the Dutch health care system is needed. A holistic evaluation may provide valuable insight to understand how barriers interrelate which is deemed necessary for the innovation of teledermatology in practice.

OBJECTIVE

Guided by a complex adaptive system perspective, this study aims to understand Dutch dermatologists' experience and satisfaction with their training, support communication, interaction, and usage of a teledermatology platform of a Dutch digital hospital during the COVID-19 pandemic, uncovering insights to improve teledermatology services for the future.

METHODS

A web-based questionnaire was sent in December 2021 to Dutch dermatologists who (1) had an active teledermatology platform account, and (2) responded to a teledermatology consultation between October 1, 2019, and September 30, 2021. The questionnaire consisted of the validated Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) questionnaire, and new questions regarding; demographics of teledermatologists, the use of teledermatology during the COVID-19 pandemic, the performance of teledermatology by general practitioners (GP), and the role of dermatologists in the teledermatology process. The open-ended questions were analyzed by a grounded theory approach guided by a sociotechnical model and complemented by a complex adaptive system perspective. A panel discussion with 3 dermatologists was performed to provide additional insight into the responses to the questionnaire.

RESULTS

We obtained responses from 25 out of the 249 (10%) invited dermatologists. Overall, dermatologists had a positive experience with teledermatology. Interestingly, teledermatology use frequency remained unaffected by the COVID-19 pandemic. However, the insufficient quality and incompleteness of the clinical content (photos and anamneses information) of the teledermatology consultation impacted the efficiency of the teledermatology workflow. Dermatologists expressed the need for improvement to avoid time-consuming processes or physical referrals. The panel discussion enriched and confirmed the responses, suggesting solutions like mandatory fields for the GPs for a complete anamnesis.

CONCLUSIONS

Dutch Dermatologists view teledermatology as a valuable tool to provide access to dermatology care. However, improvements regarding the quality and completeness of the provided clinical content are necessary for the effectiveness and efficiency of the complex teledermatology system in Dutch health care. This could increase both the dermatologists' satisfaction and the quality of teledermatology services. Managing trade-offs, such as time investments versus image quality, is crucial for teledermatology implementation and should be assessed from a complexity perspective to understand trade-offs and prevent unintended consequences.

A Pilot of a Telehealth-Hospice Transition Intervention for Children and Young Adults with Cancer

BACKGROUND AND AIMS

Telehealth can improve care for patients with progressive cancer enrolling in hospice. Coordinated telehealth visits (patient/family-hospital-hospice) may improve communication, satisfaction with and interdisciplinary hospice collaboration. This pilot examines the impact of three coordinated telehealth visits on these outcomes.

METHODS

This is a prospective pilot study of 0-29-year-old patients with cancer initiating hospice care between 2021-2023. Adult patients, caregivers, oncology and palliative care clinicians, hospice nurses and administrators were surveyed about feasibility and acceptability with telehealth (Technology Acceptance Model 2) after first and third telehealth visits. Hospice satisfaction (Consumer Assessment of Healthcare Providers and Systems) was completed by caregivers after visit 3 and during bereavement. Healthcare professionals completed the Assessment of Interprofessional Team Collaboration Scale II (AITCS-II). Survey responses were summarized and differences in scores were analyzed.

RESULTS

Of 40 eligible patients, 24 enrolled, 19 completed visit 1, and 13 completed visit 3. Fourteen caregivers and two adult patients completed visit 1 surveys; nine caregivers and two adult patients completed visit 3 surveys. Participants highly rated telehealth acceptability after visit 1 (Median: 4.5, IQR: 4.0-4.7) and 3 (Median: 4.4, IQR: 4.0-4.7). Hospice services were rated as highly satisfactory at visit 3 (Median: 4.0, IQR: 3.7-4.0) and during bereavement (Median: 3.7, IQR: 3.5-4.0). Healthcare professionals (n = 85 surveys) reported excellent interprofessional collaboration (Hospital clinicians median: 99/115 and hospice teams 111/115).

CONCLUSIONS

Participants found coordinated telehealth visits to be feasible, acceptable, and satisfactory. Telehealth may be utilized as an acceptable alternative to clinic visits and fosters hospital-hospice collaboration.

Understanding the experiences of PHC nurses in caring for older patients in the post-fifth wave of the COVID-19 pandemic: an exploratory qualitative study

Objective

To ensure the best possible care, the perspective of PHC nurse work experience during the COVID-19 pandemic should be considered when developing nursing care protocols for older patients who receive PHC services.

Method

This exploratory qualitative study was conducted with 18 nurses working continuously in PHC between the first and fifth waves of the pandemic. Semi-structured thematic interviews were undertaken. Qualitative thematic content analysis was conducted to identify and group the themes that emerged from the discourse. Interviews were transcribed and analyzed using thematic analysis.

Results

The first topic describes the nurses' experiences of physical and mental suffering in caring for older patients in response to the pandemic. The second topic covers the experience of reorganizing PHC work. The third topic focuses on the difficulties of caring for older patients. The final topic includes issues of support needs for nurses in PHC work.

Conclusion

The experience and understanding of PHC nurses in caring for older people during the COVID pandemic should lead to significant changes in the system of nursing care for geriatric patients and in the cooperative role within geriatric care specialist teams. Drawing on the experience of COVID-19, it is necessary to work on the weak points of PHC exposed by the pandemic in order to improve the quality of care and life for geriatric patients.

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study

BACKGROUND

With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings.

