Ready or Not: Pivoting to Video Visits with Homebound Older Adults During the COVID‐19 Pandemic

To the Editor: In 2018, our home‐based primary care (HBPC) program embarked on a direct‐to‐patient telehealth pilot. At that time, results were accurately characterized by the title: “Not yet ready for prime time,” as reported in this journal, with only 7.9% of eligible patients successfully completing at least one telehealth visit (39/493). ¹ Barriers to telehealth visits included technical, operational, and access issues. These issues led to rethinking our strategy, and our subsequent pilot used trained emergency medical technicians to bring the video platform to the patient's home for a telehealth visit with their primary care physician. ² Here we describe our third telehealth iteration, this time during the COVID‐19 pandemic, in a program designed to serve chronically ill homebound older adults.

As part of an integrated health system, our program provides comprehensive primary care to approximately 2000 chronically ill homebound patients residing in downstate New York. We use a multidisciplinary team composed of physicians, nurse practitioners, nurses, social workers, and medical coordinators. A meaningful 24/7 clinical response is achieved through a nurse clinical call center and telehealth‐enabled community paramedicine program that can evaluate and treat enrollees in the home under the direction of an HBPC physician, transporting to the hospital only when medically necessary and aligned with goals of care. ³

During the New York COVID‐19 pandemic surge, our program faced a new reality in which face‐to‐face contact conferred a serious risk of disease transmission for both staff and program enrollees. Ready or not, we pivoted to an expansive phase of direct‐to‐patient telehealth. We rapidly shifted most care delivery from in‐home, face‐to‐face visits to remote telehealth and telephonic care. We leveraged existing staff to rapidly reach large numbers of patients for telehealth consent in advance of planned appointments, walking them through downloading and testing the Health Insurance Portability and Accountability Act (HIPAA)–compliant telehealth application so the scheduled clinician was prepared to conduct the visit.

Participation in telehealth visits by enrollees during the early spring COVID‐19 surge was remarkably greater than in our 2018 pilot. Between March and May 2020, our program continued to treat a high number of chronically ill older adults (1712 unique individuals; average age = 82.5 years; 66.6% with five to six activity of daily living dependencies) and observed an increase to 48.6% of eligible enrollees successfully completing at least one telehealth visit (643/1,323) compared with the 7.9% in 2018.

Although a remarkably greater proportion completed a telehealth visit compared with 2018, an even greater proportion of 74.8% of eligible patients consented to using telehealth and were instructed for downloading the application (989/1,323). Of 26.2% of patients who consented to using telehealth but who did not complete a telehealth visit, 32.9% completed at least one face‐to‐face visit (114/346). Additionally, 194 had only telephonic visits, and 38 had no scheduled visits during this study period (Figure 1). Of note during the pandemic, 85 (9%) of scheduled telehealth attempts were unsuccessful and had to be completed by telephone.

Figure 1.

Flow of home‐based primary care telehealth consenting process and visit type outcomes.

On reflection, the need to obtain telehealth consent and download a HIPAA‐compliant application remained a barrier to completing telehealth visits. However, an important component of rapid deployment was leveraging nonclinical staff to consent and conduct previsit preparation. Additionally, when the first choice platform was unsuccessful, waivers of telehealth HIPPA regulations allowed providers to use telehealth with a larger number of patients. ⁴

The unique set of circumstances created by the COVID‐19 pandemic, including the need to physically isolate to prevent disease transmission as well as changes in telehealth reimbursement, motivated our providers, program enrollees, and their caregivers to embrace this modality at rates dwarfing our prior direct‐to‐patient telehealth attempts. We found telehealth to be a viable solution for providing continuity of care to highly vulnerable patients at risk for poor outcomes due to the pandemic. Enrollees and caregivers who were otherwise unable or unwilling to consider telehealth an option now sought it out, purchasing devices and looking to formal and familial caregivers to help facilitate visits when they were unable to do so on their own.

We caution that, although telehealth has expanded ways for providers and patients to connect, there remain a significant subset of patients who are unable to access telehealth. In these situations, we used either telephonic or face‐to‐face visits. The “digital divide” remains prominent among older adults and has the potential to increase isolation and decrease access to care. ⁵ Additionally, we would not suggest that telehealth visits fully replace face‐to‐face visits at any point. Aspects of the physical examination that can only be performed in person remain of paramount importance in accurate and appropriate care provision in certain cases, and personal connection, a foundation in a trusting relationship, may be more difficult to achieve through a video visit. Further study on outcomes of older adults receiving care through telehealth is needed, including chronic and acute disease management, impacts on acute and post‐acute care utilization, days home, and measures of isolation and depression.