Forced to seek new ways to connect with patients during the COVID-19 pandemic, caregivers increasingly turned to telemedicine as an integral component of care. Older individuals, particularly those who are cognitively impaired with limited access to technology, have been especially vulnerable to the social isolation imposed by the international crisis. Recognizing this, Cleveland Clinic has partnered with Cuyahoga County Adult Protective Services (APS) to ensure these high-risk patients are not overlooked.
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“We have a longstanding relationship with Cuyahoga County APS, and many of the cases the agency refers to us involve suspected financial exploitation, neglect, or self-neglect. We would ordinarily see these patients in clinic, but that has not been an option during the pandemic,” explains Cleveland Clinic geriatrician Ronan Factora, MD. “Unfortunately, pandemic-related restrictions only heightened the risks faced by geriatric patients; in fact, data shows that cases of elder abuse actually increased during this period.”
To combat these potential perils, Cleveland Clinic and APS developed a novel hybrid telehealth model that enables caregivers to manage patients in the comfort of their own homes.
APS defines at-risk patients as those 60 years or older who are victims of abuse/exploitation or suffer from cognitive/functional impairment. The program is only open to residents of Cuyahoga County at this time.
Once a patient has been identified, a virtual visit is then scheduled with a Cleveland Clinic geriatrician. The APS nurse will visit the patient’s residence and help them prepare for the appointment. Patients are shown how to use an electronic tablet equipped with a HIPAA-compliant platform, and the nurse is available to help with any technical difficulties that may arise.
The nurse also assists with cognitive testing—either MOCA or SLUMS—and the physical evaluation, explains Ami Hall, DO, a Cleveland Clinic geriatrician who helps manage the program. “This hybrid approach has the added benefit of allowing us to see a patient’s living environment,” she says. “We can do a virtual walk through of their home to evaluate the patient’s access to utilities as well as the quantity and quality of their food. In addition, these interactions allow us to identify potential problems, including hoarding, pests, and mobility issues like tripping hazards or obstructed passages.”
Following the visit, team members meet to determine the necessary next steps. This may include a “statement of expert evaluation” regarding the patient’s capacity to make decisions and obtain medical follow up. “We also ensure each patient has access to community resources to help meet their specific needs,” explains Dr. Hall. “This program gave us the opportunity to connect with our patients during the pandemic, and today it allows us flexibility when patients have transportation issues or are reluctant to come to the clinic.”
Geriatricians continue to explore the advantages of this ongoing initiative. Of 56 people seen virtually over a 12-month period, 53% had a guardian assigned, 55% stayed in their home and 45% were moved to a supervised setting. Additionally, the team reported that 55% of program participants lacked regular health care prior to receiving a virtual visit. However, 74% began primary medical care after participating in the program.
“There is this misconception that APS intervention always leads to an individual losing their independence or ending up in a nursing home,” notes Dr. Factora. “In reality, however, our ultimate goal is to provide the minimum intervention necessary to ensure a person’s needs are met. In addition to addressing concerns around cognitive capacity, we also helped reconnect patients with primary care providers. Many of these folks have not been to a doctor in years, but the support of APS allows us to help at-risk seniors get appropriate care.”
Dr. Factora explains that the program’s collaborative model offers unique benefits to a particularly vulnerable population. “We are dealing with complex issues,” he notes. “Although our primary focus is the prevention of elder abuse, the program can also have a significant effect on patients’ physical and mental health by addressing other issues, including social isolation and financial wellbeing.”
“There is no perfect solution, but the more people you have at the table, the more robust the solution will be,” he adds. “By working together as a multidisciplinary team that includes community agencies, we are able to provide comprehensive and effective support to individuals in need.”