OBJECTIVE

The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic.

METHODS

We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time.

RESULTS

The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic-visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology-key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system-changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver's role (eg, participation of caregivers during video visits); (4) health care organization-leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time-capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates).

CONCLUSIONS

This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Parkinson's disease physical therapy services during COVID-19: A phenomenological study

OBJECTIVES

Parkinson's disease (PD) is the most rapidly increasing movement disorder globally. Physical therapies improve the motor and non-motor symptoms of PD. During the COVID-19 pandemic, telehealth was the primary method of physical therapy service adaptation in response to restrictions preventing in-person therapy attendance. This study explores the perspectives of people with PD and their therapists who experienced physical therapy service delivery before and during the COVID-19 pandemic in Melbourne, Australia.

METHODS

A phenomenological study that purposively recruited patients and therapists from a movement disorders service at an outer metropolitan rehabilitation hospital. Participants completed in-depth interviews, and data were analysed using reflexive thematic analysis.

RESULTS

Ten people with PD and five therapists completed interviews. Six themes were identified: patients value access to therapy, a key mechanism is trust, an opportunity to empower patients, ticking boxes for telehealth, contrasting experiences of telehealth and something is better than nothing.

CONCLUSIONS

This study explored the experiences of people with PD and their therapists by contrasting their prepandemic and in-pandemic experiences. People with PD valued telehealth access during the pandemic, but extra support was initially required to use telehealth successfully. Empowering aspects of telehealth included patients learning new skills and self-management strategies from telehealth interactions with therapists. Therapists at this health service were motivated to continue with telehealth beyond the pandemic. Despite finding it challenging initially, they were surprised by how well people with PD managed telehealth using locally developed procedures based on clinical judgement and staff training that addressed patient safety while supporting people with PD to utilise telehealth.

The Development and Use of a New Visual Tool (REVISIT) to Support Participant Recall: Web-Based Interview Study Among Older Adults

BACKGROUND

Qualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient's recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults.

OBJECTIVE

We developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults.

METHODS

The REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors' experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work.

RESULTS

REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. REVISIT appeared to support older patients' and caregivers' recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews.

CONCLUSIONS

REVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

Telehealth uptake among middle-aged and older Americans during COVID-19: chronic conditions, social media communication, and race/ethnicity

OBJECTIVES

This study investigated whether and to what extent constructs of the protection motivation theory of health (PMT)-threat appraisal (perceived vulnerability/severity) and coping appraisal (response efficacy and self-efficacy)-are related to telehealth engagement during the COVID-19 pandemic, and how these associations differ by race/ethnicity among middle-aged and older Americans.

METHODS

Data were from the 2020 Health and Retirement Study. Multivariable ordinary least-squares regression analyses were computed adjusting for health and sociodemographic factors.

RESULTS

Some PMT constructs are useful in understanding telehealth uptake. Perceived vulnerability/severity, particularly comorbidity (b = 0.13, 95% confidence interval (CI) [0.11, 0.15], p < 0.001), and response efficacy, particularly participation in communication via social media (b = 0.24, 95% CI [0.21, 0.27], p < 0.001), were significantly and positively associated with higher telehealth uptake during the COVID-19 pandemic among middle-aged and older Americans. Non-Hispanic Black adults were more likely to engage in telehealth during the pandemic than their non-Hispanic White counterparts (b = 0.20, 95% CI [0.12, 0.28], p < 0.001). Multiple moderation analyses revealed the significant association between comorbidity and telehealth uptake was similar across racial/ethnic groups, whereas the significant association between social media communication and telehealth uptake varied by race/ethnicity. Specifically, the association was significantly less pronounced for Hispanic adults (b = -0.11, 95% CI [-0.19, -0.04], p < 0.01) and non-Hispanic Asian/other races adults (b = -0.13, 95% CI [-0.26, -0.01], p < 0.05) than it was for their non-Hispanic White counterparts.

CONCLUSION

Results suggest the potential of using social media and telehealth to narrow health disparities, particularly serving as a bridge for members of underserved communities to telehealth uptake.

"We Have Outgrown Our Space; Our Facility Is Old and Falling Apart": Physical Design Implications to Address the Needs and Priorities of a Critical Access Hospital (CAH)

OBJECTIVE

This exploratory study examines a rural critical access hospital (CAH) staff's perception of current obstacles and needs concerning the physical environment.

BACKGROUND

CAH intends to improve access to healthcare, coordinate with experts and providers, and serve as the rural population's healthcare hub. It is imperative to understand environmental qualities that impact the quality of care to develop effective policies and design guidelines for rural healthcare. Nevertheless, a limited number of studies have focused on user or organizational outcomes related to the physical environment of rural healthcare settings.

METHODS

This cross-sectional exploratory qualitative case study was conducted as part of the facility planning process for a CAH in rural North Carolina. Hospital staff participated in a survey exploring their satisfaction with the overall physical environment privacy, space allocation, and department adjacency. An open-ended question asked staff to elaborate on needed improvements and changes in their department.

RESULTS

Findings show low satisfaction levels for space allocations for emergency department, lab, surgery, and wound care. Safety and quality were the two emerging outcomes of the physical environment's shortcomings. Two clusters emerged from the content analysis, representing facility needs (rightly sized spaces, functional needs, COVID-19 needs, and improved access) and ambient conditions (clutter, visibility, flooring quality, noise, privacy, cleanliness, aesthetics, and temperature).

