Novel solutions for dermatologic care of geriatric patients and the role of the dermatology house call.

To the Editor: In their letter, Simpson and Kovarik discuss strategies for optimizing virtual dermatologic care for older patients during the COVID-19 pandemic. They suggest telephone encounters supplemented with photographs for patients with established diagnoses as alternatives to video visits. They also advocate for simplified connections for video visits, practice sessions with staff, larger screens and speaker phones to assist with visual/auditory limitations, and 3-way video visits, such that a friend/family member is present for support. These recommendations are valuable when caring for some older patients with dermatologic concerns. Novel solutions are necessary for managing geriatric patients with more severe physical, mental, and social limitations.

The number of older homebound adults is increasing. Physically traveling to an office visit is often problematic, and it becomes financially challenging if a caregiver or special transportation is needed. In a study of older adults (>65 years), homebound status was associated with greater 2-year mortality, (hazard ratio, 2.08; 95% confidence interval, 1.63-2.65; P < .001) after adjusting for sociodemographics, comorbidities, and functional status. Therefore, telehealth must be optimized for this population. Smartphone ownership and internet use were reported by 42% and 67% of adults 65 years and older, respectively. Older patients can use and adopt technology, but they may need more training. Physicians should be mindful of visual, hearing, and cognitive impairments.

We suggest additional strategies to those discussed by Simpson and Kovarik when caring for older adults via telemedicine. Caregivers (family or paid) may be enlisted to help with downloading apps, logging on, lighting/environmental issues, and camera manipulation. Staff can train caregivers/patients on image collection (ie, near and far photos or using a coin or a ruler for scale). If caregivers are not available, consider partnering with other medical professionals who normally visit the home. For example, if the patient has a need for skilled nursing (e.g., wound care), a home health nurse would be an ideal partner because wound/skin care instructions could be communicated during the virtual visit. If no assistance is available and the patient has difficulty manipulating the camera during the video visit, a visual chart with different morphologies can be used to help the patient describe the dermatologic concern.

A dermatology house call is an innovative way to care for older patients who cannot be treated via telehealth and/or when a biopsy is necessary. The Mount Sinai Visiting Doctors and the Weill Cornell Evelyn Gruss Lipper House Call program are well-established academic, home-based primary care programs. , Similar house call programs could be implemented nationwide by partnering with already existing primary care programs to care for homebound patients with dermatologic concerns. “Dermatology house calls” conducted in partnership with academic home visiting programs would provide potential opportunities for multiple levels of trainees from dermatology, geriatrics, and internal and family medicine to diagnose and treat patients during a time when more virtual learning prevails.

The COVID-19 pandemic has propelled us to formulate novel solutions to care for older patients with dermatologic conditions, which may also benefit this population in the future.