As providers have ramped up their use of telehealth during the Covid-19 pandemic, one group — the elderly — has experienced particular challenges in adopting the technologies. This article describes the strategies four innovative provider organizations have used to engage with their older patients via telehealth.
The Covid-19 pandemic catapulted telehealth into the mainstream and it is likely to remain there even after the pandemic subsides. It’s proved highly effective for younger, digitally savvy patients. But older patients, and particularly the frail elderly, often struggle with the technology. How can primary care providers help these patients adopt telehealth? And when are face-to-face visits still the best option?
To answer these questions, we interviewed executives and frontline providers at four innovative primary care organizations that serve predominately elderly populations: Iora Health, Oak Street Health, ChenMed, and Landmark Health. These organizations participate in Medicare Advantage plans and receive a capitated payment for each patient regardless of the volume of services they provide. This gives them both the flexibility and the incentive to develop creative ways to provide value-based primary care, including pivoting to telehealth with their challenging populations.
From in-person care to telehealth
Before the pandemic, virtually all visits at these four providers were done face-to-face in the clinic. When Covid-19 hit, they rapidly shifted to telephone check-ins and used these calls in part to assess patients’ telehealth needs, preferences, and capabilities. Oak Street Health, for example, surveyed patients about their telehealth access, asking if they had a smartphone, tablet, or desktop computer with camera and internet. If patients had one of the three, they were considered “video-capable.” After assessing whether patients possessed the required technology, the next step was to gauge their ability to use it.
These organizations then quickly transitioned to video visits – initially only for patients with the appropriate technology and capability, and later for other patients to whom the organizations provided additional support. “Video visits provide so much more information than telephonic visits: ‘Does the patient look sick?’ ‘What is his home environment like?’,” said Rushika Fernandopulle, CEO and founder of Iora Health. As CMS relaxed the HIPAA compliance guidelines to allow providers to use public platforms for exchanging health information, these organizations initially leveraged familiar platforms like FaceTime, Skype, WhatsApp and Google Meet to facilitate a speedy adoption. At Iora, for example, video visits jumped from zero in the period between January and mid-March to 41% from mid-March to June. ChenMed, Oak Street Health, and Landmark Health saw video visits jump from zero to 26%, 13% and 9% respectively during this same period.
These platforms provided an adequate interim solution but lacked certain capabilities and optimal security. Thus the providers made additional IT investments “to create an easy-to-use, safe, and secure video visit experience,” explained Gaurav Dayal, ChenMed’s chief growth officer. ChenMed embedded video capability in its electronic health record (EHR) system and linked it with clinicians’ schedules, creating a “virtual patient room.” This allows clinicians to securely communicate with patients, document visits, and easily switch among patients on a single platform; it also allowed ChenMed to standardize video visits and integrate them into existing clinical workflows, speeding up adoption.
Iora Health likewise started with a public platform, Google Meet, but found that setting up a visit could take up to 30 minutes especially when patients need to download the app and receive instruction about using it. Because this increased wait times and led to missed calls by care teams, Iora switched to Doxy.me, a secure telehealth platform with a one-click link, which reduced set-up times to under 6 minutes. Iora also introduced “virtual care champions,” non-clinical staff with telehealth expertise who could troubleshoot, test new formats, and discuss clinicians’ feedback with the management.
While some patients readily adapted to telehealth, older patients — and particularly the elderly — often struggled, requiring these organizations to develop creative strategies early in the pandemic.
Challenge #1: Patients who lack access to the internet or appropriate devices
“Keep in mind that our average patient is of low or moderate income,” ChenMed’s Dayal told us. Around 40% of ChenMed’s patients do not own a smartphone or tablet or may not have sufficient data plans or Wifi at home to conduct a video visit. Similarly, about half of Oak Street’s patients and 30% of Iora’s lack appropriate technology or internet access. This figure was 60% to 70% for Landmark, as it serves the most vulnerable elderly patients (around 75% of its patients are older than 70, and almost all have at least five chronic conditions).
Iora Health and Oak Street Health deliver tablets to patients who lack them. Iora mails custom-formatted tablets to its highest-risk patients and health coaches remotely instruct the patients on how to use the technology. Oak Street Health repurposed its fleet of pickup vans, previously utilized to drive patient to and from clinician’s appointment, to provide delivery service and drop off the tablets at patients’ homes. Both providers have found this solution to be sufficient for most patients. For the 5% to 10% of patients unable to use the technology on their own, Iora Health and Oak Street Health provide on-site help. For example, Oak Street Health’s van drivers, with proper personal protective equipment, deliver a cellular-enabled tablet to the patient and log the patient into the video visit so he or she can start right away. Later, drivers pick up the tablets, clean them and deliver them to other patients.
