Telemedicine for elderly hospital at home patients: are the times ripe?

Telemedicine for elderly hospital at home patients: are the times ripe?

Number of replies: 8

BY THE NEW WHAHC COMMITTEE CO-CHAIR Dr Vittoria Tibaldi - WEDNESDAY, 13 april 2022

The COVID-19 pandemic has highlighted what the aging of the population and the consequent increase in the incidence of chronic-degenerative diseases had already suggested: the need to change the current model of health care and paying more attention to care delivered in the community.

It has now been established that hospital at home is a feasible and safe alternative to hospitalization for selected patients. Numerous initiatives in the field of hospital at home were born or strengthened during the world Sars-Cov-2 pandemic in the U.S., South America, Canada, Israel, UK, France, Spain, Northern Europe and Australia. 

The pandemic has also accelerated the use of remote monitoring and telehealth/telemedicine to provide patients with hospital-level care without the risk and costs associated with hospital stay. The use of healthcare technologies at home is growing because

  • it is safe and generally well accepted to patients and clinicians
  • it can improve quality of life and encourage people to stay active at home and in the community instead of being hospitalized or institutionalized
  • it can ameliorate interaction between patients, caregivers and clinicians, promoting a more informed participation of patients and caregivers in the care process
  • it can enhance clinical team coordination and supply chain management, improving efficiency and costs
  • it can allow an easier access to care, especially for people living in remote locations or far from healthcare facilities
  • it can allow doctors and nurses to reach out other offices or colleagues without the need to move from home

 In Italy, the first HAH experiences in the field of the telemedicine started in the year 2009 with a project aimed to evaluate the use of a telemonitoring platform in the real-life context (MyDoctor@Home project, with the contribution of Telecom Italia). In the same year a project on teleradiology (the RAD-HOME project) was born to explore the quality of imaging and clinical outcomes of using mobile, light-weight x-ray equipment to provide radiologic examinations to frail elderly patients at home. Other projects were conducted in the following years to study the role of telemonitoring in the acute management of elderly patients with heart failure or acute exacerbation of COPD, by using portable and Bluetooth connected medical devices and a dedicated platform. In general, our early experiences highlighted that the use of technology at home is safe, is acceptable to patients and clinicians and has the potential to improve quality of life.


A remote monitoring with an experimental telemedicine system (TESI eViSuS®, Tesi S.p.A., Bra, Italy) was implemented during the pandemic for COVID patients. In addition to nurse and physicians’ visits, caregiver training sessions or scheduled nurse/physician-led tele visits were provided until discharge. Data is encouraging: the hybrid in-person and tele-visit approach has the potential to create a “safe” environment, by addressing self-confidence and safety issues, and to empower motived caregivers to manage frail older adults with Covid-19 at home, avoiding hospital admission when possible. The system is still in use for selected patients, with or without Covid infection.



Another technological solution is being tested at our Geriatric Unit on outpatient elderly people suffering from Mild Cognitive Impairment (MCI). This experiment is part of a larger project, the “REHOME” project, focused on the remote rehabilitation of cognitive (MCI), motor (post-stroke, Parkinson' disease) and sleep disorders. The REHOME solution integrates several types of sensors and innovative methodologies (such as exergaming and gamification approaches) to face patients’ and clinical needs by ensuring the continuity of care and rehabilitation services from health facilities to domestic scenarios. The project has a multidisciplinary working group that involves 7 industries, 3 research institutions and 2 hospitals. Considering the aging of population, the consequent growing of neurological diseases and the need of solutions favouring a safe management of patients outside the hospital walls, this project can help to evaluate the pros and cons of an innovative monitoring and rehabilitation solution.

An AI-enabled clinical-decision support tool is the next step in the research program of the HAH of Turin. The aim is to create an algorithm that helps the ED clinicians to select the right patients for this peculiar setting of care.

There are many advantages in the use of care programs with the support of technological devices when managing patients who have chronic conditions, but we need to know more about the use of healthcare technology in a special context of acute care, as hospital at home is. Highly motivated patients and/or caregivers with fairly good technological skills are needed, ethical and legal issues can be addressed, the lack of an adequate mobile network can be considered (rural areas, old houses), a sustainable reimbursement plan is necessary.

Telemedicine is usually defined as the exchange of medical information from one location to another using electronic communication. Telemedicine has multiple applications and can be used for different services, which includes wireless tools, email, two-way video, smartphones, and other methods of telecommunication’s technology. Consultations with patients through video conferencing or video visit, point-of-care laboratory tests, electronic transmission of digital images, monitoring of vital signs remotely are some examples of application of telemedicine. It is important to understand which type of technology to choose and which kind of patient is eligible. The use of technology can be a problem or an obstacle to care where the right requirements for use do not exist. For example, the adoption of technology could be associated to an increase in patients/caregiver stress or in clinician burnout.

In the last two years our way to visit patients has changed. We no longer wear usual clothes but we wear work uniform, gowns, masks and gloves. Elderly people we treat often complain about the inability to see our smiles or to appreciate the warmth of our hands. Physical and visual contact is very important for particularly frail patients such as elderly people. The use of technologies should be carefully handled in this special population.

The use of telehealth/telemedicine plays an increasingly important role in management of HAH sick patients, with or without COVID infection. Scientific data collected so far show that “virtual” care can enhance patient experience, improve health outcomes and healthcare quality, ameliorate the work life of caregivers, lower the costs of care and encourage the scaling of acute care delivery in the home. However, a wider adoption of telemedicine in this setting of care requires more studies on cost-effectiveness and optimal organizational models. To define standards, best use and eligible patients is mandatory. To ensure compliance with relevant laws, data governance, patient privacy and protection against cyber risks is necessary.