CONCLUSION

The findings from this study suggest that the interior and exterior facility and ambient conditions of the CAH play a key role in quality and safety outcomes.

Older Adults With Functional Limitations and Their Use of Telehealth During COVID-19

We investigated the association between functional limitations and telehealth use among older Medicare beneficiaries in 2020. We use logistic regression models to estimate associations between functional limitations and the use of technological tools (i.e., computers, Internet, telehealth). We consider Internet use and informal technological support as moderators for telehealth use. Respondents (N = 3151; Mage = 78.31) with more functional limitations were more likely to use video-based telehealth. Net of functional limitations, those with a consistent Internet use were more likely to use emails/texts/portal messages to communicate with a healthcare provider. Further, more functional limitations were associated with a higher probability of using emails/texts/portal messages, but only among respondents who received informal technological support. Healthcare access may have been more difficult for older adults with functional limitations during the COVID-19 pandemic, especially for those with little prior experience with the Internet, or those without friends/family to provide technological support.

Policy and practices in primary care that supported the provision and receipt of care for older persons during the COVID-19 pandemic: a qualitative case study in three Canadian provinces

BACKGROUND

The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape.

METHODS

A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined.

RESULTS

Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different.

CONCLUSIONS

COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners.

General Practitioners' Perspectives About Remote Dermatology Care During the COVID-19 Pandemic in the Netherlands: Questionnaire-Based Study

BACKGROUND

The COVID-19 pandemic affected the delivery of primary care and stimulated the use of digital health solutions such as remote digital dermatology care. In the Netherlands, remote store-and-forward dermatology care was already integrated into Dutch general practice before the COVID-19 pandemic. However, it is unclear how general practitioners (GPs) experienced this existing digital dermatology care during the pandemic period.

OBJECTIVE

We investigated GPs' perspectives about facilitators and barriers related to store-and-forward digital dermatology care during the COVID-19 pandemic in the Netherlands, using a sociotechnical approach.

METHODS

In December 2021, a web-based questionnaire was distributed via email to approximately 3257 GPs who could perform a digital dermatology consultation and who had started a digital consultation (not necessarily dermatology) in the previous 2 years. The questionnaire consisted of general background questions, questions from a previously validated telemedicine service user satisfaction questionnaire, and newly added questions related to the pandemic and use of the digital dermatology service in general practice. The open-ended and free-text responses were analyzed for facilitators and barriers using content analysis, guided by an 8-dimensional sociotechnical model.

RESULTS

In total, 71 GPs completed the entire questionnaire, and 66 (93%) questionnaires were included in the data analysis. During the questionnaire distribution period, another national lockdown, social distancing, and stay-at-home mandates were announced; thus, GPs may have had increased workload and limited time to complete the questionnaire. Of the 66 responding GPs, 36 (55%) were female, 25 (38%) were aged 35-44 years, 33 (50%) were weekly platform users, 34 (52%) were working with the telemedicine organization for >5 years, 42 (64%) reported that they used the store-and-forward platform as often during as before the pandemic, 61 (92%) would use the platform again, 53 (80%) would recommend the platform to a colleague, and 10 (15%) used digital dermatology home consultation. Although GPs were generally satisfied with the digital dermatology service, platform, and telemedicine organization, they also experienced crucial barriers to the use of the service during the pandemic. These barriers were GPs' and patients' limited digital photography skills, costs and the lack of appropriate equipment, human-computer interface and interoperability issues on the telemedicine platform, and different use procedures of the digital dermatology service.

CONCLUSIONS

Although remote dermatology care was already integrated into Dutch GP practice before the pandemic, which may have facilitated the positive responses of GPs about the use of the service, barriers impeded the full potential of its use during the pandemic. Training is needed to improve the use of equipment and quality of (dermoscopy) images taken by GPs and to inform GPs in which circumstances they can or cannot use digital dermatology. Furthermore, the dermatology platform should be improved to also guide patients in taking photographs with sufficient quality.

Identifying emergency department patients with life-limiting illnesses may be getting a little easier

This editorial comments on the article by Haimovich et al. in this issue.

Teamwork Management and Benefit of Telemedicine in COVID-19 Outbreak Control on an Offshore Vessel in the Gulf of Thailand, Songkhla Province, Thailand: A Case Report

In May 2021, there was a COVID-19 outbreak on board a construction support ship traveling from India to Thailand. Controlling the outbreak on this offshore vessel from 11 May to 2 June 2021 was applied. This case report describes the teamwork management of COVID-19 control on the vessel in the Gulf of Thailand. We summarized the COVID-19 outbreak control process on board, including active COVID-19-infected cases (CoIC) and close contacts (CoCC) identification, isolation, quarantine, treatment, and clinical monitoring using telemedicine to report their health measurements twice daily, including emergency conditions if they occurred. Active COVID-19 cases were identified by two rounds of reverse transcription polymerase chain reaction (RT-PCR) tests in all crew members, in which 7 of 29 (24.1%) showed positive results. Both the CoIC and CoCC were strictly and absolutely isolated and quarantined on the vessel. No serious medical conditions were reported during the monitoring. The third-round RT-PCR tests were conducted, and all tested negative one week later. Teamwork management in proactive COVID-19 case identification, isolation, comprehensive treatment, and close monitoring of health conditions using telemedicine devices is beneficial for controlling the COVID-19 outbreak on board.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits

BACKGROUND

Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care.

