Rudimentary forms of telemedicine have existed since the late 1950s, when two-way interactive television was used to transmit neurological exams across campuses for medical students, and similar setups were employed for group psychotherapy consultations.
West Health, originally formed as the West Wireless Health Institute, has for more than a decade worked in the modern telemedicine space, seeking solutions for delivering healthcare in a better way—to drive efficiencies in medical care, to lower costs and to achieve successful outcomes.
Now, with the advent of the COVID-19 pandemic, the telehealth models advanced by West Health and its collaborators are proving to be timely and exemplary, especially with older adults who now must shelter in place in the community. And, West is disseminating multiple tools and implementation guides so other organizations can learn to do the same.
Recently, Generations Now spoke with Dr. Zia Agha, Chief Medical Officer for West Health, and Dr. Jon Zifferblatt, West’s Vice President, Strategy and Successful Aging, about using telemedicine with frail older adults in the community.
“Our North Star has always been to develop care where seniors reside, rather than in a hospital. In any of our projects—whether in home-based care, primary care or in our PACE locations—we have the opportunity at all levels to leverage telehealth,” says Agha.
“COVID has just hastened the speed of employing it,” adds Zifferblatt.
Both physicians have seen a tremendous uptick in the need for remote medicine, and up to 50 percent of medical interactions since the COVID crisis began have been over the phone, or via video, says Agha. West is seeing similar numbers with its older patients across many programs, even though some elders have a more difficult time figuring out the technology, which is why West has been learning about and sharing an evolving suite of best practices for telehealth use with older adults.
A successful model used by West Health and others have staff members act as a telepresenter, going into the older adult’s home to facilitate the video visit with the care provider. Telepresenters can be medical assistants, certified nursing assistants, licensed practical nurses, emergency medical technicians and personal care aides or other professional caregivers.
Two telepresenters generally are paired with one physician per day, to ensure the physician can complete two visits per hour. One telepresenter first calls the patient to explain the process and obtains a consent form for the telehealth visit (verbal consent is sufficient in an emergency situation). The second telepresenter, once at the home, performs a clinical assessment of the patient, including taking vitals and performing a physical exam. The telepresenter then calls the provider to launch the two-way video visit, providing details from the assessment and exam, facilitating the visit and ensuring the patient can see and hear and provider and vice versa.
This labor-intensive approach to a so-called remote-only visit still is less expensive than if the patient were to end up in the hospital or risk COVID-19 exposure in an emergency room or in a clinic.
When telepresenters go into older, frail adults’ homes, this gives the physician valuable information on these elders’ lifestyles and situations. “For example, a telepresenter may walk into a home, open the refrigerator and discover there is no food,” says Agha. Or perhaps there are prescription medications from the 1960s mixed in with those purchased a week prior. “This is something you’d never learn from a 10-minute office visit,” he adds.
Some particularly tech-savvy older adults could be left with telehealth equipment and perform similar functions without a telepresenter’s help, but as Agha stressed, the end point of this exercise is not to eliminate all human interaction, but instead to make full visits possible for older adults without them having to leave their residences.
“It’s well beyond efficiency and cost considerations,” said Zifferblatt, “it’s really first and foremost about allowing elders to preserve their level of independence and quality of life by having the visit at home.”
West has been deploying this telehealth model within its PACE program, to effect visits in participants’ homes and to send information back to the PACE provider.
In mid-April, West had just gone live with new telehealth sites, including the capability to connect emergency rooms to staff of local nursing homes and long-term care facilities, to provide more resources and help to manage the COVID-19 crisis. Even in the midst of the crisis, older adults still can have other medical needs; this reality means the telehealth option can keep some of those patients out of the hospital. West fully protects their telepresenters by pre-interviewing patients regarding any potential COVID-19 symptoms and equipping staff with the necessary Personal Protective Equipment.
As to why telehealth hasn’t been more readily adopted nationwide, especially considering its upsides, Agha says that it has been successful when rolled out on a large scale at Kaiser Permanente and within the Veterans Administration, but due to the vagaries of healthcare financing, it has been slower to catch on elsewhere. But he thinks the current public health crisis may just give a needed push to finally reform healthcare billing and payment structures.
“Payers have been wary of unfettered telehealth, fearing it would be an additive, not a substitute for regular care,” said Zifferblatt. “Some thought it might be a way for practitioners to increase revenue without increasing value, so bumpers were put in place to avoid that.” He thinks those barriers will change as the system evolves from traditional fee-for-service care or risk-based care, where there is less potential for abuse. He also notes that it’s sometimes difficult for humans to get comfortable with doing things in different ways. But now, with the escalation of Zoom meetings and online school instruction, some of those psychological barriers may be breaking down.
“Due to what has happened in the past four weeks, I do not think we will go back to practicing medicine the way we were before February 2019,” said Agha. “But we’ve learned a lot that will improve how we deliver care, and it’s on us to make sure those learnings stick, so we can continue on the path toward delivering the right care, at the right time, at the right cost.”
“Our goal is to do this telehealth demonstration and share what we learn from it with as many partners as we can at the national level—through blogs, webinars and whatever else it takes to accelerate telehealth adoption,” he adds.
For more information on West’s approach to telehealth, click here.