Special Consideration Needed for Older Patients Using Telecare

When most people think about healthcare, the images that come to mind include a trip to their local provider’s office, lab, or hospital for services such as physicals, blood tests, and procedures. However, medical professionals and their patients are increasingly transitioning to more remote services that leverage our advances in communication technologies, resulting in the burgeoning “tele” world of healthcare. But are these services reaching everyone?

Telemedicine, telehealth, and telecare are three examples of remote, interactive services that allow patients to receive healthcare from within their own homes. Although these terms are often used interchangeably, they in fact refer to different aspects of healthcare delivery. Telemedicine applies to physicians who use technology to support the delivery of medical, diagnostic, or treatment-related services. Telehealth is like telemedicine but applies to a broader collection of providers, such as nurses or pharmacists. Telecare (see Figure 1) is generally more consumer-oriented by providing the patient with technology to manage their own care safely from home, such as health apps or digital monitoring devices.

Figure 1. Telecare Slide from MVC Workgroup Presentation

The adoption of “tele” services saw incredible growth in 2020 in response to the pandemic. A report found that Medicare telehealth visits increased 63-fold recently, from 840,000 in 2019 to 52.7 million visits in 2020. However, now that adoption of these services (and the platforms needed to host them) are more commonplace, providers are asking whether it benefits their most vulnerable patients and who may be left behind.

These questions drove the discussion of the most recent MVC workgroup on chronic disease management. Over the course of the session, attendees were particularly interested in how telecare improves elderly care, and whether patients over the age of 65 could adequately access such services. For those older adults utilizing telecare, evidence from the ongoing COVID-19 pandemic identified convenience and affordability as telecare’s primary strengths. In addition, research evidence suggests that the two most effective telecare interventions in this population are automated vital sign monitoring and telephone follow-up by nurses.

Some of the challenges often cited for this population include lack of appropriate internet access or devices, limited digital literacy, medical conditions that may impede participation (i.e., hearing or vision impairments, dementia, etc.), and the need to regularly monitor vitals in very high-risk patients. Although the authors compiling these challenges specifically reference older adults, they could just as easily apply to people experiencing poverty, people with disabilities, and people with more limited language and literacy skills.

Some recommended strategies to address common challenges include tablet delivery services, “mobile medical assistants” who perform video set-up for the patient, assistance from an on-site caregiver, practice or “mock” video visits prior to the appointment date, partnerships with community health workers to support or train patients in their homes, and providing self-monitoring devices. Other simple considerations include the size of the text displayed on the page (use larger text to enhance readability), providing adequate instructions in advance and in multiple languages, and engaging experts in user experience design.

In addition to these considerations, some researchers suggest that, in general, the adoption of new technologies can be predicted in part by Everett Rogers’ Diffusion of Innovation Theory. One study incorporating this theory found that the chances of telecare adoption were highest for three types of older adults: those already receiving long-term or nursing care, those living alone, and those who have fixed daily telecare points of contact.

Increased integration of technology in healthcare is inevitable as advancements continue and we shift to a more digital world. Since the number of people in the U.S. who are age 65 or older will more than double over the next 40 years, it is imperative that older adults are not left behind when transitioning to such services. Rather than fear the challenges, researchers and practitioners are seeking ways to find solutions and help all patients benefit from healthcare access within their own homes.

The MVC Coordinating Center encourages its members to collaborative with one another to benefit from peers’ success stories and lessons learned. If your hospital or physician organization has developed an age-friendly telecare protocol, please consider sharing your story with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. To catch up on the recent MVC workgroup discussion about telecare, watch the chronic disease management workgroup recording here.


Studies Find Value in Virtual Reality for Pain Management

Pain management is a critical component of effective care for patients. Amidst the opioid epidemic, however, pain management is highly nuanced for clinicians balancing their patient’s needs and wishes with state and hospital guidelines for prescribing. Although these guidelines are designed to curb opioid misuse—over 10 million patients misused prescription opioids in 2019—they are sometimes at odds with patient-based considerations. One research article, for example, found that, “many physicians expressed appreciation for opioid prescribing guidelines and simultaneously voiced concern about opioid restrictions that obviate the application of clinical reasoning.” In addition, some studies have called into question whether policies aimed at curbing overprescribing of opioids have a meaningful effect. One study noted that joint replacement surgeries from 2014 to 2017 saw increases in the percent of patients receiving opioids without clinically meaningful improvements in post-operative pain.

Therefore, when non-opioid pain management methods emerge in the medical literature as efficacious, there is a significant potential for impact coupled with great interest in its feasibility. Around the time the opioid epidemic was declared a public health emergency by the U.S. Department of Health and Human Services, one such pain management method emerged within medical research: virtual reality therapy.

Virtual reality therapy entails wearing virtual reality goggles and participating in an immersive, three-dimensional computer environment that distracts the patient from their pain. In some instances, it was proven effective for decreasing opioid use during painful wound procedures, and in other cases for helping patients learn how to manage chronic pain and achieve decreases in reported pain scores. Amid this excitement, one research team endeavored to measure the, "cost and effectiveness thresholds [virtual reality] therapy must meet to be cost-saving as an inpatient pain management program." They found that inpatient virtual reality therapy could reduce costs for a hospital if the length of stay was reduced because of its use; reductions in opioid use and related reimbursements were not enough in isolation to overcome the costs of virtual reality. This study found cost savings achieved in 89% of the trials it investigated.

Once studies have determined that a treatment is effective, the next question is whether it is effective for a more heterogeneous population—often, the patients included in medical research are white, relatively advantaged patients with higher-than-average education and literacy. With a growing focus in healthcare on health equity, it is important to determine whether virtual reality therapy also has potential in diverse patient populations. Just two months ago, a study from UC San Francisco was published that investigated the use of virtual reality among frontline pain management clinicians, particularly those in safety-net healthcare settings. The study found that clinicians and leadership in these healthcare settings were very interested in virtual reality therapy as a safer alternative to opioids. However, they also noted a need for significant tailoring for various cultures, languages, and technical abilities. They also expressed concerns about obtaining reimbursements and integrating the technology into complex workflows.

Virtual reality may offer potential savings as well as greater patient satisfaction for some hospitals and health systems right now. For others, it may take time and collaboration before virtual reality therapy is a feasible pain management alternative. The MVC Coordinating Center is interested in documenting how its members are approaching pain management and rising technologies like virtual reality. If your hospital or physician organization has found success in offering virtual reality therapy to patients or implemented other successful opioid-reduction interventions, please share your story with the MVC Coordinating Center (michiganvaluecollaborative@gmail.com) so other MVC members may benefit from your experience.