Implementation of a telemedicine geriatric co-evaluation in the emergency department: a prospective pilot study.

  INTRODUCTION: Complex drug management is a common challenge in the treatment of geriatric patients. Pandemic scenarios, such as the current one (COVID-19), call for a reduction of face-to-face meetings, especially for elderly patients. Therefore, the aim of the present study was to compare the innovative concept of applying telemedical assessment to geriatric patients in the emergency department (ED) with ED standard treatment. The therapeutic recommendations regarding drug management from the two assessments were compared. A special focus was the use of potentially inadequate drugs (PIMs) for geriatric patients according to the “Fit for the Aged” (FORTA) classification. METHODS: 50 patients (40% female) aged ≥70 years and assessed with an Identification of Seniors at Risk Score (ISAR score) of ≥2 admitted to the ED were prospectively enrolled in this study between November 2017 and February 2018. In addition to the standard treatment in the ED, co-evaluation via video transmission was independently carried out by a board-certified geriatrician. Drug recommendations by ED physicians (A) and the geriatrician (B) were compared. RESULTS: There was a significantly higher frequency of recommendations regarding changes to preexisting medication (p <0.001, n = 50) via geriatric telemedicine in comparison with standard ED treatment. The geriatrician intervened significantly more often than the ED physicians: discontinuation of a drug, p <0.001; start of a new drug, p = 0.004; dose change of a drug, p = 0.001; n = 50). Based on the additional therapy recommendations of the geriatrician, the amount of medication taken by the patient was significantly reduced compared with standard ED treatment (ED assessment t(49) = 0.622 vs geriatrician’s assessment t(49) = 4.165; p <0.001; n = 50). Additionally, the number of PIMs was significantly reduced compared with standard medical treatment (p <0.001). The geriatrician changed 53.9% of the drugs (35/65) whereas the ED physicians changed only 12.3% (8/65). Recommendations for immediate drug therapy, however, were made more frequently by ED physicians (p <0.039, n = 50). DISCUSSION: An early assessment of elderly emergency patients by a geriatrician had a significant impact on the number of drug interventions in the ED. The number of PIMs could be significantly reduced. Whether this also has a positive effect on the further inpatient course needs to be investigated in further prospective studies. The study was retrospectively registered at ClinicalTrials.gov (NCT04148027).  .

Promoting Healthy Aging During COVID-19.

Older adults have been markedly impacted by the coronavirus disease 19 (COVID-19) pandemic. The American Geriatrics Society previously published a White Paper on Healthy Aging in 2018 that focused on a number of domains that are core to healthy aging in older adults: health promotion, injury prevention, and managing chronic conditions; cognitive health; physical health; mental health; and social health. The potentially devastating consequences of COVID-19 on health promotion are recognized. The purpose of this article is multifold. First, members of the Healthy Aging Special Interest Group will present the significant difficulties and obstacles faced by older adults during this unprecedented time. Second, we provide guidance to practicing geriatrics healthcare professionals overseeing the care of older adults. We provide a framework for clinical evaluation and screening related to the five aforementioned domains that uniquely impact older adults. Last, we provide strategies that could enhance healthy aging in the era of COVID-19.

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

[Inpatient equivalent treatment : A new form of care also in gerontopsychiatry]. / Stationsäquivalente Behandlung : Eine neue Versorgungsform auch in der Gerontopsychiatrie.

Since 2018, following a revision of the German Social Code Book V (SGB V), it has been possible for psychiatric hospitals to provide inpatient outreach treatment in the domestic environment of psychiatric patients. Special structural features and documentation requirements must be observed. In addition to a member of the medical and nursing professions, the treatment team must include at least one member of a third professional group (e.g. occupational therapy, social work, physiotherapy). The reimbursement of services is negotiated between the respective medical institution and the health insurance companies and includes regionally divergent billing on the basis of lump sums, per minute worked or mixed models. From a psychiatric psychotherapeutic point of view the treatment of gerontopsychiatric patients in their living environment and thus in their social context offers many advantages. A prerequisite for the success of this approach is a multiprofessional treatment team that is also experienced in somatic illnesses and logistically highly flexible. Under the conditions of the corona pandemic special challenges arise from the prohibition of visiting nursing homes and the risk of infection for patients and members of the treatment team associated with outreach work.