For new patients who lack technology or internet access, Oak Street Health sends “mobile medical assistants” who conduct an in-person intake at the patient’s home then set up a video visit with the care team via the tablet. The assistant remains with the patient during the video visit to help him or her use the technology.
Challenge #2: Patients with medical conditions that impede their use of telehealth
Some patients have conditions that make communication via phone or video difficult. Consider Landmark Health’s patient population: 40% have a hearing impairment, 15% have a vision impairment, and 10% have dementia. “Telehealth can be a trap with these patients who have complicated issues that can easily be missed or masked…and that can lead to serious complications,” explained Landmark’s regional medical director Anthony Zizza.
Landmark Health actively engages non-clinician caregivers (predominately patients’ family members) in telehealth visits to facilitate communication between the patient and the clinician. These caregivers are typically collocated with the patient and help to interpret the visit for the patient and communicate his or her responses to the clinician. In one example, a nurse practitioner coached the spouse of a patient with lung disease on how to appropriately use a nebulizer. Landmark Health is now working on expanding its own recently implemented video app to allow non-clinician caregivers to be included in the call even when they are not in the same location.
For patients whose impairment prevents them from directly engaging in telehealth visits, and who lack a non-clinician caregiver who can act as a liaison, these providers see the patient in person, either at the clinic or at home, with the necessary precautions against Covid-19. For patients who can travel to the clinics, Iora, ChenMed and Oak Street provide transportation services.
Challenge #3: Patients who have the appropriate technology but have limited digital literacy
It shouldn’t be assumed that patients who have access to the right technology also have the skills needed to use it. Said one clinician, “Most of my video visits are spent looking at the ceiling fan.” At Landmark Health, around 50% of the patients with appropriate technology did not know how to use their smartphone for video visits. Oak Street found that 20% to 40% of those who were identified as “video-capable” were not competent with the technology.
Iora and Oak Street introduced “practice visits,” in which administrative staff conducts a mock video visit with patients 1 to 2 days prior to the first video visit with the clinician. The practice visits substantially improved the success of the real video visits, according to both providers and patients.
Landmark deploys “healthcare ambassadors,” experienced community health workers, to support patients in using its video app. They visit patients at home and walk them through downloading and setting up the app, and then conduct several test video visits.
Challenge #4: Highest-risk patients who need regular monitoring of their vital signs
Around 10% to 20% of these organizations’ frail elderly patients are at high risk for serious complications related to their chronic conditions which may soon require urgent care and hospitalization. These highest-risk patients need to be seen regularly. In the pre-pandemic era, the care teams provided once- to twice-weekly in-person visits to perform physical exams and update care plans if needed. With the stay-at-home orders, in-person monitoring became much more difficult.
All four organizations acted quickly and pragmatically to enhance the telehealth visits with objective physical measurements. Landmark’s providers, for example, dropped off monitoring devices, such as blood pressure cuffs, pulse oximeters, and weight scales for their highest-risk patients. They remotely coached the patients and their caregivers on how to measure vital signs, so they could identify irregularities and, when needed, get urgent care. Although self-monitoring improved patients’ health literacy and confidence in their abilities, it can be time-consuming for patient and clinician alike. Nonetheless, sometimes it’s the best option. To improve the efficiency of telehealth visits with physical measurement, Oak Street Health has its medical assistants help patients collect the vital signs via video or telephone and the assistants then enter them in the EHR before the clinician joins the visit.
The Covid-19 pandemic accelerated the transition of healthcare delivery from in-person to telehealth. While these strategies apply across patient populations, older patients, and particularly the home-bound frail elderly, present particular challenges but perhaps stand to uniquely benefit as telehealth increases their access to health care services.
Umar Ikram, MD, MPH, is a Commonwealth Fund Harkness Fellow at the Institute of Strategy and Competitiveness at Harvard Business School and Department of Health Policy and Management at Harvard T.H. Chan School of Public Health.
Susanna Gallani is an Assistant Professor of Business Administration in the Accounting and Management Unit at Harvard Business School.
Jose F. Figueroa, MD, MPH, is an Assistant Professor of Health Policy and Management at the Harvard T.H. Chan School of Public Health, and Associate Physician at the Brigham & Women’s Hospital.
Thomas W. Feeley, MD, is a Senior Fellow at the Institute of Strategy and Competitiveness at Harvard Business School and Professor Emeritus at the University of Texas MD Anderson Cancer Center.
Copyright 2020 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate.