Long before the COVID-19 pandemic descended upon us in March 2020, Sinai Geriatrics’ Telemedicine Program for Homebound Elders was providing virtual access to specialist care for frail, homebound adults over the age of 65 in Toronto. Individuals in this vulnerable population often have serious, complex health issues and have difficulty accessing specialist care.
I decided to join this program near its inception in 2015, as I realized that many older patients with heart failure and other chronic health conditions find it very taxing to come in to clinic. Heart failure patients use this program the most. More than half of the patients currently living with heart failure are older than 70 years of age. In order to be eligible for the program, patients must be over the age of 65, home bound, living in Toronto and have a primary or secondary diagnosis of heart failure or other chronic health conditions. With COVID-19 making it even more important for older adults to stay out of hospital, the telemedicine program has allowed me to continue to provide quality, essential care to some of our most vulnerable patients who cannot easily access office-based care in the first place.
Once someone is referred to the program, the program’s geriatrics clinical nurse specialist, Nga Truong, usually reaches out to the patient to do a comprehensive geriatric assessment that includes the patient’s medical and health history and arranges for blood testing. She also arranges for a convenient time when a home visit could occur. The Government of Ontario’s Ontario Telemedicine Network (OTN) provides our program access to secure videoconferencing technology that has improved a lot from the program’s inception. It helps to provide an accurate depiction of important physical examination findings and allows for us to provide excellent communication with patients and their families.
During a typical appointment, Nga arrives at the home and takes a history and does a physical examination. She also goes through the medications to see if there have been any changes since the last visit. Nga and I then connect using the OTN videoconferencing software. I go over the history and also examine the patient. I discuss the plan with the patient including any medication changes and the need for bloodwork. I then fax the prescriptions off to the pharmacy and we then go over any questions the patient and their family may have.
Despite the lack of physical contact that occurs between me and my patients, the video technology allows for a different level of personal connection with our patient. With this program, we have the opportunity to see where the patient lives which allows us to better understand the social context of their illness (and even see pictures of their loved ones or the kind of art that they like!). From a very practical perspective, it allows us to physically check the medications our patients are taking and how they are organized; this can help prevent medication errors. It also provides us an opportunity to see the food they are consuming and educate them about choosing a diet best suited to their medical needs.
Another benefit of the telemedicine program is that it allows access to care for patients who otherwise might not have access to subspecialty cardiology consultation. We have observed that these patients tend to require less emergency room visits and hospital admissions than prior to joining the program.
Since the program began, there have been over 500 telemedicine visits with specialists representing 21 unique specialties including cardiology, nephrology and geriatric psychiatry. Many specialists involved in the program have stated that this model of care has allowed them to fill a unique care gap and maintain continuity of care for frail older patients.
COVID-19 has increased interest in the telemedicine program, as many patients are looking to avoid coming to the hospital for elective and non-urgent reasons. I think the future of virtual care involves combining the videoconferencing virtual assessments with other heart failure monitoring technology that can be used independently by the patient/caregiver at home. This could lead to comprehensive and excellent care for an increasing population of patients without the need to leave the home.
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