Abstract
Background: One of the most vulnerable groups is older persons who seek medical care (patients), especially those who are cognitively impaired with limited access to technology or knowledge of its use.
Intervention: Cuyahoga County Adult Protective Services (APS) partnered with the geriatricians who work at Cleveland Clinic to arrange for clients to be seen virtually in their home environment. Once a patient was identified as having cognitive concerns or an unaddressed medical issue, an appointment was scheduled for a concurrent in-home nurse and virtual visit with a geriatrician.
The APS nurse visited the patient's residence to perform an in-home assessment followed by the virtual portion of the visit concurrent with the geriatrician using a Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic platform.
Outcomes: Fifty-six patients were seen and evaluated in-home by a nurse and then simultaneously virtually by a geriatrician over a 12-month period. Among these patients, 53% had a guardian assigned, 55% were able to stay in their home, and 55% lacked regular health care before the visit, but afterward, 74% started primary medical care.
Conclusion: Physicians working collaboratively with community agencies for in-home technology-enhanced visits led to positive outcomes for this vulnerable older population.
Introduction
Technology helped change the way providers delivered healthcare in the midst of the COVID-19 pandemic. It allowed outreach to patients in need of care despite shut downs, quarantine, and pandemic fears. One of the most vulnerable groups is our population of older persons, especially those who are cognitively impaired with limited access to technology and/or knowledge of its use. Because of the isolation imposed during the pandemic, Cuyahoga County Adult Protective Services (APS) had to come up with a creative way to reach out to the vulnerable, especially when there was concern about their well-being. They partnered with the Cleveland Clinic Geriatricians to arrange for their clients to be seen virtually in their home environment.
Results
Once a patient was identified by APS per criteria (60 yr+ Cuyahoga County Resident with cognitive/functional impairment and victim of abuse/exploitation), an appointment was scheduled for a virtual visit with a geriatrician. The APS nurse visited the patient's residence and started the in-home portion of the visit. Safety concerns within the environment were identified, vitals gathered, and medications reviewed (including pill counts). Safety concerns included availability of utilities, food quality/access, pests, and hoarding. Trip hazards or obstructed passages within the home were also identified when mobility concerns arose.
The virtual portion of the exam was done on an electronic tablet (for example, ipad) with the Geriatrician utilizing a HIPAA compliant platform. The nurse directly interviewed the patient then performed cognitive testing and an appropriate physical examination. Two commonly known cognitive tests Montreal Cognitive Assessment (MOCA) and Saint Louis University Mental Status Examination (SLUMS) were used. Paper copies were used with the Geriatrician's guidance.
Discussion
There are multiple benefits to virtual visits. The patient often feels more comfortable at home. There is no need to plan for transportation (which saves the caregiver time). During the telehealth visit, it is possible to see the patient's home and identify any concerns. Ambulation can be assessed within the home environment (which is useful to assess gait characteristics, how they navigate their home, and to identify any environmental trip hazards.) Physical appearance can be assessed along with many components of a general physical exam which can be facilitated with the assistance of the nurse who can also examine the heart and lungs (which is otherwise difficulty to do virtually alone without the availability of sophisticated equipment.)
After the visit is concluded, documentation takes place within the electronic medical record. Additional collateral information provided by APS (before and after the visit) can also be incorporated. A debriefing occurs between team members to determine the next steps of care. The plan may include completion of a “statement of expert evaluation” regarding this person's decision making capacity, arrangements for medical follow up, and follow-up with a geriatrician if appropriate. The patient is often offered community resources to meet the needs identified during this visit.
The impact of this collaboration is monitored in outcomes such as need for guardian/conservator assignment, ability of the patient to stay in their own home, need for placement in a facility, and if medical care was established/re-established after the visit. Out of 56 people seen virtually over an approximately 12 month period, 53% had a guardian assigned; 55% stayed in their home (remaining 45% moved to supervised setting, including 36% to nursing home); 55% lacked regular health care prior to the visit, but afterwards, 74% of them started primary medical care. These outcomes show that when physicians work collaboratively with community agencies using technology to reach out to vulnerable seniors, then the physical distances commonly encountered during the pandemic can be bridged.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none.
- Received for publication December 7, 2021.
- Revision received January 18, 2022.
- Accepted for publication January 21, 2022.
