Telehealth in geriatric oncology: A novel approach to deliver multidisciplinary care for older adults with cancer

Introduction

Colleagues and team members of Arti Hurria, MD will remember that despite her lengthy list of achievements, she was always thinking to the future. Shortly before she passed, Dr. Hurria compiled a "Top 10 Dream List" of items she most wanted to accomplish moving forward. Among the wishes on her list was the development of telehealth-delivered, multidisciplinary, customized care programs for older adults with cancer, especially for those who would otherwise not have access to it. At the time of her passing, Dr. Hurria was in the process of evaluating telehealth interventions within geriatric oncology.

Providing Care to Underserved Populations Utilizing Telehealth

Cancer is a disease occurring more frequently in aging populations, with over 50% of all cancer cases associated with individuals age ≥ 65.^1,2 This same demographic is expected to see cancer diagnoses increase 67% by 2030.² In the United States, older adults living in rural areas account for one-quarter of all adults age ≥65³, and this proportion might be even higher in other regions of the world. Among individuals living in rural and/or isolated populations, access to specialized medical resources within driving distance and time are often limited.⁴ As a result, the cost and burden of traveling to and from health centers means that older patients with cancer are more likely to go without medical care and are more vulnerable to undertreatment.⁵

The development of telehealth as a cost-effective alternative to traditional consultations in rural areas can assist in bridging the gaps in care experienced by older adults. The National Conference of State Legislatures defines telehealth as “The use of technology to deliver health care, health information or health education at a distance.”⁶ According to Grand View Research, Inc. the global market for telehealth is expected to reach $113.1 billion by 2025 to meet the rising health care demands of chronic conditions.⁷ In 2016 the Department of Veterans Affairs (VA) conducted a pilot program providing electronic tablets to veterans who did not have access to computers in their homes, allowing the participants to interface with providers through telehealth. The VA successfully utilized the tablet technology to connect remotely to the patient with a “cost of $1,600 per patient compared to more than $13,000 per patient for Veterans Health Administration home-based primary services.”⁸ Results of this VA telehealth consultation program were a reduction in costs and a decrease in hospital readmission rates. In 2012, cost savings of Medicaid patients using telehealth services in Alaska reached several million dollars.⁹ Bashshur et al reviewed the impact of telehealth for the management of chronic illnesses, finding reductions in hospital readmissions, length of stay, and decreased frequency of emergency room visits.⁴ At the same time, older adults also increased their use of technology. Between 2011 and 2014, digital health technology use among adults age ≥ 65 increased from 21 to 25%,¹⁰ while among those age ≥75 increased from 7 to 50% since the year 2000.¹¹ As the use of technology increases, telehealth has the possibility of transforming how we meet the health care needs of older adults with cancer.

Potential Role of Telehealth for Older Adults with Cancer

In settings with limited resources, obtaining specialized care, especially from a multidisciplinary team with geriatric expertise, is enormously challenging. Few studies have explored solutions to address this problem and, to the best of our knowledge, none have attempted to meet the needs of this population via telehealth-delivered geriatric oncology interventions in rural areas or community sites.

To address this gap, Dr. Hurria and colleagues developed a prospective, longitudinal study to examine the feasibility of delivering geriatric assessment-based interventions via telehealth to older patients with cancer at two City of Hope community sites in California. The ongoing study also aims to assess the availability of multidisciplinary resources for older adults available at the community sites, and to decrease grade 3-5 chemotherapy toxicities in patients in this population through multidisciplinary interventions. Within the study design, special consideration was given to the efficient dissemination of care for older patients with cancer who would have limited access to resources generally available at a comprehensive cancer center.

To accomplish the overall aims of the study, a cancer-specific geriatric assessment, which includes a chemotherapy toxicity risk score,¹² is utilized to identify patients at high risk for chemotherapy toxicity and to generate referrals to a multidisciplinary team. The geriatric assessment is a multidimensional, interdisciplinary diagnostic process focusing on determining an older adul’s medical, psychosocial, and functional capabilities to develop a coordinated and integrated plan for treatment and long-term follow up.^12,13 While there has been discussion on how to utilize geriatric assessment results in settings with limited resources, one model suggests that if geriatric expertise is not readily available, a geriatric assessment may still be performed to help identify patients at risk, with the goal of having them referred to geriatric care givers outside the hospital, or to a multidisciplinary team at a cancer center.¹⁴ Our study utilizes an advanced practice nurse-driven model to implement the interventions based on the recommendations triggered from the results of the geriatric assessment. Previous studies have shown improvement in outcomes for patients with cancer through the use of a nurse practitioner-led clinic for symptom management during treatment, along with other multidisciplinary interventions (nutrition, social work, etc.).¹⁵

Implementation of Telehealth in Older Patients with Cancer

Combining geriatric assessment-based recommendations and nurse practitioner-led, multidisciplinary interventions, our telehealth study allows patients at community sites to complete a geriatric assessment on the first day of a new cytotoxic treatment. Patients complete the geriatric assessment using an electronic tablet, and results are emailed to the nurse practitioner on the main campus for review. Geriatric assessment results, as well as suggested recommendations for multidisciplinary interventions, are automatically generated and summarized by utilizing predetermined triggers according to the patien’s answers. The multidisciplinary team then reviews these results focusing on the patient as a whole, with the primary goal of providing and implementing geriatric assessment-based interventions via telehealth. Multidisciplinary team members include a geriatric nurse practitioner, occupational therapist, physical therapist, social worker, pharmacist, and nutritionist. Once the team has reviewed the recommendations, patients are seen by the nurse practitioner via video-enabled, HIPAA compliant/encrypted interfaces (Zoom, Skype for Business). During the initial visit, the geriatric assessment results are explained to the patient, general recommendations are provided, and orders for consultations are entered (Figure 1). A potential set of recommendations may include additional assistance for transportation to chemotherapy appointments, providing resources to prepare meals if a patient was unable to cook or care for himself, and/or an in home safety risk evaluation for falls, among others. The last step is to remotely implement multidisciplinary interventions based on geriatric assessment results through telehealth consultations with physical therapy (PT), occupational therapy (OT), and nutrition. After the initial visits, subsequent follow up visits are made using telehealth, timing them to occur on days in which patients are scheduled for a chemotherapy infusion or for an in-person follow up with their local oncologist. In some cases, patients are followed telephonically, and recommendations for the use of services available at the community (such as PT or OT) might also be made. At the end of a patien’s time on study (six months after enrollment, the conclusion of chemotherapy, or a change in treatment), patients again complete the geriatric assessment, as well as a feasibility questionnaire which provides an opportunity for patient feedback by asking them to evaluate how comfortable they were using telehealth. Although this study is ongoing and data continues to be collected, anecdotal information suggests that patients and local healthcare workers appreciate the care provided in the study and the use of telehealth. Feedback has included comments such as: “It was great to speak with someone I could communicate freely and honestly with!”

Figure 1.

Telehealth Pilot Program Schema

Future Directions

Telehealth can serve as a bridge to providing access to specialized care for older patients with cancer living in limited-resource settings. In the U.S. and worldwide, there are deficits in primary care physicians, and specialists working in rural or outlying areas are scarce, increasing the need for alternatives in care. ^16,17 Providing multidisciplinary care through telehealth might be a valuable tool to meet the needs of underserved older adults with cancer, and it is certainly an alternative that needs to be further explored. Barriers to telehealth visits include the availability of a reliable internet service (in the US, more than 30 million people lack broadband internet, including about 39% of those living in rural areas⁸), privacy concerns, skepticism, and cost to institutions.¹⁸ However, at least one large randomized study has found that care by a medical specialist via videoconferencing is comparable to in-person care, and that it might have a positive impact on the quality of life of rural patients.¹⁹

While bringing multidisciplinary team members to the patien’s clinic via telehealth is a step in the right direction, research efforts by our team are underway to connect a patient to a secure telehealth line in the comfort of their own home; thereby eliminating additional travel barriers altogether. The VA has piloted this method and continued it based on its success: in particular, one VA study found that veterans were able to communicate with their providers from home via an electronic tablet without traveling to the clinic, while also tracking and reporting health metrics remotely.²⁰

Conclusion

Dr. Hurria was well known for her love of teamwork. She often began team meetings with a big smile and a “How is the team today?” It is no wonder that she looked to a team solution for addressing the needs of underserved older patients with cancer in remote areas. While more research is needed to better understand the needs of patients living in rural areas and treated at community sites, telehealth-delivered multidisciplinary interventions can potentially help fill the gap in care for patients who otherwise would not have access to specialized geriatric assessment-based care. As we strive to continue our efforts to address her “Top 10 Dream List”, we, as Dr. Hurria’s team, are committed to developing telehealth to provide customized, accessible care for all older adults with cancer.