|Ahead of print publication
Abbreviated health-care services for older persons during the COVID-19 pandemic – A wake-up call for a longer-term plan
Shaileja Yadav1, Ashish Goel2
1 Department of Community Medicine, University College of Medical Sciences, New Delhi, India
2 Department of Medicine, University College of Medical Sciences, New Delhi, India
|Date of Submission||11-Dec-2020|
|Date of Acceptance||07-Jan-2021|
|Date of Web Publication||22-Jan-2022|
Department of Community Medicine, University College of Medical Sciences, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
The last 1 year has underscored the need of a robust global public health system like never before. Both the infection itself, and the measures taken to contain it, have forced us to adopt new ways of life. Measures taken by the Indian government ranged from initial advisories on social distancing and hand hygiene to a full-fledged nationwide lockdown. The lockdown disrupted all the routine health-care activities – right from the suspension of curative outpatient department (OPD) services to preventive immunization and antenatal care services; the entire system has been affected. The problem has been especially complex for older patients due to the fact that they are at a higher risk for infection by the virtue of their age and likely to have a more severe disease due to the presence of multiple comorbidities, including but not limited to the other pandemic of diabetes that we have been witnessing over the past few decades. Resuming a health-care service for older people requiring inperson visits for OPD consultation may not be a good enough option for them. Thus, we have two major issues with geriatric population – access and utilization of health-care services. While telemedicine has been widely employed to solve the problem of access; does it really solve the issue of utilization of health-care services by a scared geriatric patient who needs a caregiver, too? In this article, we explore the impact and some of these changes, telemedicine, and other potential solutions, focusing on the health care needs of older persons and the future discourse.
Keywords: Access, COVID 19, geriatric patients, health-care delivery, lockdown, primary health care, telemedicine, utilization
| Introduction|| |
The last 1 year has underscored the need of a robust global public health system like never before. The COVID-19 pandemic has impacted not only health care but has necessitated several changes in the every aspect of human life and style. Both the infection itself, and the measures taken to contain it, have forced us to adopt new ways of life. In this article, we explore the impact and some of these changes, focusing on the health-care needs of older persons and the future discourse.
| COVID-19 and its Consequences|| |
Unprecedented control measures were initiated rapidly once India recorded its first case on COVID-19 on January 30, 2020. Initially, advisories on social distancing and hand hygiene were issued, but as the pandemic progressed to later stages a full-fledged nationwide lockdown was implemented from March 24, 2020. The lockdown was implemented and extended in over three phases, and the reversal also was done using a phased approach.
The government was well aware that while the lockdown was essential to meet the new pandemic challenge, the economy needed movement to survive. Over time, most restrictions were eased across the country, but from the public health point of view, the situation continues to evolve as the cases are constantly on a rise. However, the rising cases of COVID-19 are not the only health-care challenge we have had to face. The lockdown also disrupted all the routine health-care activities – right from the suspension of curative outpatient department (OPD) services to preventive immunization and antenatal care services, the entire system has been affected. The system that had been designed to carefully keep the disease burden in a balance, had been disrupted, and it would only be intuitive to expect a surge in other diseases.
The problem has been especially complex for older patients due to the fact that they are at a higher risk for infection by the virtue of their age and likely to have a more severe disease due to the presence of multiple comorbidities, including but not limited to the other pandemic of diabetes that we have been witnessing over the last few decades. Resuming a health-care service for older people requiring in-person visits for OPD consultation may not be a good enough option for them. While policy-makers have tried to address the issue of access by providing tele-medicine facilities across all the hospitals, yet considering that the pandemic is not going away soon, it is important to understand the problem in a little more detail in order to be able to make decisions regarding an uninterrupted and sustainable health-care delivery.
| Missing Dots – Problem of Access and Utilization|| |
Disruption of OPD services in times of disasters or infectious diseases outbreak is not new. There are many examples from the past. A systematic review of the literature documenting the impact of Ebola outbreak of 2016 in West Africa reported a decrease in both health-care service provision and utilization, including decrease in OPD consultations and decrease in admissions. However, another article assessed the impact of this decrease in service utilization and reported decline in vaccine coverage, reduced life expectancy, reduced community cohesion, education loss, reduced child protection, widespread job losses and food insecurity, and increase in morbidity and mortality. Similar chain of events can be seen unfolding now. Diabetes, chronic obstructive pulmonary disease, and hypertension were the top three conditions to see the worst hit in patient care among the chronic diseases. Access to care has been difficult due to unavailability of drugs, unavailability and/or unaffordable cost of transportation services, unavailability of routine OPD procedures, shortage of health-care staff, in addition to outright shutting down of OPD services. Decline in patient footfall covers all pediatric to elderly age groups, private to government hospitals, primary centers to tertiary care hospitals, OPD to inpatient services, and all disciplines ranging from surgery to dental.,,, Not only patient care but also the supply chain and other ancillary operations have taken a hit due to the pandemic leading to the shortage of pharmaceutical products globally. What this means for future is-higher mortality levels, especially among patients living with chronic conditions due to discontinued or interrupted therapy, delayed diagnosis, and in some cases misdiagnosis, progressing to more severe forms of the disease and possibly augmentation of behavioral risk factors, including possible misuse of prescription drugs and dangerous substances, especially in patients with chronic conditions. This impact will be disproportionately higher for the geriatric patients suffering from chronic diseases.
