Strategies to Ensure Continuity of Care Using Telemedicine with Older Adults during COVID-19: A Qualitative Study of Physicians in Primary Care and Geriatrics.

Objectives: Our objective was to interview primary care physicians (PCPs) and geriatricians on their experiences using telemedicine during the COVID-19 pandemic to examine strategies used to maintain continuity of care with their patients, ages 65 and older. Methods: Using purposive sampling, we selected physicians based on community size (metro/suburban/rural) and practice setting (academic/community) and conducted semi-structured interviews via Zoom (mean: 30 minutes). Interviews were recorded, transcribed, coded, and analyzed using framework analysis. Results: We enrolled 33 physicians (15 PCPs and 18 geriatricians) from July to November 2020. Findings indicate that many physicians successfully bridged the digital divide by: assessing patients' technological readiness in advance, being flexible with telehealth modes, using available home or facility-based staff, educating patients on telehealth privacy and usefulness, making accommodations for disabilities, and involving caregivers. Discussion: These findings can inform future policy and practice and assist physicians in resolving addressable barriers to telehealth use among older patients.

Transitioning to telehealth? A guide to evaluating outcomes.

Objectives: Telehealth use has surged since the onset of the coronavirus disease 2019 (COVID-19) pandemic, but the evaluation of telehealth outcomes and performance has not necessarily matched the pace of its uptake. In this article we aim to guide the design of a telehealth evaluation system encompassing all four domains of the outcome measurement framework developed by the National Quality Forum (NQF) - access to care, cost, experience, and effectiveness. We aim to achieve this through proposing survey items that can be distributed to patients or clinicians as a questionnaire and providing suggestions on areas of focus for evaluation studies. Methods: Using PubMed and Google Scholar search engines, we performed a literature review of articles related to the evaluation of telehealth outcomes that were published in English since 2000. Results: We found existing survey tools to assist the development of an evaluation questionnaire, and categorized items into the four NQF outcome domains. For each outcome domain, we also summarize existing work on evaluation and make recommendations on areas for future assessment. In particular, we found that telehealth accessibility and accommodations have been historically under-studied and provide tools to address this. Conclusions: Evaluating telehealth outcomes is critical to ensure efficient and high-quality care delivery, and we believe establishing an evaluation system will help practices assess and improve their telehealth systems as well as their ability to use telehealth to respond to the diverse needs of patients. Public Interest Summary: Since the start of the coronavirus disease 2019 (COVID-19) pandemic, telehealth use has been on the rise. Evaluating outcomes related to telehealth is critically important, but given the urgency of telehealth uptake, many health systems and practices may not yet have evaluation systems in place. This article guides the design of a telehealth evaluation system by proposing several validated and novel survey questions that can be used as part of a patient or clinician questionnaire and suggesting important measures of outcome for evaluation studies to assess across the four domains of telehealth quality as outlined by the National Quality Forum (NQF) - access to care, cost, experience, and effectiveness. We present tools to reach priority populations who often lack access to remote care, including older adults, underrepresented minorities, and people with disabilities.

Emergency physician perspectives on using telehealth with older adults during COVID-19: A qualitative study.

OBJECTIVES: Emergency medicine physicians have played a pivotal role throughout the coronavirus disease 19 (COVID-19) pandemic through in-person and remote management and treatment. Our primary objectives were to understand emergency medicine physicians' experiences using telehealth throughout the pandemic, any facilitators/barriers to successful usage, lessons learned during implementation, and successful/abandoned strategies used to engage with older adults. METHODS: Using a semi-structured interview guide, we conducted 30-min interviews. We used purposeful sampling to recruit emergency medicine physicians from all United States regions, rural-urban settings, and academic and community practices, who reported caring for patients 65 years or older in-person or virtually during the pandemic. Interviews were audio-recorded, transcribed, double-coded, and analyzed for emergent themes using framework analysis. RESULTS: A total of 15 in-depth interviews were completed from September to November 2020. Physicians had a median age of 37 years, 7 were women, and 9 had experience with telehealth before the pandemic. We identified several themes: (1) there were various motivations for telehealth use; (2) telehealth was used primarily to supplement, not replace in-person care; (3) most platforms were easy to use; (4) patients and caregivers had high acceptability of telemedicine; and (5) older adults with sensory and cognitive impairments often relied on caregivers. Emergency medicine physicians played a critical role during primary care office closures during the first wave-dispelling misinformation about COVID-19, triaging patients to testing and treatment, and providing care that would otherwise have been deferred. CONCLUSIONS: Our data show that telemedicine gained acceptability among emergency medicine physicians and provided options to patients who may have otherwise deferred care. These findings can inform future healthcare delivery for acute care needs or pandemic responses.

Telehealth was beneficial during COVID-19 for older Americans: A qualitative study with physicians.

BACKGROUND: Individuals aged 65 and older face unique barriers to adoption of telehealth, and the coronavirus disease 2019 pandemic has provided a "natural experiment" in how to meet the health needs of older patients remotely. Physician perspectives on practical considerations surrounding telehealth adoption, motivations of use, and reasons for nonuse are necessary to inform the future of healthcare delivery. The objective is to understand the experiences of physicians using telemedicine for older patients. METHODS: From September to November 2020, we conducted 30-min semi-structured interviews using purposeful sampling to identify and enroll participants from diverse settings. We included 48 U.S.-based physicians (geriatrician, n = 18, primary care, n = 15, emergency, n = 15) from all geographic regions, rural-urban and academic/community settings. Audio-recorded interviews were professionally transcribed and analyzed using framework analysis. Major themes and subthemes were identified. RESULTS: Participants had a median (interquartile range) age of 37.5 (34-44.5), 27 (56%) were women. Five major themes emerged: (1) telehealth uptake was rapid and iterative, (2) telehealth improved the safety of medical care, (3) use cases were specialty-specific (for geriatricians and primary care physicians telehealth substituted for in-person visits; for emergency physicians it primarily supplemented in-person visits), (4) physicians altered clinical care to overcome older patient barriers to telehealth use, and (5) telehealth use among physicians declined in mid-April 2020, due primarily to patient needs and administrator preferences, not physician factors. CONCLUSION: In this qualitative analysis, physicians reported a rapid, iterative uptake of telehealth and attenuation of use as coronavirus disease 2019 prevalence declined. Physician experiences during the pandemic can inform interventions and policies to help buoy telehealth for ongoing healthcare delivery and ensure its accessibility for older Americans.