To sum up I have some questions and doubts that I want to share with the tribe:

  • are elderly patients and their caregivers ready for this technological change?
  • are hospital at home care workers ready to handle the technological change?
  • how can we lead the shift towards an increasingly technological way of working?
  • who are the elderly patients who can benefit from telemedicine?
  • can we define any standards for the use of telemedicine in this population?

Please, let me know your answers or questions. Time to share our opinions is close - WHAHC 2023 is just around the corner!


ABOUT THE AUTHOR

Dr VITTORIA TIBALDI

MD, Specialist in Geriatrics, PhD in “Clinical Science”.

Aprox. 20 years experience in Hospital at Home care at the Unit of Geriatrics (Head of the Unit: Prof. Mario Bo), City of Health and Science of Turin-Molinette Hospital (Italy). Author of book chapters and papers published in national and international peer-reviewed journals. Principal Investigator in projects in geriatric field, with special attention to hospital at home care of frail elderly patients (focusing on dementia, COPD, heart failure, delirium, telemedicine). Invited speaker or moderator in national and international meetings.


In reply to First post

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by Laura Ceci Galanos -
You can add your comments here and post your questions for Dr. Vittoria Tibaldi to answer.
In reply to First post

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by James Pollard -

Hello Vittoria, great discussion and points. Some responses below. Kind Regards. James


  • are elderly patients and their caregivers ready for this technological change? Absolutely yes - we perpetually underestimate "elderly" ability to engage with technology. Part of that is us choosing the right digital platform that is easy to use.

  • are hospital at home care workers ready to handle the technological change? Again yes, but training and ongoing support may be required for many staff, especially as the establish familiarity, and with (in our setting) an ageing workforce.

  • how can we lead the shift towards an increasingly technological way of working? I feel part of the problem has been demonstrating the economics make sense - in Australia, HITH as been running effectively and safely for three decades without the electronic solutions - so adding cost and complexity it is then difficult to demonstrate the savings achieved versus "baseline" operations without. Tele-review is however taking off - but funding for this is an issue in some settings.

  • who are the elderly patients who can benefit from telemedicine? There are two populations - those who can have remote rather than physical reviews (many / most patients, especially when treatment is going as expected) and those who need continuous remote monitoring (a smaller but sicker group - so benefit from remote monitoring to flag issues early, but still may be better with physical attendance / reviews regularly.

  • can we define any standards for the use of telemedicine in this population? A long and complicated answer - perhaps a workshop at the next WHAHC conference?

In reply to James Pollard

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by vittoria tibaldi -
Dear James,
I apologize for the late reply to your kind and inspiring answers.

I agree with you that the technological change is now inevitable and necessary. However, I think that the technological development is not the same in the different countries and this must be taken into consideration.

A workshop on how to define population that benfits from telemedicine and standards of use sounds very good!

Thank you.

Best
Vittoria
In reply to First post

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by Itamar Offer -
Thanks Vittoria
Building on your excellent review and James’s comments-
I believe that we must ask ourselves: what’s in it for the professional teams? Nurses, Physicians and all other professionals that are providing care at home.
A simplistic approach would mention reimbursement for distant care. I think that the answer is much more complex.
How are the lives of the professionals become better when using telehealth solutions?
Graham Elliis showed us his excellent experience with POCUS for immediate diagnosis confirmation. This is of value to my mind. Same for POC lab results. But there is a logistic hassle around it.
I’ll be happy to learn from other community members, what will make their lives better.
CU in WHAHC2023. Itamar
In reply to Itamar Offer

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by vittoria tibaldi -
Dear Itamar
I apologize for the late reply to your kind answer.

Shifting the gaze from the economic advantages for the healthcare system to the advantages/disadvantages for the healthcare professionals providing care at home is an interesting and fundamental point of view, especially in understaffed health systems.This topic could be the starting point for an interesting dabate at the WHAHC 2023.

Thank you.

Best
Vittoria
In reply to Itamar Offer

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by Jane Jones -

Regarding telehealth software development, it is a win-win solution all around. The real value is the connection between all the users involved in the healthcare chain and how they can really benefit from it. Patients and doctors that are main participants of healthcare have become two active users of eHealth. More and more people would rather apply for the service of physicians, therapists, psychologists and nurse practitioners via the Doctor On Demand applications. 

In reply to Jane Jones

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by Dewi Clements -
Thank you for this article! Telemedicine platforms are now extremely in demand and will be for a very long time. Millions of dollars are invested in platforms that offer the best functionality, unique propositions, and, most importantly high healthcare services by top specialists. According to Sloboda Studio, accessibility is one of the most influential telemedicine benefits. With telemedicine platforms, patients have the ability to make an appointment with the doctor no matter where they are. A video call can take place where a person is and can take less than 30 minutes. It is especially important in areas where there aren’t many hospitals or there is a lack of specialists, this is more than relevant for the elderly people.
In reply to First post

Re: Telemedicine for elderly hospital at home patients: are the times ripe?

by Yana KLee -

Thank you for your published research. I believe that remote patient monitoring should be introduced further and more. It is clear that older people will be slower to get used to the use of technology in treatment. But there are many benefits to remote monitoring: RPM software provides online medical data. As a result, clients have the opportunity to contact their doctors and get advice at any time and from any point, patients can see the details of dynamic treatment through a convenient system. Regarding the issue of laws, I recommend reading the Law on Transfer and Accountability of Health Insurance. It monitors the confidentiality of medical data transfers. Fast Healthcare Interoperability Resources. This is a special instruction that checks the processing of information through the API (for telemedicine products).