What warrants special attention in case of an older patient is not just the vulnerability to the infection owing to their age (and geriatric syndrome) and comorbidities, but also their social standing in the community. A significant proportion of geriatric patient pollution might be dependent, physically, and or financially, on their caregivers for their health. Thus, any decision taken to solve the issue of access to health care should factor in this dependence and should ensure that the lack of a caregiver does not act as a deterrent to accessibility. In addition, the apprehension to even step out in these uncertain times is a problem that cannot be overlooked for the geriatric patient. Thus, we have, but two major issues here –access and utilization of health-care services. While telemedicine has been widely employed to solve the problem of access, does it really solve the issue of utilization of health-care services by a scared geriatric patient who needs a caregiver, too?
| Telemedicine: Does One Size Fit the All?|| |
While the investment of Government of India (GOI) in telemedicine services dates back at least two decades, a lot has been said in its favor in recent times as its need became more evident. The most recent investment of GOI in the field is the recently launched national tele-consultation service-e-Sanjeevani OPD. It has provision for both audio and video consultations for the residents of even remotest areas. Be it neuro-consultation for stroke, or service delivery postdisasters, literature extensively documents the efficiency of telemedicine in delivering care in various settings. E-mailing your doctor, video-chatting for follow-up visits or even urgent care, remote consultation with a specialist, and now using social media applications such as WhatsApp for quick review of reports are all the examples of telehealth. Personal communications with doctors delivering telehealth in tertiary care hospital identified the following modes of operations:
- Inter-departmental teleconsultation for COVID-19 patients: to reduce exposure for health-care workers, dedicated doctors are posted for “telemedicine” duties, where they give telephonic consultation for COVID-19 patients. If the need be, a bed side referral for in-person visit is also arranged
- Teleconsultation for OPD patients without prior appointment: A schedule with time slot dedicated for each specialty is made public and patients call their doctors during the mentioned hours
- Teleconsultation for OPD patients with prior appointment: Patients make a call for making appointment. The appointment schedule is shared with the doctors, who make calls to the patients for consultations.
All these modes are operational through social media platforms enabled smart-phones to allow easy exchange of media (photos of medical records) in addition to free video-calling service, when needed. After teleconsultation if the doctor felt the need, the patients were called in for visits.
The benefits of this mode are very apparent – substantial reduction in risk of exposure to both the patient and doctor and triage of patients lessens the crowd at hospitals. Both of these are essential components to the problem we highlighted earlier – the expected surge in non-COVID-19 cases in coming times. It would be interesting to see how the modality would continue to deliver in the longer term and how it will address the challenge of lack of awareness, communication barriers, language barriers, infrastructure, digital divide, connectivity, and bandwidth besides evolving to deliver acute in addition to chronic health care.
- Lack of awareness: Lack of awareness by large has been a public health concern in India, leading to delayed care seeking and even irrational drug use in the elderly.,, This lack of awareness is an issue with nontelehealth services as well, but teleconsultation services are limited by time-constraints and lack of an option to examine the patient, which can help in speedy diagnosis
- Communication barrier with the elderly with disabilities and functional impairments: Geriatric syndrome is characterized by the issues such as hearing loss, cataracts, and refractive errors leading to vision impairment, cognitive impairment, and a decline in global function of the organs. This makes it difficult for the doctor on the phone, who has time constraints and physical constraints (of not being able to examine the patient) to arrive at a diagnosis. Thus, such patients, due to the lack of proper communication, have to be called for in person visits
- Constraints with telemonitoring: Telemonitoring is a part of telemedicine where the physician relies on biological, radiological, and clinical indicators provided by the patient or patient's caregiver to monitor the patient's health. This is especially relevant in case of elderly patient population, a large section of which suffers from chronic diseases and requires periodic monitoring of disease markers. Measuring simple things like blood pressure to getting an magnetic resonance imaging done for follow-up is a potential problem with the elderly with lack of access, lack of caregiver, and loss of function and/or cognitive decline
- Language barrier: India is a land of diversity, and sometimes, that is a problem. The problem of language diversity acting as a barrier to access to health care in the Indian subcontinent is one which is documented, but insufficiently addressed. This was also reported in a study conducted by Naveen et al., where they documented the need to sometimes translate medical information in the patient's native language. One might argue that this holds true for in-patients visits also, to which the doctors replied “Mostly the problem arises with medical terminologies. Body language and hand gestures, in such cases, make it a lot easier for us to understand the patient in person”
- Lack of availability of ancillary services and resources: The provision of telemedicine only solves the problem of consultation. The shortage of drugs still persists, and the risk of exposure remains high for patients visiting laboratory or medical imaging facilities. This becomes a logistic issue while using telemedicine to solve the problem of access to healthcare, as only part of the problem, that is consultation is resolved, while the other part still remains. This also translates to more expensive health care, which will be difficult to afford for the elderly who are mostly financially dependent on their families
- Digital divide: This problem is a pertinent one for geriatric patients. Although geriatric population might have access to digital devices, digital literacy among this population is still a major concern while introducing any technology driven solution. Ghosh M proposed a framework to understand this divide in terms of perceived risk, perceived usefulness, perceived ease of use, and anxiety to understand this divide
- Connectivity: Internet and phone connectivity is a constant issue with the application of information and communications technology
- Acute care: Chronic patients usually require a follow-up for review of medications and thus telemedicine has proven very efficient for them. However, patients presenting with acute exacerbations or a new-onset disease find it relatively more difficult to take consultation over phone call.
