Advancing geriatric health through telemedicine: strategies for primary health care

Half of the world’s population, around 4.5 billion people, are lacking access to essential health services. Even though, in a world where illness knows no bounds, the pursuit of health transforms into a luxury accessible only to the privileged, leaving elderly individuals marginalized and underserved. Unfortunately, there is no definitive answer about the number of elderly individuals lacking access to geriatric care due to limited data availability, different definitions of geriatric care, and heterogeneity. Out-of-pocket health spending is higher among older individuals in poorer households, rural areas, and those with older family members, contributing to financial hardship and further poverty1. So, elderly individuals often find themselves homebound due to deteriorating health, limited financial ability, physical, mental, and social limitations. Geriatric care plays an essential role in addressing the unique healthcare needs of the elderly population, by addressing their chronic conditions, providing preventative care, and maintaining the quality of life. Even though the pace of elderly population is much faster than in the past2, there is a significant shortage of trained geriatricians, nurses, social workers, and pharmacists3–6. Clinicians are increasingly providing geriatric services to older people, despite the lack of comprehensive guidance on age-appropriate implementation and treatment. Older people are not monolithic, and their health conditions and treatment goals vary, impacting their preferred types of care and preferences. A systematic review done among 137 countries found that nearly 8 million people die every year because of lack of access to high quality care7. However, it is notable that studies often overlook the elderly population in their analyses. Highlights There is no definitive answer about the number of elderly individuals lacking access to geriatric care due to limited data availability, different definitions of geriatric care and heterogeneity. Telemedicine in primary health care can be a feasible approach to assist older people in connecting with healthcare providers and caregivers while reducing complications regarding time, distance, and money. Health system, physical and patient- driven strategies can improve health-related quality of life, satisfaction, and reduce care costs for elderly patients. Telemedicine in primary health care allows organizations to pull providers from larger pools, ensuring the right care level is provided for each appointment, thereby enhancing patient care. It has been proven as a feasible approach to assist older people in connecting with healthcare providers and caregivers while reducing complications regarding time, distance, and money. Positive results were reported on adherence to medication, self-efficacy, and effectiveness, among the telemedicine studies compared to usual care8–10. High-intensity telemedicine has also significantly reduced emergency department use and has been proven as an alternative to traditional acute illness care11. WHO proposes a primary health care (PHC) strategy for Universal Health Coverage, potentially saving money and achieving 75% of Sustainable Development Goals’ health improvements. Even though the PHC system is the point of contact, it lacks the time, expertise, and resources to carry out standard comprehensive geriatric examinations and do multidisciplinary telemedicine approaches12. In addition to having difficulty accessing digital health technologies, patients may not trust the care provided by the virtual platform. Based on the identified barriers and facilitators, tailoring geriatric care through a telemedicine approach in primary health centers is essential to improve their access to their needs, and optimize health outcomes, especially in underserved communities. Health system-driven strategies Overcoming geographical barriers Several elderly people struggle with mobility owing to physical restrictions or a lack of cheap transportation, while others find themselves fully homebound. Addressing the current inequities among marginalized populations can be done through establishing partnerships between health providers and private industry vendors, NGOs to ensure the provision and support of technical assistance. Community health workers as coordinators can book the telemedicine visits and can assist the transition from face-to-face consultations to teleconsultation, empowering older persons13–15. Remote telenursing assistance was introduced as a new service outside regular care facilities, available to patients at no cost16. Overcoming linguistic barriers Equitable access to telehealth also includes elders and caregivers with cultural and linguistic differences. Effective communication is a two-way exchange between patients and healthcare systems. Telehealth systems designed in a way to assign the patient to the provider, and align with their linguistic differences have shown a better impact on patients’ health outcomes17. Language translation technologies or certified translators can also help connect older adults with any healthcare provider. Breaking the digital divide Van Dijk and Hacker identified four categories of barriers that cause a digital divide: mental, material, skills, and usage. In older people, besides mental and material challenges, skill barriers may have more to do with the user-friendliness of telehealth platforms than basic skills18. Even though they are eager to adopt technology, lack of clarity, understanding, practice, and support exists19. Provide patients with low technical literacy options like telephone calling instead of video conferencing technology. Woodall et al and Zhai advocated for low-cost internet bandwidth for those with limited internet access and increased funding for virtual primary care expansion in rural and underserved areas20. To ease the implementation of virtual care, enterprises should invest in governance systems and user experience. Electronic health records storage and transfer Due to the