What are the challenges with geriatric care during COVID-19?
COVID-19 poses several challenges in caring for our older adults. As we know, our elderly tend to have more adverse outcomes if they develop COVID-19. As such, many are seeking alternative platforms for care or are not receiving their routine care for chronic conditions. While telehealth, either by video or phone, is beneficial to continuing care and an option for us, caring for seniors who live alone and may not have access to MyChart through their phone or a computer, those who do not have the technology to support the video platform, and/or those with no phone, it creates a new challenge. Those with physical limitations, such as hearing impairment, also pose challenges.
For those of us who care for older adults, care of this population becomes not only about continued treatment of chronic illnesses, but also heightened identification of social isolation, food insecurity, elder neglect, and support in the home (ie. are their typical support systems still in place?). This is especially true of those vulnerable adults in the community with limited-to-no social support at baseline, those who have cognitive impairment, and those who have low health literacy. Further, many of the assisted livings facilities and nursing homes have intensified their quarantine restrictions.
The media has reported on outbreaks in nursing homes across the state. Why are nursing homes susceptible to these outbreaks?
Long term care facilities have medically complex, typically chronically ill, residents. Given the infectious nature of COVID-19 and the hands-on care needed in relatively close quarters, a nursing facility, much like a college dorm, a cruise ship or a prison, can spread quickly. The nursing home that I work with has not had any COVID-19 cases. They have been lucky, but also they have worked hard to limit exposures to their residents and staff. Symptom checks and vitals are done regularly (every shift). This has included visitor restriction (no volunteers, no family or friends, no non-essential staff, etc.), monitoring for symptoms (including taking a temperature) at time of arrival to the facility each day, limiting items that come in to the facility, closing common spaces and dining facilities within the home, and keeping residents in their rooms where possible. Staff have also worn masks since April.
Are you and any of our other providers still going in to nursing homes?
I continue to provide care to our long-term care patients. I try to limit my visits to the facility to once every other week, mostly to keep up with mandatory paperwork and routine regulatory visits. I talk to the LPN who cares for our wing of patients weekly. If there is an acute need that cannot be handled over the phone, I will go to the facility. Keeping the residents of the facility safe is a top priority. Typically, our Duke Family Medicine residents will go out to the nursing home monthly and on occasion weekly, but since mid-March, have not been allowed to enter the facility to limit exposure. Lorraine Sease, M.D., MSPH, provides back up coverage for me.
How has care of the home-bound enrolled in the Just for Us program adjusted?
The Just for Us program continues to monitor patients through the efforts of our team that has diligently called patients weekly since mid-March, assessing for such issues as food insecurity, medication problems, and health concerns. They also uncover acute issues that we need to address. Sarah Lipscomb, NP, and I are doing home visits on a limited basis. We have only done home visits when requested for an acute issue that cannot be attended to over the phone/video platform or when an unstable issue has arisen that needs in-person attention for a complete assessment to avoid a visit to the emergency department.
Planning to do a home visit is really about keeping our patients and ourselves safe. Since mid-March, we have been following protocols recommended by the Home Care Centered Institute and our home visit colleagues on best practices for providing continued home visits in the time of COVID-19 if they must be done. The care Sarah and I have been providing has not particularly changed, but how we do it has. If we have to go into a home, we screen the patient for COVID-19 symptoms and any exposure that they are aware of prior to going into the home, we wear our surgical mask and booties (in fairness, we tended to do this before COVID-19). I transitioned my cloth medical bag to a plastic file box that contains everything I need for ease of cleaning. I am more consistently bringing my own folding stool into a home. I also tend to now wear scrubs for easier cleaning.
How do your patients feel about COVID-19?
In general, I think everyone is apprehensive about the virus and the possibility of contracting the virus. My older adults are especially concerned, but so are my younger patients. For some, who are home bound at baseline, there have been no real changes to their daily routine. Many of my seniors (or their caregivers/families) are worried about coming out of their home, which creates issues related to social isolation. Coming to the clinic is something they cannot see themselves doing, especially if they have to take ACCESS, Uber, or a taxi.
For others, the opportunity to see specialists via teleheatlh has been huge! I have patients who are finally able to see the specialists that they have needed to see but have not been able to get to due to transportation barriers (bed-bound patients who would have to pay upwards of $200 for private ambulance transport per visit).
How are you feeling heading into the third month of this response?
Every day is a little different for me. I think I am adapting to the new care delivery model that COVID-19 has thrust upon us, but I sure do miss seeing my patients in person! Currently, I do a mix of things: telephone visits, video visits, in-office visits, home visits (includes ALFs), and nursing home visits. I am grateful to be working at Duke Family Medicine Center where we were lucky to quickly transition to telehealth so our patient care did not stop.
Teah Bayless, DO, assistant professor of family medicine and community health, is director of geriatrics at Duke Family Medicine Center and medical director of Just for Us, a Division of Community Health program offering coordinated primary care for the home-bound and elderly.