How to Use Telemedicine With Your Older Patients

Contrary to popular perception, older patients appear ready to embrace telemedicine.

Telemedicine is a powerful tool in the clinical care of older patients, according to a pair of experts.

The COVID-19 pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives.

Contrary to popular perception, older patients appear ready to embrace telemedicine as shown in a recent report from Strata Decision Technology. The report is based on data collected from 43 health systems as well as telehealth visit data drawn from the American Medical Association and the Centers for Medicare & Medicaid Services.

As a percentage of all medical visits from March to July 2020, the report found telehealth visit utilization was highest for the 30–39 age cohort, at 27.95% of all medical visits. However, telehealth visit utilization also was significant for older age cohorts:

• 50–59: 24.70%
   
• 60–69: 23.61%
   
• 70–79: 22.52%
   
• 80–89: 20.29%
   
• Over 90: 19.04%

Telehealth visits provide older patients with greater access to medical care than in-person visits, says Jeffrey Gelblum, MD, a practicing neurologist at First Choice Neurology in Aventura, Florida, and an associate professor at Nova Southeastern University in Fort Lauderdale, Florida.

"Historically, we had to deal with older folks who may not be able to drive and older folks who would have difficulty finding a parking space. If the weather was bad, some older folks did not want to go to a doctor appointment. Driving for older folks is problematic in terms of compliance. But now with telehealth, that situation has been resolved," he says.

Telemedicine also gives medical practices an opportunity to see older patients more frequently than in-person visits, says Kristofer Smith, MD, MPP, president of home-based medical care at Brentwood, Tennessee–based naviHealth and former senior vice president of population health at Manhattan, New York­–based Northwell Health.

"If you can increase the number of interactions with patients and families to build a relationship, you tend to get stickier relationships faster," Smith says.

Rising to the challenges

Dealing with the technology requirements of telehealth visits is the primary telemedicine challenge for older patients, Smith and Gelblum say.

"The first challenge is the ability to have enough Wi-Fi or broadband data access so that you can have a visit beyond a telephone call and have a video visit. Between 25% and 40% of communities do not have sufficient access. For many older patients, they are not technologically comfortable, so that is another challenge," Smith says.

Encouraging older patients to conduct telehealth visits on their smartphones is a prime strategy to overcome the Internet access challenge, Gelblum says.

"We tell our older patients that they got their Apple phones for a reason and, 'let's go there for your telehealth encounter. The quality is going to be great. If you do not have Internet access, there are no worries—you go on a 4G or 5G network.' So, the smartphone is much more liberating for our senior population. At least down here in South Florida, most older patients are smartphone-equipped," Gelblum says.

Related: Patients Eager to Embrace Telemedicine, New Survey Finds

At Northwell Health, the health system enlisted emergency medical technicians to facilitate telehealth visits in patient homes, Smith says. The EMTs would bring Wi-Fi devices with them as well as a laptop or iPad.

With the EMT model of telehealth care, Northwell Health was able to achieve nearly 100% execution of video visits. In addition to facilitating the telehealth visits, having an EMT present has an added benefit, Smith says. "When the healthcare provider in the central location needed additional information such as a physical exam or a medication review, we had a trained professional who could augment the video visit with additional data so that we could make better clinical decisions about the next steps for the patients."

The EMT model is only possible for patients who have insurance coverage through at-risk contracts such as Medicare Advantage, he says. "For the frail elderly practice that we ran at Northwell Health, we were at risk for total cost of care. So, we were responsible for keeping patients out of the emergency room and the hospital. With being at risk for total cost of care, we could afford these types of augmentation for clinical care. In a fee-for-service model, it simply does not work."

Best practices in telehealth visits for older patients

Unlike younger patients, who are intimately familiar with using computer and smartphone technology, older patients should be walked through their telehealth visits, Gelblum says. "There has to be clear, succinct, step-by-step instructions because the technology is not intuitive for them. So, we have an instruction sheet that we send to them via email that gives them step-by-step instructions."

For older patients, a telehealth visit must be simple, Smith says. "The pace of the interaction has to be slow and clear. So, you need to work with the patients and families to make sure you are asking single questions at a time. You pause to make sure that the patient heard the question because many of these patients are hard of hearing. You pause to make sure you get the answer."

To make sure older patients are comfortable during a telehealth visit, it is important to engage them on a personal level, Gelblum says.

"As far as I am concerned, a telemedicine visit is an old-fashioned house call with a smartphone. I like to engage my patients with what they are doing. I might see something on the stove in the background and I will ask what they are cooking. Then the conversation may become a 10-minute discourse on a homemade recipe for cabbage soup."

Telehealth visits present significant opportunities for patient engagement, Gelblum says.

"For any clinicians getting into conducting visits via telemedicine, I would tell them that they are going to have great avenues of discussion—more avenues of discussion than you could ever get in your office. That is because your office is your environment. When you use telehealth, you are seeing the ultimate in the activities of daily living and emotional status."