lack of appropriate existing primary healthcare virtual infrastructure, discrepancies in integration with EHR can lead to administrative load and provider burnout21. Fast Healthcare Interoperability Resources Application Programming Interfaces seamlessly integrate with third-party video conferencing platforms. This technology enables healthcare providers to easily share and exchange information. As people age, their care becomes more complex due to increasing medical, socioeconomic, cognitive, and functional status. Prescriptions for older adults are challenging due to interindividual variability, comorbidities, disability, and medication usage. The implementation of integrated and coordinated telehealth systems has significantly led to better health outcomes22. Multidisciplinary telemedicine approach A multidisciplinary approach can be used to improve the elderly’s quality of life. Weekly vital parameter monitoring and nutritional counseling, biweekly psychological counseling, and a monthly consultation with a specialist can be included in the approach23. For example, neuropsychological assessments, including mini-mental state examinations, daily living activities, geriatric depression scales, and health surveys, have been shown to reduce depressive symptoms and improve quality of life24. Telemedicine is considered as a safe option and showed a 74% diagnostic concordance and 79.8% treatment concordance between in-person and remote doctors13. Integration of clinical decision support system Multimorbidity is a global health issue in primary care, and Digital Service Systems can be used for telemedicine functions like telemonitoring, consultation, case management, and patient education. However, the structure of CDSSs varies. Telemedicine and CDSSs can support patients with multimorbidity, but further exploration is needed to expand the medical conditions examined, examine CDSS tasks for multiple condition screening and diagnosis, and explore the patient’s role as the direct user of the CDSS25. CDSS has been shown to improve the hospital care of older patients26, but evidence in telemedicine is limited even though the potential is higher. Telemonitoring and telescreening It is advisable to monitor their activities of daily living due to limitations in mental and physical efficiency while aging9. Remote patient monitoring models using community volunteers are effective in reducing hospital utilization for individuals with chronic diseases, making them easily implementable in community settings27. Smartphones inserted with a gas or smoke detector, flood detector, motion sensor, fall detectors, gait monitors, talking pillbox and sleep monitor are some examples of telemonitors. Telemedicine screening tools have been used for early detection of diseases such as stroke28, diabetic retinopathy29, autism spectrum disorders30, and early detection of cancer31, in a primary healthcare setting itself. Reimbursement and regulatory coverage One of the primary barriers was the lack of adequate reimbursement rules for healthcare workers, such as nurses and allied healthcare professionals20. Reimbursement should be provided for structured telemedicine communications in public and private health plans, whether text-based or voice, video, or device-based, as they may be clinically appropriate services similar to face-to-face encounters32. Capitation models based on patient characteristics, including remote monitoring for home care patients, accurately reflect the time spent managing complex diseases. Physician driven strategies The advanced preparation of health visits Telemedicine is a newer experience for older adults and their caregivers and may not seem easy to them due to the technology gap. Physicians are implementing various strategies to improve telehealth capabilities, including calling patients before visits, using phone calls for audiovisual platforms, delivering tablets to those without devices, and utilizing caregivers for video visits. ACP promotes episodic telemedicine services as an intermittent alternative to primary care physicians for urgent acute care requirements33. Physicians should professionally judge to determine if the patient needs telehealth/ in person care and should not compromise their ethical obligation to deliver clinically appropriate care for the sake of new technology adoption. For example, older adults with uncomplicated urinary or respiratory tract infection can be treated through telemedicine but people with complex medical issues such as chest pain or stroke would need an in person care. Confirming availability with patients helps them receive timely medical care, preventing the worsening of their conditions. Offering educational materials in multiple languages and channels and developing training modules for healthcare providers and older adults on video conferencing software, troubleshooting technical issues, mock trials, and safeguards will meet their needs. These include trained geriatricians, pharmacists, clinical social workers with a target audience of primary care trainees, and presence of community health officers. Meeting patient needs via multi modalities of telehealth If the telehealth platform experiences any downtime, backup platforms ensure doctors can seamlessly switch to avoid disruptions in patients’ appointments. User-friendly devices and platforms with simple access to teleconsultations are recommended14. Given the hearing and visual challenges, user-centered designs with large, thick fonts, cursors, selectors, and adjustable audio capabilities with options for voice-to-text or text-to-voice are recommended to enhance the quality34. Switching to telephone calls is another way to accommodate patients with the least technical approach. Every patient is unique, so there is no one-size-fits-all all approach to telehealth vs in-person care. Providers should decide on an appropriate mix of telehealth and in-person visits to make a tailored treatment plan for each patient. Ancillary services and community partnerships Community health workers, and nurses play a crucial role in monitoring patient’s