Abstract
The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.
Key Points
Clinicians are increasingly providing telehealth care to older adults despite a lack of comprehensive guidance on age-friendly implementation and practice.
The reach of telehealth for older adults remains limited due to several factors, including existing or perceived challenges around physical and cognitive limitations, and a lack of comprehensive guidance on older-adult-focused implementation.
This is the first comprehensive set of provider-focused telehealth principles and guidelines, developed by aging and telehealth experts, to address the specific needs of an aging population.
Why Does This Paper Matter?
The emergence of COVID-19 stretched the US healthcare system and its providers thin. Older adults were tremendously impacted due to their medical complexities and increased risks associated with exposure to COVID-19. Amidst lockdowns and office closures, providers turned to telehealth to provide care to older adults. Because many programs were created rapidly in response to the pandemic, providers had very few resources to consult about how to serve older adults well. Existing resources were often narrow in scope or did not specifically address the unique needs of older adults despite the fact that older adults, especially those in underserved communities, are uniquely at risk when receiving services within a healthcare system that is not designed to meet their needs.
Telehealth should remain a vital tool for caring for older adults as it allows providers to care for people whom they might otherwise have difficulty accessing – such as those who are homebound, those without access to transportation, those with mobility challenges, and those in rural areas where specialists may be non-existent or difficult to access, for example. The Collaborative for Telehealth and Aging (C4TA) was created to develop a set of comprehensive recommendations for providers to help them create telehealth programs designed with older adults' needs in mind. C4TA is a unique and robust group of subject matter experts including geriatricians, experienced telehealth providers, health system administrators, and older adult and patient advocates. C4TA's recommendations are that telehealth must be delivered in ways that are person-centered, equitable and accessible, and integrated and coordinated across people and systems. C4TA's 18 guidelines provide specificity around each principle. Future work will support providers as they make decisions about how best to operationalize these recommendations and analyze their utility.
Introduction
In 2020, COVID-19 taxed the healthcare system exacerbating existing disparities in care access1 and increasing older adults' medical vulnerability. Staffing shortages, staff exhaustion and trauma, and financial instability impacted patient care.1, 2 Ambulatory care practices reported 60% fewer visits early in the COVID-19 pandemic; most deferred elective and in-person visits and increased their use of telehealth.2 Older adults were disproportionately threatened given the risks associated with preventable acute exacerbations of chronic conditions from delayed care,3 and their high-risk association with COVID-19.4 The pandemic presented the U.S. healthcare system with extraordinary challenges, however, it also accelerated innovation in, and adoption of, telehealth.
Telehealth, defined as the use of communications technology to deliver healthcare at a distance, offers advantages including faster referral times,2 reduced clinic cancellation rates,5 hospitalizations,6 and emergency department use,6, 7 increased satisfaction scores,8, 9 and financial savings,6, 9 reduced or eliminated travel,9 and increased caregivers' mental health and sense of wellbeing.10 However, ongoing challenges include the difficulty of serving people with cognitive challenges such as dementia,10 or physical challenges such as visual and/or hearing impairment,11 and the challenges associated with low technical literacy and access.12
Prior to the pandemic, widespread adoption and utilization of telehealth to care for older adults was limited to specific use cases (such as telephonic care) and hampered by reimbursement, licensing, training, and other challenges.13, 15, 14 However, in March 2020, the Centers for Medicare and Medicaid Services relaxed regulatory restrictions that historically prevented telehealth expansion.16 Quickly, providers began using telehealth to serve older adults in unprecedented numbers.17 In early 2020, roughly 13,000 Medicare fee-for-service beneficiaries received telehealth visits each week; by late April 2020, this number reached nearly 1.7 million and telehealth accounted for nearly 50% of all primary care visits for Medicare beneficiaries.17
Telehealth visits slowly declined throughout 2021 as the worst of the pandemic passed, vaccination rates increased, and providers reopened their offices. However, telehealth is now part of the healthcare infrastructure and will continue to be used to care for older adults post pandemic,18 making it crucial that telehealth is optimized for older adults. Telehealth must be thoughtfully designed and delivered to ensure that care is effective, safe, and efficient. Additionally, telehealth must ensure that care is equitable as it has the potential to both ameliorate and exacerbate inequities in care.19 The goal of this report is to introduce a set of provider-focused principles and guidelines for age-friendly telehealth practices, which will help providers meet the needs of older adults. We adopt the World Health Organization's definition of ‘age-friendly’ which states “age-friendly practices recognize there is great diversity in the capacity and circumstances of older adults, anticipate and respond to older adults' needs and preferences in an equitable way, respect older people's decisions and choices, and protect the most vulnerable”.20