METHODS

A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends.

RESULTS

Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%).

CONCLUSIONS

Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

Impact of a collaboration revolving around virtual capacity evaluations

OBJECTIVE

To assess the impact of virtual capacity assessments on access to medical care, community supports, and transitions to higher levels of care.

STUDY SETTING

Virtual capacity evaluations of homebound suspected elder abuse/neglect/financial exploitation victims identified via exclusion criteria and initiated by Cuyahoga County adult protective services (APS) and conducted with Cleveland Clinic Geriatric Medicine.

STUDY DESIGN

A retrospective chart review was conducted in conjunction with APS using their database to determine the outcomes of individuals who underwent virtual capacity evaluation from May 2020 through September 2021. Variables collected included completion of a statement of expert evaluation, guardianship assignment, offering community services, transfer to a higher level of care, and establishment of primary care.

DATA COLLECTION/EXTRACTION

Data were extracted from medical records and the APS database. Outcomes were measured as percentages.

PRINCIPAL FINDINGS

Fifty-four individuals underwent evaluation. Statements of expert evaluation were completed in 38 cases (70%). Guardianship was assigned in 28 cases (52%). Community services were offered to 51 (89%). Thirty-one (57%) remained at home. At baseline, only 23 (43%) were receiving primary care. Post evaluation, 44 (81%) were connected or reconnected to their medical provider.

CONCLUSION

Of individuals who underwent our virtual capacity evaluations, most were able to remain at home, offered community services for support, and linked to primary care.

Perceptions and Use of Telehealth among diverse communities: A Multisite Community Engaged Mixed Methods Study

BACKGROUND

Telehealth has been increasingly adopted by healthcare systems since the start of the COVID-19 pandemic. Although telehealth may provide convenience for patients and clinicians, there are several barriers to accessing it and using it effectively to provide high quality patient care.

OBJECTIVE

This study, was part of a larger multisite community engaged study conducted to understand the impact of COVID-19 on diverse communities. The work described here explored the perceptions of and experience with telehealth use among diverse and underserved community members during COVID-19.

METHODS

We used mixed methods across three regions in the US (Midwest, Arizona, and Florida) from January 2021-November 2021. We promoted our study through social media and community partnerships, disseminating flyers in English and Spanish. We developed a moderator guide and conducted focus groups in English and Spanish mostly using a videoconferencing platform. Participants were placed in focus groups with others who shared similar demographic attributes and geographic location. Focus groups were audio-recorded and transcribed. We analyzed our qualitative data using the framework analytic approach. We developed our broader survey using validated scales and with input from community and scientific leaders and distributed it through social media in English and Spanish. We included a previously published questionnaire which had been used to assess perceptions about telehealth among patients with HIV. We analyzed our quantitative data using SAS software and standard statistical approaches. We examined the effect of region, age, ethnicity/race and education on use and perceptions of telehealth.

RESULTS

We included data from 47 focus groups. Due to our mode of dissemination, we cannot calculate a response rate for the survey. However, we received 3447 English language and 146 Spanish language responses. Over 90% of participants had internet access and 94% had used telehealth. About half of all participants agreed or strongly agreed that telehealth would be beneficial in the future because it better fit their schedules and they would not need to travel. However, about half also agreed or strongly agreed they would not be able to express themselves well and could not be examined when using telehealth. Indigenous participants were especially concerned about these issues when compared to other racial groups.

CONCLUSIONS

This work describes findings from a mixed methods community engaged research study about telehealth including perceived benefits and concerns. Although participants enjoyed the benefits of telehealth (not having to travel and easier scheduling) they also had concerns (not being able to express themselves well and not having a physical exam) about telehealth.. These sentiments were especially notable among the Indigenous population. Our work highlights the importance of fully understanding the impact of these novel health delivery modalities on the patient experience and actual or perceived quality of care received.

CLINICALTRIAL

Culinary Nutrition Education Programs in Community-Dwelling Older Adults: A Scoping Review

BACKGROUND

Culinary nutrition education programs are increasingly used as a public health intervention for older adults. These programs often integrate nutrition education in addition to interactive cooking workshops or displays to create programs suitable for older adults' needs, ability and behaviour change. Synthesising the existing literature on nutrition education and interactive cooking programs for older adults is important to guide future program development to support healthy ageing.

OBJECTIVES

To determine the extent of published literature and report the characteristics and outcomes of interactive culinary nutrition education programs for older adults (> 51 years).

DESIGN

This scoping review followed the PRISMA-ScR guidelines recommended for reporting and conducting a scoping review.

METHODS

Five databases were searched of relevant papers published to May 2022 using a structured search strategy. Inclusion criteria included: older adults (≥ 51 years), intervention had both an interactive culinary element and nutrition education and reported dietary outcome. Titles and abstracts were screened by two reviewers, followed by full-text retrieval. Data were charted regarding the characteristics of the program and outcomes assessed.

RESULTS

A total of 39 articles met the full inclusion criteria. The majority of these studies (n= 23) were inclusive of a range of age groups where older adults were the majority but did not target older adults exclusively. There were large variations in the design of the programs such as the number of classes (1 to 20), duration of programs (2 weeks to 2 years), session topics, and whether a theoretical model was used or not and which model. All programs were face-to-face (n= 39) with only two programs including alternatives or additional delivery approaches beside face-to-face settings. The most common outcomes assessed were dietary behaviour, dietary intake and anthropometrics.

