Facilitating telehealth for older adults during the COVID-19 pandemic and beyond: Strategies from a Singapore geriatric center.

Dear Editor,

The COVID‐19 outbreak has placed immense pressure on national healthcare systems globally, to increase bed capacity, protect healthcare workers and care for vulnerable groups. As governments implemented social distancing and stay‐home measures to rein in the pandemic, the ability of older adults to access clinical services has been impacted. Older adults are at higher risk of complications and mortality from COVID‐19. Yet, they require continuity of care to control chronic conditions and minimize hospital admissions and emergency attendances. Telehealth services protect healthcare workers and patients from unnecessary potential exposure to the highly infectious severe acute respiratory syndrome coronavirus 2 while allowing for continuity of care.

Older adults face many barriers to the adoption of telehealth services such as cost, access, trust of technology, privacy concerns, design and user interface challenges. Older adults have less experience with emerging technologies and without sufficient impetus may prefer default in‐person consultations. They may require caregivers to assist with use of technology for healthcare. Cognitive impairment is also highly prevalent among older adults, along with physical limitations such as poor vision, hearing or sensory impairment. However, these barriers are not insurmountable. The COVID‐19 pandemic has in fact led to greater uptake of telehealth services among older adults.

A larger proportion of older adults in our geriatric center have accepted teleconsultations compared with younger patients seen by the general medicine department (Fig. 1) during the COVID‐19 pandemic. This demonstrates the potential and appetite for more widespread use of telehealth services among older adults.

Figure 1

(a) Ratio of geriatric medicine in‐person versus teleconsults by week during the COVID‐19 outbreak in Singapore; (b) ratio of general medicine in‐person versus teleconsults by week during the COVID‐19 outbreak in Singapore. n, total number of consults.

We instituted the following strategies to enhance greater uptake of telehealth consultations among older adults:

Collaborations with nearby community clinics have been established to facilitate a pre‐ and post‐consultation laboratory and simple radiological investigations. This minimizes travel for older adults and does not limit care due to lack of laboratory or radiological services. Shared computer access of these investigations allows our physicians to follow up on the results of these tests.

A smooth and seamless workflow was created for patients and their caregivers to arrange teleconsultations. Clinic staff will call beforehand to ensure that the patient is stable and does not request an in‐person review. A weblink is provided via email and short message service (SMS). Patients or their caregivers need only click on the link to access the teleconsultation. They are required to download the teleconsultation application and clinic staff call them beforehand to counsel on the process and coach them on the steps required before confirming the teleconsultation appointment. Special attention is paid to older adults to ensure they are familiar with the workflow and are comfortable with the digital platform before the teleconsult.

Medication delivery to patients’ homes is provided free of charge during this pandemic period in line with government policy to minimize unnecessary travel. Pharmacists will call patients up before dispensing medications and provide counseling as needed.

Telehealth services have rapidly expanded to include a variety of healthcare services frequently used by older adults to maximize convenience and uptake by them. These include teleconsultations with social workers, psychologists, dieticians, therapists, case managers and nurses. Anecdotally, where patients and caregivers find it difficult to find time to meet with allied health professionals and coordinate multiple appointments, teleconsultations allow for greater convenience and even conferences with family members who may have previously not been as involved in the care of the older adult.

Telehealth consultations have helped our institution provide continuity of care to older adults who would otherwise decline healthcare attendances due to fears of contracting COVID‐19. This has enabled us to identify problems early to institute care and avoid unnecessary admissions to prevent strain on the healthcare system. Notably, telehealth consultations decreased rapidly after reaching a peak of 43% of total consultations when a partial lockdown was instituted. The rate of telehealth usage returned to approximately the same levels as those seen in the general medicine clinic. This may have occurred as community transmission of COVID‐19 was brought under more control with the partial lockdown, and patients and caregivers were not as fearful of venturing out as compared with the start of partial lockdown. However, this shows that with the right incentives and strategies or during times of resurgence of pandemics, a significant proportion of older adults are able to engage in the use of telehealth to minimize risks and maximize benefits. As more older adults and their caregivers become familiar with telehealth, it is likely that use of this service will only increase. Further study into the factors for and against use of technology in older adults is warranted to tailor interventions for this group better.

However, there are drawbacks and limitations of telehealth. Clinical examination and assessment are important in caring for older adults who may present atypically. If during the teleconsultation the attending physician decides on the need for an in‐person review, the teleconsultation fee is waived and an in‐person review is arranged. Urgent cases are referred to the emergency department for timely assessment. Not all older adults have blood pressure machines at home. Interval, longitudinal measurement of vital signs and parameters such as weight and body mass index are important in the holistic management of older adults. Opportunities for such baseline measurements are curtailed with teleconsultations. Risks of privacy and data breaches exist for all modes of telecommunication and regulations tend to play catch up to the rapid pace of technological development. In recognition of the need for education and instruction of physicians using telehealth platforms, the Ministry of Health (Singapore) recently launched an online course and guidelines to ensure uniformity of standards across telehealth practices. Careful patient selection is thus important to accrue maximum benefits of teleconsultation to older adults.

While telehealth services have been developed before the COVID‐19 pandemic, the fears and public health impact of the pandemic have fortuitously led to the increased uptake of telehealth services among older adults. This group is likely to benefit greatly from telehealth due to the convenience, time and travel savings. The greater uptake has led to greater familiarity among staff on the workflows and benefits of telehealth consultations. A growing critical mass of telehealth utilization allows institutions to devote more resources to developing telehealth services and would enable us to take advantage of the rapid gains and benefits of technology. This would only bring greater benefits to patients and the healthcare system.

Disclosure statement

The authors declare no conflicts of interest.