Connecting the disconnected: Leveraging an in-home team member for video visits for older adults

Abstract

Background: Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes.

Methods: This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change.

Results: Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password.

Conclusions: Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

Keywords: geriatrics; home telehealth; telehealth; video visit; virtual care.

FIGURE 1

Template for fieldnotes. This includes the full template that our in-home team member and pharmacist used to note all observations just before and during the visit. Upon arrival at the participant’s home, the in-home team member observed the participant as they attempted to join the visit and intervened as necessary to assist them with connecting to and completing the video visit. Both the pharmacist and in-home team member recorded observations as fieldnotes using this template. Both parties noted challenges that occurred as well as any subsequent intervention(s) for resolution.

FIGURE 2

Coding strategy and representative codes. Coding strategy with representative codes. The final codebook used to code fieldnotes contained 72 codes. Sixty seven codes were defined according to prior work’s codebook and anticipated codes according to data extraction. Fifteen codes were discarded or not used, and five codes were added throughout the coding process, upon which all participants were reviewed again for applicability. Fifty-seven unique codes were used overall, representing seven unique Consolidated Framework for Implementation Research (CFIR) constructs. Codes were grouped and associated with one or more related CFIR constructs, by group. This figure depicts the number of codes related to each individual CFIR construct and provides an example of a code within that construct.

FIGURE 3

Facilitators, barriers, in-home technology troubleshooting, and new findings. We present the most common facilitators, barriers, in-home technology troubleshooting, and new findings that the in-home team member and pharmacist observed in their fieldnotes. The most common facilitators to successful visits were participants owning a device (13, 65%) and were comfortable using technology (11, 55%). The most common barriers were that a participant’s usual support, like a tech-savvy family member, was not available during the visit (7, 35%), or they were uncomfortable using technology (9, 45%). The in-home team member assisted 10 (50%) participants and the pharmacist assisted six (30%), most often this was help with the platform (5, 25%), the hyperlink (4, 20%) or the device (4, 20%). Notable new findings were that although many participants had a device or used video visits before, some did not have a single device with video, audio, internet, and access to their email username and password (7, 35%). Additionally, some participants did not have access to email at all (4, 20%).