CONCLUSION

Culinary nutrition education programs provide an environment to improve dietary habits and health literacy of older adults. However, our review found that only a small number of programs were intentionally designed for older adults. This review provides a summary to inform researchers and policy makers on current culinary nutrition education programs for older adults. It also recommends providing face-to-face alternatives that will be accessible to a wider group of older adults with fewer restrictions.

Physician Views of Telehealth for Special Populations of Older Adults: Preliminary Findings

This study's objective was to determine how frontline physicians perceived telehealth for older adults with sensory impairments, cognitive impairments, mobility challenges, or those receiving end-of-life care. We conducted a multiple-methods study of US emergency, geriatric, and primary care physicians. Phase 1 involved semi-structured interviews with 48 physicians on their experiences using telehealth with older adults. In phase 2, we used those qualitative findings to generate a web-based survey administered to 74 physicians. In phase 3, we reintegrated qualitative data to enrich survey results. We identified 3 key findings: (1) 50% of emergency physicians, 33% of geriatricians, and 18% of primary care physicians considered telehealth to be a poor substitute for providing end-of-life care (p = .68); (2) for hearing, vision, and cognitive impairments, 61%, 58%, and 54%, respectively, saw telehealth as a good or fair substitute for providing care (p = .14); and (3) 98% indicated that telehealth was a good or fair substitute for in-person care for those with mobility impairment (p < .001). Preferences and comfort using telehealth with older adults vary by clinical context, patient population, and physician specialty, requiring tailored adaptations.

Frontline Physician Perspectives on Their Experiences Working During the First Wave of the COVID-19 Pandemic

BACKGROUND

During the first wave of the COVID-19 pandemic physicians worked on the front lines, immersed in uncertainty. Research into perspectives of frontline physicians has lagged behind clinical innovation throughout the pandemic.

OBJECTIVE

To inform ongoing and future efforts in the COVID-19 pandemic, we conducted a qualitative exploration of physician perspectives of the effects of policies and procedures as well as lessons learned while caring for patients during the height of the first wave in the spring of 2020.

DESIGN

A confidential survey was emailed to a convenience sample. Survey questions included demographic data, participant role in the pandemic, and geographic location. Eleven open-ended questions explored their perspectives and advice they would give going forward. Broad areas covered included COVID-19-specific education, discharge planning, unintended consequences for patient care, mental health conditions to anticipate, and personal/institutional factors influencing workforce well-being amid the crisis.

PARTICIPANTS

We received fifty-five surveys from May through July 2020. Demographic data demonstrated sampling of frontline physicians working in various epicenters in the USA, and diversity in gender, race/ethnicity, and clinical specialty.

APPROACH

Inductive thematic analysis.

KEY RESULTS

Four themes emerged through data analysis: (1) Leadership can make or break morale; (2) Leadership should engage frontline workers throughout decision-making processes; (3) Novelty of COVID-19 led to unintended consequences in care delivery; and (4) Mental health sequelae will be profound and pervasive.

CONCLUSIONS

Our participants demonstrated the benefit of engaging frontline physicians as important stakeholders in policy generation, evaluation, and revision; they highlighted challenges, successes, unintended consequences, and lessons learned from various epicenters in the first wave of the COVID-19 pandemic. There is much to be learned from the early COVID-19 pandemic crisis; our participants' insights elucidate opportunities to examine institutional performance, effect policy change, and improve crisis management in order to better prepare for this and future pandemics.

Telephone and Smartphone-Based Interventions for Cognitive and Cardio-Metabolic Health in Middle-Aged and Older Adults: A Systematic Review

PURPOSE

Dementia and cardio-metabolic diseases share many risk factors. Management of these risk factors could contribute to successful aging, including the prevention of cardio-metabolic disease and dementia. The increasing use of smartphones offers an opportunity for remote preventive interventions. We provided a systematic review of telephone and smartphone-based interventions targeting the prevention of cognitive decline, dementia cardio-metabolic diseases or their risk factors among adults aged over 50 years.

PATIENTS AND METHODS

We searched Pubmed and the International Clinical Trials Registry Platform for experimental studies. We used the Cochrane risk-of-bias tool (Version 2) for randomized trials or TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) checklists to assess study quality for completed studies.

RESULTS

We analyzed 21 completed (3 for cognition, 18 for cardio-metabolic outcomes) and 50 ongoing studies (23 for cognition, 27 for cardio-metabolic outcomes). Smartphone interventions were used in 26 studies (3 completed, 23 ongoing). Other interventions involved telephone vocal support and text messaging. Few studies were at low risk of bias. There were heterogeneous cognitive and cardio-metabolic outcomes. The highest quality studies found no significant effects on cognition, and inconsistent results for HbA1c, blood pressure or physical activity. The lower quality-studies found effects on global cognition, working memory, memory and language and inconsistent results for clinical, biological or behavioral cardio-metabolic outcomes.

CONCLUSION AND IMPLICATIONS

Despite the large number of commercially available mobile health applications, the magnitude of the scientific evidence base remains very limited. Based on published studies, the added value of telephone and smartphone tools for the prevention of cardio-metabolic diseases, cognitive decline or dementia is currently uncertain, but, there are several ongoing studies expected to be completed in the coming years.

