Video-Enhanced Care Management for Medically Complex Older Adults With Cognitive Impairment

Susan N. Hastings, MD, MHSc; Elizabeth P. Mahanna, MPH; Theodore S. Z. Berkowitz, MS; Valerie A. Smith, DrPH; Ashley L. Choate, MPH; Jaime M. Hughes, PhD, MPH, MSW; Juliessa Pavon, MD, MHSc; Katina Robinson, MS; Cristina Hendrix, DNS, GNP-BC; Courtney Van Houtven, PhD; Pamela Gentry, RN; Cynthia Rose, RN; Brenda L. Plassman, PhD; Guy Potter, PhD; Eugene Oddone, MD, MHSc

Disclosures

J Am Geriatr Soc. 2021;69(1):77-84. 

In This Article

Abstract and Introduction

Abstract

Objective: This pilot study assessed feasibility of video-enhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery.

Design: Pilot randomized controlled trial.

Setting: Durham Veterans Affairs Health Care System.

Participants: Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20–31) and their care partners.

Intervention: The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone.

Measurements: Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability.

Results: Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm.

Conclusion: Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.

Introduction

Unrecognized cognitive impairment (CI) is common, especially among older adults with chronic medical illness.[1,2] CI that does not meet the threshold of dementia affects approximately 22% of adults older than 70 years in the United States[3] and yet the diagnosis of CI is often missed in primary care clinics.[4,5] This may be due, in part, to the high prevalence of coexisting conditions that compete for a provider's time and attention. Although universal screening for CI is not recommended, a targeted case-finding approach in groups with higher-than-average risk is widely cited as a good strategy.[6] Older adults with medical complexity certainly constitute such a high-risk group.

Older patients with multiple chronic conditions and the added burden of CI often find themselves in the perfect storm of complexity, simultaneously experiencing escalated healthcare utilization and demands for self-management despite reduced capacity.[7] In a study in the Veterans Health Administration (VHA), patients who screened positive for CI had twice the number of hospitalizations and their mean length of stay was nearly four times as long as those who screened negative.[8] CI is known to be associated with higher healthcare costs, increased severity of comorbid illnesses, potentially avoidable hospitalizations, and long-term institutional care.[9,10] Older adults with CI are seen frequently by healthcare providers of various disciplines and in multiple settings, such as hospitals, emergency departments (EDs), specialty clinics, and home health. The need to receive, process, and integrate information from multiple sources is especially difficult for patients with CI. This highlights the importance of care management, which is intended to help patients and care partners more effectively manage the full spectrum of health conditions, better coordinate care across primary and specialty visits, and avoid unnecessary ED and hospital use.

Care management intended to help with coordination of care and chronic disease self-management is often delivered over the telephone.[11–13] VHA has made major investments in expanding telehealth capabilities to include a video platform that enables patients to interact with providers in virtual medical rooms using the camera on a smartphone, computer, or tablet.[14,15] Although increasing numbers of older adults use the internet and are open to technology-enhanced interventions,[16,17] it is uncertain whether the advantages of video visits, such as the ability to see nonverbal cues and view the living environment, negate the disadvantages, such as the need to master new technology to participate.[11,12,18–21] Thus, the primary objectives of this study were to test the feasibility, acceptability, usability, and perceived value of a 14-week video-delivered nurse care management program for medically complex older veterans with CI and their care partners compared with a similar telephone-based program.

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