In addition to these problems, a general attitude of doctors against telemedicine “worrying that patients may get trapped in endless “phone menus” and that physicians will be marginalized in the process” is an issue that needs to be addressed. Naveen et al. also list down a number of problems ranging from outdated phone numbers, privacy issues to incivility, and ethical considerations related to practicing telemedicine services.
| Updating the Solution|| |
Evidently, inter-sectoral co-ordination is required to troubleshoot these issues with telemedicine, in order to make it more sustainable and better suited to need of Indian patients. While IT sector should ensure connectivity, digital education and ensure secured handling of private patient information, integrated technology-based platforms with real-time availability of services can solve the issue with referral linkages to imaging and lab testing facilities, and global co-ordination among stakeholders will help us overcome the shortage of drugs. The importance of strong leadership at the central and state level dedicated to ensuring seamless delivery of health-care services cannot be emphasized enough in this regard. The decisions of the policy-makers should be continuously informed by well researched evidence, such as the one presented by Naveen et al. describing immediate, short-term, and long-term measures that can be replicated nationwide. The prevention of stockpiling of drugs, financing emergency supply of emergency medicines, and encouraging rational use to antibiotics are some of the strategies that should be implemented right away. Another alternative is doorstep delivery of drugs and home-based testing facilities available through e-bookings. Online start-ups have been delivering medicines at the doorstep on uploading prescriptions. Ministry of Health and Family Welfare has specified guidelines for doorstep delivery of drugs through online retail services, including prescription validity of 30 days, geographical limits for sellers, and mandatory maintenance of bills and details of all transactions. These solutions, if implemented timely, should take care of the problem of access for not only geriatric, but all the patients. As for the communication, and language barrier, the introduction of competency-based medical curriculum in the medical colleges including communication skill as a core competency is a promising solution in the long term.
Keeping in mind, the limitations of elderly patients which act as a barrier to utilization of health-care services, primary health center (PHC)-based telemedicine facilities, community paramedicine, and mobile integrated health-care programs might prove more efficient. Primary center-based telemedicine facility with appropriate infection prevention and control measures can easily become a reality now with transformation of PHCs into health and wellness centers (HWCs). It would serve the health-care providers and policy-makers well to understand the digital literacy divide that sets apart the elderly and develop technology-based solutions accordingly. Envisioned around robust health management information system and equipped with necessary technological infrastructure, prioritizing continuum of care and expanding range of services, including the “elderly and palliative health care services” package and “screening and basic management of mental health ailments” package, HWCs are our one stop answer to the problem of access and utilization of health-care services In light of the pandemic, these centers could be equipped with dedicated tele-consultation rooms where provision for an adequate communication device is made. This will solve multiple issues – no need to travel far to a tertiary care hospital, connectivity, digital education, and resources will not be a barrier. This will also streamline the patient flow toward primary care settings, decongesting the secondary and tertiary care hospitals. But the lack of preparedness of existing primary care settings, might become a barrier to this solution. Accredited social health activist worker (part of national health mission), Anganwadi worker (under Integrated Child Development Services scheme and auxiliary nurse-midwives, are already are a part of our existing healthcare infrastructure providing primary health-care services to the people. While their mandate is mostly promotive and preventive services, an upscaling of resources is required to expand the range of curative and rehabilitative services they can provide. Same is envisioned with HWCs also. These community health-care workers, by virtue of their door to door access and personal connection with the community, are best equipped to overcome the problem of utilization of services by geriatric patients. The promotive services by these workers will also become of paramount importance in addressing the apprehensions and anxiety of the geriatric patients. Thus, incentivization of these promotive services, especially behavior change communication activities can be considered as a policy option, while keeping check points to prevent misuse of the same. Another possible policy option is rewarding community initiatives and innovations that provide promising solutions to the problems of access and utilization.
- Easy to use and secure technology-driven platforms informed by research to allow continued and effective use of teleconsultation
- Primary Centre/HWC-based telemedicine facility to overcome multiple problems of access (lack or unavailability of doctors/nurses) and utilization (secure, easy to use platforms in neighborhood of patients)
- Employing frontline workers for generating awareness and addressing concerns to alleviate anxiety of elderly regarding utilization of services.
| Conclusion|| |
In conclusion, while we continue to battle the COVID-19 infection and its effects, a careful investment in telemedicine, primary health care and public health services will help us be better prepared for future. Lockdown allowed government to upscale its infrastructure to deal with COVID-19 infection, but to deal with the after effects of the same, an “update” in the system would be required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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