Strategies to Ensure Continuity of Care Using Telemedicine with Older Adults during COVID-19: A Qualitative Study of Physicians in Primary Care and Geriatrics

Objectives: Our objective was to interview primary care physicians (PCPs) and geriatricians on their experiences using telemedicine during the COVID-19 pandemic to examine strategies used to maintain continuity of care with their patients, ages 65 and older. Methods: Using purposive sampling, we selected physicians based on community size (metro/suburban/rural) and practice setting (academic/community) and conducted semi-structured interviews via Zoom (mean: 30 minutes). Interviews were recorded, transcribed, coded, and analyzed using framework analysis. Results: We enrolled 33 physicians (15 PCPs and 18 geriatricians) from July to November 2020. Findings indicate that many physicians successfully bridged the digital divide by: assessing patients' technological readiness in advance, being flexible with telehealth modes, using available home or facility-based staff, educating patients on telehealth privacy and usefulness, making accommodations for disabilities, and involving caregivers. Discussion: These findings can inform future policy and practice and assist physicians in resolving addressable barriers to telehealth use among older patients.

Exploring cancer patients', caregivers', and clinicians' utilisation and experiences of telehealth services during COVID-19: A qualitative study

OBJECTIVES

The COVID-19 pandemic has significantly impacted oncology. With pandemic restrictions limiting close contact between individuals, telehealth (the use of teleconferencing/videoconferencing to conduct real-time medical consultations) has been increasingly utilised. This qualitative study aimed to explore adult cancer patient, caregiver, and clinician (doctor, nurse, allied health) telehealth experiences during COVID-19 in urban and rural Australian settings and identify potential enablers and barriers to sustained telehealth implementation.

METHODS

English-speaking participants completed semi-structured interviews regarding their telehealth experiences since March 2020. Interviews ceased when data saturation occurred. Iterative thematic analysis was conducted using NVivo 12 Pro.

RESULTS

Thirty-four interviews (clinician=14, patient=13, caregiver=7) were conducted from April to August 2021. Analysis generated seven themes relating to telehealth use: 1) Acceptability as a form of consultation, 2) Impacts on healthcare provision, 3) Communication & relationships, 4) Efficient form of consultation, 5) Comfort of conducting telehealth in different environments, 6) Technological barriers and 7) Future preferences.

CONCLUSIONS

The rapid uptake of telehealth during the pandemic has mostly been well-received, and telehealth can be appropriately used in oncology.

PRACTICE IMPLICATIONS

Barriers including providing appropriate facilities, technology, and telehealth training; and selecting appropriate patients must be addressed to enable sustained telehealth use in future cancer care.

Older adults can use technology: why healthcare professionals must overcome ageism in digital health

Older adults rapidly adopted technology for healthcare, known as digital health, during the COVID-19 pandemic. Older adults are increasingly using telehealth, smartphone apps, and other digital health technologies to reduce barriers to care, maintain patient-provider communication, and promote disease self-management. Yet, many healthcare professionals have maintained outdated beliefs rooted in societal ageism that digital health and older adults are incompatible. As a result, older adults have been disproportionally excluded from health services and clinical trials that use digital health relative to their younger counterparts. In this commentary, we urge all healthcare disciplines to challenge ageist beliefs and practices that have contributed to the "digital health divide" among older patients. We provide examples of evidence-based strategies and current scientific initiatives that can promote digital health inclusion in research, clinical practice, and training. By achieving digital health inclusion, we can increase access, provide preventative and comprehensive care, and decrease healthcare costs for older patients.

Feasibility and Assessment of a Hybrid Audiology Service Delivery Model for Older Adult Hearing Aid Users: A Pilot Study

PURPOSE

The aim of this study was to provide insight for the feasibility and outcomes of hybrid (combination of in-person office and Internet-based appointments) audiology services.

METHOD

This pilot included two phases. First, we surveyed audiologists regarding what elements of a best-practice, in-person delivery of a hearing intervention could be delivered via Internet-based appointments. Next, we piloted the feasibility and assessed outcomes of the procedures identified. Ten first-time hearing aid users aged 70 years and older were fit with Phonak Audeo M90-312T hearing aids. Two Internet-based follow-up appointments were completed using the myPhonak app. We administered the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S), the Client Oriented Scale of Improvement (COSI), the Quick Speech-in-Noise Test (QuickSIN), and real-ear aided responses (REARs) to determine whether participants experienced improvements on hearing-related outcomes. The Telehealth Acceptance Questionnaire (TAQ) and the Visit-Specific Satisfaction Questionnaire (VSQ-9) were administered to gauge comfort with telehealth and satisfaction with Internet-based appointments.

RESULTS

Survey results revealed that after an initial in-person appointment, nearly all follow-up hearing intervention components could be delivered remotely. We performed Wilcoxon signed-ranks tests to determine if the baseline and outcome results differed for outcomes. Baseline scores improved after 6 weeks (ps = .02 and. 005 for QuickSIN and HHIE-S) for speech-in-noise performance and self-perceived hearing difficulties. REARs from 500 to 4000 Hz measured after 6 weeks did not differ from baseline (ps = .612 and .398 for the right and left ears), suggesting no significant deviation from prescriptive targets because of remote fitting adjustments. All participants reported improvement in COSI goals after the intervention. TAQ results suggested that comfort with telehealth improved after attending Internet-based appointments (p = .005). VSQ-9 results revealed no differences in reported patient satisfaction between in-person and Internet-based appointments.

CONCLUSIONS

We were able to develop a feasible hybrid audiology service delivery model for older adults. Our results enhance the evidence base for the implementation of telehealth audiology services.