Efficacy and safety of COVID-19 vaccines in older people.

Several vaccines against coronavirus disease 2019 (COVID-19) are on the cusp of regulatory approval. Their safety and efficacy in older people is critical to their success. Even though care home residents and older people are likely to be amongst the first to be vaccinated, these patient groups are usually excluded from clinical trials. Data from several Phase II trials have given cause for optimism, with strong antibody responses and reassuring safety profiles but, with the exception of AstraZeneca's vaccine, recruited few older people. Overall, the sparse data from Phase II trials suggest a reduction in both antibody responses and mild to moderate adverse events in well older people compared to younger participants. Many of the Phase III trials have made a conscious effort to recruit older people, and interim analyses of the Pfizer and Moderna vaccine have led to press releases announcing high degrees of efficacy. However, older people with co-morbidities and frailty have once again been largely excluded and there are no published data on safety and efficacy in this group. Although the speed and impact of the pandemic on older people with frailty justify an approach where they are offered vaccination first, patients and their carers and supervising health care professionals alike will need to make a decision on accepting vaccination based on limited evidence. Here we review the main candidate vaccines that may become available, with a focus on the evidence of safety and efficacy in older people.

Incorporating Issues of Elderly Loneliness into the Coronavirus Disease-2019 Public Health Response.

As the systems that people depend on are increasingly strained by the coronavirus disease-2019 (COVID-19) outbreak, public health impacts are manifesting in different ways beyond morbidity and mortality for elderly populations. Loneliness is already a chief public health concern that is being made worse by COVID-19. Agencies should recognize the prevalence of loneliness among elderly populations and the impacts that their interventions have on loneliness. This letter describes several ways that loneliness can be addressed to build resilience for elderly populations as part of the public health response to COVID-19.

August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19.

PURPOSE: The European Geriatric Medicine Society (EuGMS) is launching a second interim guidance whose aim is to prevent the entrance and spread of COVID-19 into long-term care facilities (LTCFs). METHODS: The EuGMS gathered experts to propose a guide of measures to prevent COVID-19 outbreaks in LTCFs. It is based on the specific features of SARS-CoV-2 transmission in LTCFs, residents' needs, and on experiences conducted in the field. RESULTS: Asymptomatic COVID-19 residents and staff members contribute substantially to the dissemination of COVID-19 infection in LTCFs. An infection prevention and control focal point should be set up in every LTCF for (1) supervising infection prevention and control measures aimed at keeping COVID-19 out of LTCFs, (2) RT-PCR testing of residents, staff members, and visitors with COVID-19 symptoms, even atypical, and (3) isolating subjects either infected or in contact with infected subjects. When a first LCTF resident or staff member is infected, a facility-wide RT-PCR test-retest strategy should be implemented for detecting all SARS-CoV-2 carriers. Testing should continue until no new COVID-19 cases are identified. The isolation of residents should be limited as much as possible and associated with measures aiming at limiting its negative effects on their mental and somatic health status. CONCLUSIONS: An early recognition of symptoms compatible with COVID-19 may help to diagnose COVID-19 residents and staff more promptly. Subsequently, an earlier testing for SARS-CoV-2 symptomatic and asymptomatic LTCF staff and residents will enable the implementation of appropriate infection prevention and control. The negative effects of social isolation in residents should be limited as much as possible.

Home Video Visits: Two-Dimensional View of the Geriatric 5 M's.

Telehealth visits using a video-to-home format are opportunities for virtual house calls. Embracing the benefits of the format allows a patient-centered approach to care that can reveal things that in-person clinic visits may miss.

Rapid Integration of Home Telehealth Visits Amidst COVID-19: What Do Older Adults Need to Succeed?

OBJECTIVE: Our objective was to identify and address patient-perceived barriers to integrating home telehealth visits. DESIGN: We used an exploratory sequential mixed-methods design to conduct patient needs assessments, a home telehealth pilot, and formative evaluation of the pilot. SETTING: Veterans Affairs geriatrics-renal clinic. PARTICIPANTS: Patients with scheduled clinic visits from October 2019 to April 2020. MEASUREMENTS: We conducted an in-person needs assessment and telephone postvisit interviews. RESULTS: Through 50 needs assessments, we identified patient-perceived barriers in interest, access to care, access to technology, and confidence. A total of 34 (68%) patients were interested in completing a home telehealth visit, but fewer (32 (64%)) had access to the necessary technology or were confident (21 (42%)) that they could participate. We categorized patients into four phenotypes based on their interest and capability to complete a home telehealth visit: interested and capable, interested and incapable, uninterested and capable, and uninterested and incapable. These phenotypes allowed us to create trainings to overcome patient-perceived barriers. We completed 32 home telehealth visits and 12 postvisit interviews. Our formative evaluation showed that our pilot was successful in addressing many patient-perceived barriers. All interviewees reported that the home telehealth visits improved their well-being. Home telehealth visits saved participants an average of 166 minutes of commute time. Five participants borrowed a device from a family member, and five visits were finished via telephone. All participants successfully completed a home telehealth visit. CONCLUSIONS: We identified patient-perceived barriers to home telehealth visits and classified patients into four phenotypes based on these barriers. Using principles of implementation science, our home telehealth pilot addressed these barriers, and all patients successfully completed a visit. Future study is needed to understand methods to deploy larger-scale efforts to integrate home telehealth visits into the care of older adults.

New Ways of Working? A Rapid Exploration of Emerging Evidence Regarding the Care of Older People during COVID19.

Health and social care staff have had to quickly adapt, respond and improve teamwork, as a response to the COVID-19 pandemic. Our objective was to rapidly summarize the emerging evidence of new ways of working in the care of older people during this period. We conducted an exploration of the emerging evidence within the timeframe of 1 March 2020 to 11 May 2020. To capture a broad perspective, we undertook thematic analysis of Twitter data which was extracted through a broad search for new ways of working in health and social care. For a more in-depth focus on the health and social care of older people, we undertook a systematic scoping of newspapers using the Nexis UK database. We undertook a validation workshop with members of the interprofessional working group of the Irish National Integrated Care Programme for Older People, and with researchers. A total of 317 tweets were extracted related to six new ways of working. There was evidence of using telehealth to provide ongoing care to patients; interprofessional work; team meetings using online platforms; trust and collaboration within teams; as well as teams feeling empowered to change at a local level. 34 newspaper articles were extracted related to new ways of working in the care of older people, originating in England (n = 17), Wales (n = 6), Scotland (n = 6), Ireland (n = 4) and Germany (n = 1). Four main themes were captured that focused on role expansion, innovations in communication, environmental restructuring and enablement. The results of this exploration of emerging evidence show that health and social care teams can transform very rapidly. Much of the change was based on goodwill as a response to the pandemic. Further analysis of empirical evidence of changing practices should include the perspectives of older people and should capture the resources needed to sustain innovations, as well as evaluate gaps in service provision.

How a Barcelona Post-Acute Facility became a Referral Center for Comprehensive Management of Subacute Patients With COVID-19.

The COVID-19 pandemic's greatest impact is among older adults. Management of the situation requires a systemic response, and post-acute care (PAC) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in post-COVID-19 recovery. In the region of Catalonia, Spain, selected PAC centers have become sites to treat older patients with COVID-19. Referrals come from the emergency department or COVID-19 wards of the acute reference hospitals, nursing homes, or private homes. We critically review the actions taken by Parc Sanitari Pere Virgili, a PAC facility in Barcelona, to manage the pandemic, including its administration, health care, communication, psychological support, and ethical frameworks. We believe that the strategies we used and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented.