Older adults with complex care needs constitute a large and rapidly expanding group of Veterans receiving care within VHA. Medically complex older Veterans, who often have multiple chronic conditions as well as interacting functional and psychosocial challenges, account for a disproportionate amount of health care resources. Importantly, these Veterans also experience a disproportionate amount of suffering; they have worse functional status, higher symptom burden, and spend more of their time in acute care settings such as the hospital and emergency department (ED). Our experience and recent studies suggest that a substantial proportion of older, medically complex Veterans have unrecognized cognitive impairment (CI), and this contributes to their higher need for care and greater risk for adverse outcomes.
We evaluated a novel care management program for medically complex Veterans with CI. Patients were randomized to receive the intervention via telephone or through video visits on iPads. This study has the following aims: 1: Examine the feasibility and acceptability of a 12-week care management program for medically complex Veterans with CI, delivered via telephone or through video visits; and 2: Assess the usability and perceived value of video-enhanced care management, compared to telephone-based, among older Veterans with medical complexity and CI.
Veterans aged 65 or older with Care Assessment Need (CAN) scores >=90 were contacted by phone and screened for CI using the modified Telephone Interview for Cognitive Status. Respondents with scores in the range of 20-31 (predictive of cognitive deficits in the mild range) were invited to participate in the study, along with a friend or family member (Care Partner). Following informed consent and baseline data collection (n=40 dyads), participants were randomized (1:1) to receive the intervention via 3 monthly telephone calls, or video visits on iPads at home using VA Video Connect. The goal was to provide structured information and support in two key areas: (1) care coordination (reduce workload) and (2) protecting cognitive health (build capacity). All available subjects participated in an outcome assessment call at week 14, consisting of survey items and a semi-structured interview. Study measures included the System Usability Scale, as well as utilization (hospitalizations and ED visits) and patient-reported outcomes including the Physical Activity Scale for the Elderly, selected subscales of the Patient-Reported Outcomes Measurement System Health Profile, and Medical Outcomes Study: Social Support Survey Instrument.
Forty medically complex Veterans with possible mild CI and their care partners were enrolled and randomized (n = 20 in the video arm, n = 20 in the phone arm) between 5/31/17 and 10/23/17. Participants were stratified by familiarity with technology (defined as previous experience with using an iPad to access the Internet or using videoconferencing or videochat); 35% of Veterans were familiar with technology.
The mean age of Veteran participants was 72.4 years; the mean age of care partners was 64.7 years. All of the Veteran participants were male; 95% of the care partner participants were female.
Overall, 87.5% (n = 35) of participants received at least one intervention call, and 77.5% (n = 31) completed the follow-up assessment at 14 weeks. Intervention call completion was slightly higher in the phone arm (53 calls completed in phone arm, 46 calls completed in video arm, out of 60 possible calls). In the video arm, 52% of calls were completed as video calls, 13% were completed as video and telephone combined, and 35% were completed by telephone.
Post-intervention, the self-reported likelihood of seeing a healthcare provider using video chat was slightly higher in the video arm (31.3% in phone arm, 40% in video arm).
Usability of the video-enhanced care management program was examined using the System Usability Scale (SUS); video participants' (n=15) mean score was 59.3 on a 0-100 scale.
Perceived value of the video calls as expressed by some participants included that it was novel and fun, more interactive than telephone, convenient, and a learning opportunity. However, technical and audio issues were common; challenges included frequent changes and updates to a new videochat platform technology and adopting more than one new technology at a time was difficult for some participants. Nurse interventionists found the video calls to be useful for relationship building with the patient as well as direct observation of medications and patients performing tasks. It was less useful for viewing environmental living space to assess potential fall risks. Involving the care partner in the video calls was helpful as they often were interested, positive about and more familiar with technology, and would help the participant with video call setup and recall of call content.
Further analysis of qualitative interview data and other outcomes is ongoing.
Nurse care management delivered by video calls with Veterans with possible mild CI and their care partners was feasible, but presented challenges for some participants. It offered some benefits over phone calls including relationship, communication, assessment, and patient engagement benefits and was embraced by older adults who valued convenience of remote access, were comfortable with technology, and appreciated a learning opportunity.
Video call technology with Veterans at home using VA Video Connect continues to evolve since the study completed enrollment; for example, it now has a more user-friendly set-up and interface and is available on smartphones.
Results from this preliminary study will be used to inform the development of an RCT to evaluate the impact of a 12-month care management program for medically complex older adults with CI, aimed at reducing emergency department use and hospitalization. Specifically this study will provide critical information needed to refine intervention content and determine the population of medically complex older Veterans that will benefit most from the technology. Proactive recognition and management of vulnerable Veterans is a high priority for VHA, and medically complex Veterans with CI constitute one such high risk group. The results of this study will be of high relevance to VHA, and outside VA, given the urgent need to develop innovative means of improving care and outcomes for medically complex older adults.
- Hastings SN, Mahanna EP, Berkowitz TSZ, Smith VA, Choate AL, Hughes JM, Pavon J, Robinson K, Hendrix C, Van Houtven C, Gentry P, Rose C, Plassman BL, Potter G, Oddone E. Video-Enhanced Care Management for Medically Complex Older Adults with Cognitive Impairment. Journal of the American Geriatrics Society. 2021 Jan 1; 69(1):77-84.