Implementing Person-Centered, Accessible, and Integrated Telehealth in Geriatric Primary Care

In the spring of 2020, the COVID-19 pandemic ravaged New York City. Continuing to provide primary care to nearly 6,000 patients, all of whom are age 75 and older, was a “blur” as Dr. Veronica Rivera, MD, geriatrician at the Mount Sinai’s Martha Stewart Center for Living described it. “We were all just trying to survive.”

The Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, which houses the Center for Living, quickly adapted, like many other similar programs, to utilizing telehealth services to continue providing access to care. While they originally envisioned telehealth as a temporary change during the public health emergency, its ever-apparent benefits ultimately led to it becoming permanently integrated into their standard of care. “Most providers, despite hiccups, have adopted [telehealth],” said Dr. Rivera. In 2023, telehealth visits continued to make up 7% of visits across their three clinics.

Mount Sinai contends that for telehealth to be successful, older-adult patients must feel empowered to ask for, and actively participate in, virtual visits. This involves tailoring virtual care to their specific needs, providing tools and education that are age-friendly, and preparing medical teams to support older adults before and throughout the telehealth encounter. The telehealth program at Mount Sinai’s geriatric care clinics serves as an example of implementing telehealth and aging best practices.

A Whole-Team Approach to Providing Accessible Patient-Centered Telehealth

In-line with the Principles and Guidelines for Telehealth and Aging, Mount Sinai’s telehealth programs prioritize a person-centered approach from the initial contact at the central call center to the follow-up steps after the telehealth visit. Staff members are trained in best practices to provide age-friendly care, assessing individual technology and health literacy, and how to provide technical assistance to patients to connect with their provider virtually. The team-based approach has enabled the clinics to provide effective and person-centered virtual care to their older adult population.

Team roles and responsibilities include:

  • Call Center Agents: act as the first point of contact, triage patient symptoms and recommend appropriate levels of care on a person-by-person basis
  • Administrative Assistants and Medical Office Specialists: help prepare patients for their telehealth appointments by calling ahead of the visit to assess and document their individual readiness for the care team, record preferred method of connection and language, and identify any family or caregivers that may assist during the visit, among other things
  • Front Desk Staff and Volunteers: help patients navigate the patient portal, while volunteers offer additional technology support when available
  • Medical Assistants: begin video visits at the scheduled appointment time, document home-based vital signs taken by the patient or an in-home caregiver and assist patients with technology and connectivity
  • Physicians or Advanced Practice Providers: conduct visits and coordinate with social workers and geriatric psychologists when needed

Ensuring Integrated and Coordinated Telehealth

Mount Sinai has ensured that telehealth care is integrated and coordinated among all healthcare team members, which is a best practice for implementing age-inclusive telehealth as defined by the Principles and Guidelines. Zoom was determined to be the most user-friendly video platform. It provided features that were deemed important for the patient population, like quality audio and connectivity, and has closed captioning capabilities for hearing impaired patients. The platform was integrated into the Epic Electronic Medical Record (EMR), which allowed front desk staff to send links to access the video visit directly through the patient portal, or via text messaging, depending on patient preference. The video visit would then take place through the EMR, allowing for secure and confidential sessions.

Mount Sinai clinics are actively developing standardized workflows and determining a place in the EMR to consistently document key information from a telehealth visit. “Having a centralized place where we can document important information about patients…streamlines the process and allows [access] to information for team members who need it,” said Dr. Rivera, referring to relevant information regarding readiness and support for telehealth encounters. Standardized documentation also assists with better tracking of who is using telehealth and to better adapt and improve telehealth services.

Like many telehealth programs, digital literacy, access to devices, and a reliable Wi-Fi connection pose challenges for Mount Sinai in providing accessible and equitable telehealth. To address these factors, clinic providers and staff use different methods to connect with their older-adult patients, such as integrating supportive family and caregivers within the visit and connecting patients with community-based organizations that advocate for digital literacy among seniors. “These programs and community-based organizations for seniors exist and are powerful resources to help sustain equitable telehealth care for older-adults and to bridge the digital divide,” said Dr. Rivera.  Mount Sinai also refers to affordable internet connectivity programs, like the SanoConnect program, to increase equitable access internet, and thus telehealth care.

Mount Sinai extends the reach of their telehealth care by coordinating with a paramedicine team, which offers in-home services like IV medications and nebulizer treatments. Vendor partners provide home lab and imaging services that integrate seamlessly into the EMR, enhancing the patient’s experience and ensuring coordinated and comprehensive care.

Creating Sustainable Telehealth for Older-Adult Primary Care

Mount Sinai has used telehealth to augment care through scheduled visits for patients who are homebound, a population that often requires extensive care but can be challenging to reach. “Getting primary care for homebound patients has been difficult and continues to be difficult,” Dr. Rivera says. Providers recognized telehealth as an important tool to pursue equitable care for their service area and are encouraged by the new access it provides.

Dr. Rivera recommends developing evidence-based industry standards and protocols focused on topics such as achieving a balanced approach between video visits and in-person care, performing comprehensive assessments, and partnering with community organizations for lab and imaging services. She emphasizes the importance of these steps to ensure the success, sustainability, and safety of telehealth for older adults.

Interdisciplinary collaboration is key as well for the success of telehealth. Quickly after implementing telehealth, Mount Sinai established a workgroup that included clinic leadership and passionate providers dedicated to improving the telehealth experience for older-adult patients, which has been meeting monthly since December of 2020. “We’re all struggling with similar things,” said Dr. Rivera, on the benefit of collaborating with other leaders. The workgroup is a space where clinic representatives can discuss challenges and help each other to develop practical solutions, workflow improvements, share ideas, and learn from each other.

To further the work of providing equitable virtual care, The Department of Geriatrics and Palliative Medicine joined the Collaborative for Telehealth and Aging (C4TA) in 2021. This collaborative, led by West Health Institute, University of Virginia Department of Geriatrics, and the Mid-Atlantic Telehealth Resource Center, created principles and guidelines to optimize the benefits of telehealth for older adults. The principles promote telehealth that is person-centered, equitable and accessible, and integrated and coordinated.

The Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai is an exemplary organization providing age-inclusive telehealth care to older-adults. To join them and other health systems, advocates and philanthropists that have signed the Pledge of Support for Age-Inclusive Telehealth, and learn more about the Principles and Guidelines for Telehealth and Aging, visit the Center for Excellence for Telehealth and Aging.

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