Telehealth for geriatric post‐emergency department visits to promote age‐friendly care

Abstract

Objective To describe a feasibility pilot study for older adults that addresses the digital divide, unmet health care needs, and the 4Ms of Age‐Friendly Health Systems via the emergency department (ED) follow‐up home visits supported by telehealth. Data Sources and Study Setting Data sources were a pre‐implementation site survey and pilot phase individual‐level patient data from six US Department of Veterans Affairs (VA) EDs. Study Design A pre‐implementation survey assessed existing geriatric ED processes. In the pilot called SCOUTS (Supporting Community Outpatient, Urgent care & Telehealth Services), sites identified high‐risk patients during an ED visit. After ED discharge, Intermediate Care Technicians (ICTs, former military medics), performed follow‐up telephone, or home visits. During the follow‐up visit, ICTs identified “what matters,” performed geriatric screens aligned with Age‐Friendly Health Systems, observed home safety risks, assisted with video telehealth check‐ins with ED providers, and provided care coordination. SCOUTS visit data were recorded in the patient's electronic medical record using a standardized template. Data Collection/Extraction Methods Sites were surveyed via electronic form. Administrative pilot data extracted from VA Corporate Data Warehouse, May–October 2021. Principle Findings Site surveys showed none of the EDs had a formalized way of identifying the 4 M “what matters.” During the pilot, ICT performed 56 telephone and 247 home visits. All home visits included a telehealth visit with an ED provider (n = 244) or geriatrician (n = 3). ICTs identified 44 modifiable home fall risks and 99 unmet care needs, recommended 80 pieces of medical equipment, placed 36 specialty care consults, and connected 180 patients to a Patient Aligned Care Team member for follow‐up. Conclusions A post‐ED follow‐up program in which former military medics perform geriatric screens and care coordination is feasible. Combining telehealth and home visits allows providers to address what matters and unmet care needs.

Age‐Friendly Health Systems: Improving care for older adults in the Veterans Health Administration

“…26 Challenges noted by the Dryden and McQuown research teams include setting patient and caregiver expectations upfront and acknowledging the limits of what is known about cognitive impairment and its progression, awareness of racial and socioeconomic disparities in rural settings (e.g., reliable internet access), and meeting the complex needs of patients with hearing, visual, and cognitive impairment who may have difficulty absorbing and recalling information and connecting through telemedicine. 23,26…”

“…As an alternative, geriatric ED aftercare may be provided via telemedicine and/or home visits 48-72 hours after discharge to reduce hospital readmissions, their associated costs, and increase patient satisfaction. [23][24][25] McQuown 23 and Dryden 26 explore the benefits of and health outcomes from AFHS through the Geriatric Research, Education, and Clinical Center (GRECC) Connect (geriatric telemedicine), and the Supporting Community Outpatient, Urgent Care, and Telehealth Services (SCOUTS) programs. These programs align with the AFHS model and are associated with the expanded geriatric "5Ms" (adding multi-complexity) as described by the American Geriatric Society's Health in Aging Foundation.…”

“…27 Both programs provide opportunities to improve care and support caregivers, particularly in rural areas, and they met an unexpected surge in need during the height of the COVID-19 pandemic. 23,26 National shortages of geriatricians and mental health professionals combined with access disparities (e.g., long travel distance to health care, mobility, or visual challenges) are barriers to meeting the needs of older adults, and telemedicine is helping to bridge that gap for Veterans. GRECC Connect uses telemedicine to improve care quality and patient experience and focus on (a) what matters by planning care with patient and caregiver goals and care preferences in mind, (b) completing a thorough review of medication options and deprescribing high-risk medications when appropriate, (c) assessing and acting on mentation providing advice about activities to improve mood and cognition, (d) facilitating delivery of needed adaptive equipment, home safety evaluation, and physical therapy referral to address mobility to maintain function and safety, and (e) providing care coordination, caregiver support, and education to meet the multi-complexity needs of each older Veteran.…”

“…Postdischarge monitoring is traditionally completed by telephone or a face‐to‐face follow‐up visit in primary care. As an alternative, geriatric ED aftercare may be provided via telemedicine and/or home visits 48–72 hours after discharge to reduce hospital readmissions, their associated costs, and increase patient satisfaction 23–25 …”

“…These programs align with the AFHS model and are associated with the expanded geriatric “5Ms” (adding multi‐complexity) as described by the American Geriatric Society's Health in Aging Foundation 27 . Both programs provide opportunities to improve care and support caregivers, particularly in rural areas, and they met an unexpected surge in need during the height of the COVID‐19 pandemic 23,26 …”