health, and vital signs by doing home visits to patients with the help of digital assistants13. Social workers can perform cognitive assessments, provide counseling, and connect them with assistance programs such as home care services, transportation assistance, meal delivery or financial aid. Additionally, a pharmacy technologist or medical assistant performs medication reconciliation with patients before the virtual visit, or if they have their medications readily available, during the visit. This approach emphasizes the importance of patient involvement and medication reconciliation35. Especially for isolated and homebound adults, medication delivery services through community health workers ensure that they have timely access to the prescribed medication. Patient-centered strategies Patient education on telehealth privacy and benefits Older individuals may find telemedicine uncertain in privacy. Healthcare providers, community health workers, and telemedicine assistants can address their concerns and support to make them feel comfortable with telehealth. Explaining data security, and measures taken to protect their confidentiality is essential. By consistently providing professionalism and respect for patient privacy, providers can eventually build trust over time. Addressing disabilities using technology Healthcare providers have followed mindful pausing, active listening, enunciating more clearly, speaking slower, and speaking louder to patients throughout teleconsultations. They also used Bluetooth-enabled headphone devices and chat features to improve communication with older patients36. After-visit summaries allow patients and their doctors to review past diagnoses, treatment plans, and recommendations, ensuring continuity of care and providing accurate information for caregivers. Telehealth faces limitations in conducting certain examinations typically performed in-person. However, experimenting with different assessments can help providers identify innovative strategies for patient assessment. For instance, mini cog assessments can be performed without challenges compared to standard cognitive assessments (SLUMS). Healthcare providers can still optimize telehealth experiences or prefer in-person care for assessments. Involving family members and caregivers Older adults require a higher level of involvement from their informal caregivers for care coordination and decision making. Informal caregivers play an important role in ensuring that older individuals have easier and more timely access to community and healthcare systems, therefore meeting their complex necessities with training. Apart from assisting with technology, involving their family and caregivers with additional training can help physicians to monitor their vitals, inspection, and palpation35. Incorporating family and caregivers’ opinions in treatment planning builds trust and improves care efficiency. Providers can use telehealth technology to include family members who live far from the older adult to foster direct communication and connection. Strength and limitation The strength of this work is it has incorporated various strategies on advancing the geriatric care through telemedicine in primary care on a global perspective. Recommendations have been made for healthcare providers and health systems specifically to adapt irrespective of their location, federal policy and organizational factors. While the paper offers recommendations to be applicable across different healthcare settings, it may not account for unique challenges faced by a particular region. It could benefit more from specific examples and case studies implementing doctor-to-patient, doctor-to-doctor telemedicine platforms as well. Conclusion Older adults’ health conditions and treatment goals vary, impacting their preferred types of care and preferences. The decision-making revolves around the older adult being serviced. Care considers an older adult’s care choices, goals desires, capabilities, support system, and situations. Addressing these challenges requires collaborative efforts from healthcare providers, policymakers, community organizations, and other stakeholders to ensure equitable access to telemedicine services and optimize health outcomes for older adults. By leveraging the potential of telemedicine and adopting patient-centered approaches, primary healthcare systems can advance geriatric health. Aligning care with these goals can improve health-related quality of life, satisfaction, and reduce care costs, as older adults are not monolithic. - Strategy Description Health system strategies Reimbursement and regulatory coverage Ensure adequate reimbursement for telehealth services and capitation models based on patient characteristics. Overcoming barriers Address geographical, linguistic, and digital disparities through partnerships, language accommodations, and improved internet access. Hub and Spoke Model with EHR Integration Support integration of Fast Healthcare Interoperability Resources (FHIR) APIs for seamless EHR integration and coordinated care. Physician strategies Advanced preparation of health visits Prepare patients for telehealth by explaining benefits and limitations, setting expectations, and addressing barriers. Meeting patient needs via multi-modalities Offer backup telehealth platforms, simplify access, switch to telephone calls when needed, and determine the appropriate mix of telehealth and in-person visits. Ancillary services and community partnerships Utilize home health aides, nurses, and social workers for remote support and assistance. Telemonitoring Utilize telemedicine-based home care for comprehensive supervision and remote patient monitoring models using community volunteers. Patient-centered strategies Patient education on telehealth Address patient concerns regarding privacy and benefits of telehealth. Addressing disabilities Adapt communication for patients with impairments and provide after-visit summaries for continuity of care. Involving family members and caregivers Train caregivers in care coordination and involve them in treatment planning.