Advances in Psychotherapy for Older Adults Using Video-to-Home Treatment

Providing telemental health services to older adults has become especially important during the COVID-19 pandemic. Video-to-home (VTH) treatment is an effective treatment modality; research shows that older adults are open to using VTH. However, there are unique barriers to using VTH with older adults. Barriers include access to technology, acceptance of technology, and physical and cognitive limitations. Additional concerns include establishing rapport with older patients and the policy and ethical concerns surrounding the use of VTH. Methods of addressing these barriers have been developed, and more research is needed to develop evidence-based VTH practice.

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

OBJECTIVES

We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

ED patients with cognitive impairment and/or their care partners.

METHODS

Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.

RESULTS

From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.

CONCLUSIONS AND IMPLICATIONS

This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.

Understanding the Experience of Geriatric Care Professionals in Using Telemedicine to Care for Older Patients in Response to the COVID-19 Pandemic: A Mixed-Methods Study

Background

Geriatric care professionals were forced to rapidly adopt the use of telemedicine technologies to ensure the continuity of care for their older patients in response to the COVID-19 pandemic. However, there is little current literature that describes how telemedicine technologies can best be used to meet the needs of geriatric care professionals in providing care to frail older patients, their caregivers, and their families.

Objective

This study aims to identify the benefits and challenges geriatric care professionals face when using telemedicine technologies with frail older patients, their caregivers, and their families and how to maximize the benefits of this method of providing care.

Methods

This was a mixed methods study that recruited geriatric care professionals to complete an online survey regarding their personal demographics and experiences with using telemedicine technologies and participate in a semistructured interview. Interview responses were analyzed using the Consolidated Framework for Implementation Research (CFIR).

Results

Quantitative and qualitative data were obtained from 30 practicing geriatric care professionals (22, 73%, geriatricians, 5, 17%, geriatric psychiatrists, and 3, 10%, geriatric nurse practitioners) recruited from across the Greater Toronto Area. Analysis of interview data identified 5 CFIR contextual barriers (complexity, design quality and packaging, patient needs and resources, readiness for implementation, and culture) and 13 CFIR contextual facilitators (relative advantage, adaptability, tension for change, available resources, access to knowledge, networks and communications, compatibility, knowledge and beliefs, self-efficacy, champions, external agents, executing, and reflecting and evaluating). The CFIR concept of external policy and incentives was found to be a neutral construct.

Conclusions

This is the first known study to use the CFIR to develop a comprehensive narrative to characterize the experiences of Ontario geriatric care professionals using telemedicine technologies in providing care. Overall, telemedicine can significantly enable most of the geriatric care that is traditionally provided in person but is less useful in providing specific aspects of geriatric care to frail older patients, their caregivers, and their families.

Using Social Media for Clinical Research: Recommendations and Examples From the Brown-Lifespan Center for Digital Health

Social media integration into research has increased, and 92% of American social media participants state they would share their data with researchers. Yet, the potential of these data to transform health outcomes has not been fully realized, and the way clinical research is performed has been held back. The use of these technologies in research is dependent on the investigators' awareness of their potential and their ability to innovate within regulatory and institutional guidelines. The Brown-Lifespan Center for Digital Health has launched an initiative to address these challenges and provide a helpful framework to expand social media use in clinical research.

Remote Assessment of Quality of Life and Functional Exercise Capacity in a Cohort of COVID-19 Patients One Year after Hospitalization (TELECOVID)

Studies have reported persistent symptoms in patients hospitalized for COVID-19 up to 6 months post-discharge; however, sequalae beyond 6 months are unknown. This study aimed to investigate the clinical status of COVID-19 patients one year after hospital discharge and describe the factors related to poor outcomes. We conducted a single-center, prospective, cohort study of patients in Le Havre hospital (France) between 1 March 2020 and 11 May 2020. Baseline characteristics were collected from medical charts (including KATZ index and Clinical Frailty scale (CFS)), and a remote assessment was conducted 12 months after discharge. The main outcomes were the scores of the physical and mental components (PCS and MCS) of the Short-Form 36 (SF-36) and performance on the one-minute sit-to-stand test (STST1′). Scores <50% of the predicted values were considered as poor, and univariate and multivariate analyses were undertaken to investigate factors related to poor outcomes. Remote assessment was performed for 128 of the 157 (82%) eligible patients. Twenty-two patients were admitted to the intensive care unit (ICU), 45 to the intermediate care unit (IU), and 61 to the general ward (GW). Patients who spent time in ICU were more independent and younger. A large proportion of the sample had poor physical (30%) and mental health (27%) and a poor functional exercise capacity (33%) at the remote assessment. Higher levels of frailty at admission and hospital discharge were, respectively, associated with a higher risk of poor functional exercise capacity (StdOR 3.64 (95%CI 1.39–10.72); p = 0.01) and a higher risk of poor mental health (StdOR 2.81 (95%CI 1.17–7.45); p = 0.03). Long-term outcomes following hospitalization for COVID-19 infection may be negative for at least one year after discharge. Remote follow-up assessment could be highly beneficial for COVID-19 patients.

Perspectives of Primary Care Clinicians in Massachusetts on use of Telemedicine with Adults aged 65 and Older during the COVID-19 Pandemic

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PCPs have disparate attitudes towards telemedicine primary care for adults >65.

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Multilevel interventions are needed to optimize telemedicine care for older adults.

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PCPs find telemedicine most effective for chronic disease management.

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PCPs appreciate telemedicine’s convenience but worry about the lack of touch.

To learn how to improve telemedicine for adults >65, we asked primary care clinicians (“PCPs”) affiliated with one large Boston-area health system their views on using telemedicine (which included phone-only or video visits) with adults >65 during the COVID-19 pandemic. In open-ended questions, we asked PCPs to describe any challenges or useful experiences with telemedicine and suggestions for improving telemedicine as part of a larger web-based survey conducted between September 2020 and February 2021. Overall, 163/383 (42%) PCPs responded to the survey. Of these, 114 (70%) completed at least one open-ended question, 85% were non-Hispanic white, 59% were female, 75% were community-based, and 75% were in practice >20 years. We identified three major themes in participants’ comments including the need to optimize telemedicine; integrate telemedicine within primary care; and that PCPs had disparate attitudes towards telemedicine for older adults. To optimize telemedicine, PCPs recommended more effective digital platforms, increased utilization of home medical equipment (e.g., blood pressure cuffs), and better coordination with caregivers. For integration, PCPs recommended targeting telemedicine for certain types of visits (e.g., chronic disease management), enabling video access, and reducing administrative burdens on PCPs. As for PCP attitudes, some felt telemedicine enhanced the doctor-patient relationship, improved the patient experience, and improved show rates. Others felt that telemedicine visits were incomplete without a physical exam, were less rewarding, and could be frustrating. Overall, PCPs saw a role for telemedicine in older adults’ care but felt that more support is needed for these visits than currently offered.

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research

Background:

The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components.

Methods:

The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination.

Results:

There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care.

Conclusions:

It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.

Perceptions of Telehealth vs In-Person Visits Among Older Adults With Advanced Kidney Disease, Care Partners, and Clinicians

Importance

Telehealth has been posited as a cost-effective means for improving access to care for persons with chronic conditions, including kidney disease. Perceptions of telehealth among older patients with chronic illness, their care partners, and clinicians are largely unknown but are critical to successful telehealth use and expansion efforts.

Objective

To identify patient, care partner, and nephrologists' perceptions of the patient-centeredness, benefits, drawbacks of telehealth compared to in-person visits.

Design, Setting, and Participants

This qualitative study used semistructured interviews conducted from August to December 2020 with purposively sampled patients (aged 70 years or older, chronic kidney disease stages 4 to 5), care partners, and clinicians in Boston, Massachusetts; Chicago, Illinois; Portland, Maine; and San Diego, California.

Main Outcomes and Measures

Participants described telehealth experiences, including factors contributing to and impeding engagement, satisfaction, and quality of care. Thematic analysis was used to analyze data.

Results

Of 60 interviews, 19 (32%) were with clinicians, 30 (50%) with patients, and 11 (18%) with care partners; 16 clinicians (84%) were nephrologists; 17 patient participants (43%) were non-Hispanic Black, and 38 (67%) were women. Four overarching themes characterized telehealth's benefits and drawbacks for patient-centered care among older, chronically ill adults: inconsistent quality of care, patient experience and engagement, loss of connection and mistrust (eg, challenges discussing bad news), and disparities with accessing telehealth. Although telehealth improved convenience and care partner engagement, participants expressed concerns about clinical effectiveness and limitations of virtual physical examinations and potentially widening disparities in access. Many participants shared concerns about harms to the patient-clinician relationship, limited ability to comfort patients in virtual settings, and reduced patient trust.

Conclusions and Relevance

Older patients, care partners, and kidney clinicians (ie, nephrologists and physician assistants) shared divergent views of patient-centered telehealth care, especially its clinical effectiveness, patient experience, access to care, and clinician-patient relationship. Understanding older patients' and kidney clinicians' perceptions of telehealth elucidate barriers that should be addressed to promote high-quality care and telehealth use.

Emergency physician perspectives on using telehealth with older adults during COVID-19: A qualitative study

OBJECTIVES

Emergency medicine physicians have played a pivotal role throughout the coronavirus disease 19 (COVID-19) pandemic through in-person and remote management and treatment. Our primary objectives were to understand emergency medicine physicians' experiences using telehealth throughout the pandemic, any facilitators/barriers to successful usage, lessons learned during implementation, and successful/abandoned strategies used to engage with older adults.

METHODS

Using a semi-structured interview guide, we conducted 30-min interviews. We used purposeful sampling to recruit emergency medicine physicians from all United States regions, rural-urban settings, and academic and community practices, who reported caring for patients 65 years or older in-person or virtually during the pandemic. Interviews were audio-recorded, transcribed, double-coded, and analyzed for emergent themes using framework analysis.

RESULTS

A total of 15 in-depth interviews were completed from September to November 2020. Physicians had a median age of 37 years, 7 were women, and 9 had experience with telehealth before the pandemic. We identified several themes: (1) there were various motivations for telehealth use; (2) telehealth was used primarily to supplement, not replace in-person care; (3) most platforms were easy to use; (4) patients and caregivers had high acceptability of telemedicine; and (5) older adults with sensory and cognitive impairments often relied on caregivers. Emergency medicine physicians played a critical role during primary care office closures during the first wave-dispelling misinformation about COVID-19, triaging patients to testing and treatment, and providing care that would otherwise have been deferred.

CONCLUSIONS

Our data show that telemedicine gained acceptability among emergency medicine physicians and provided options to patients who may have otherwise deferred care. These findings can inform future healthcare delivery for acute care needs or pandemic responses.