Background
The COVID-19 pandemic has especially limited older adults from engaging in personal
contact with others, as they have been classified as a high-risk population (1, 2).
Increasing evidence shows that COVID-19 has taken a particularly heavy toll on older
adults in long-term care facilities (LTCFs) (3). Older residents of LTCFs (e.g., nursing
homes, retirement homes) often have daily care needs and are at especially high risk
of COVID-19 due to the existence of multiple medical comorbidities and pre-existing
conditions (4). As such, measures have often been put in place where such patients
must shelter in place, maintain physical distancing from others during the pandemic
and be subject to quarantine if they need to leave the facility for medical care.
The context of living in LTCF means that older adults may be subject to even more
protective measures that are administratively mandated, more so than the general population,
including preventing their loved ones from visiting.
Telemedicine (also referred to as telehealth) has been recently shown to play an important
role in distance-based treatment during this pandemic (5–8), despite the lack of quality,
evidence-based trials that exist (9). Telemedical solutions are often feasible and
acceptable in delivering care to older adults in LTCFs, even in those with sensory
impairments such as hearing or visual loss (9). However, older adults are less likely
than younger people to be able to take advantage of the opportunities enabled by modern
information and communication technology (ICT) or telemedicine (10–14). Older adults
living in LTCFs often (a) opt not to use the internet, (b) cannot afford internet
access or ICT devices, (c) lack technical solutions with which to use telemedicine
to connect virtually with doctors or other health professionals, (d) have physical
or cognitive limitations that may limit possible telemedicine use or prevent them
from using telemedicine at all without assistance, and (e) lack the skills to use
ICT or telemedicine even if they do have access (9, 11, 15–18). Furthermore, the institutional
may prevent the individual use of telemedicine; for example, individual use may depend
on internet availability, ICT access, and telemedicine tools/software at a given facility.
This article will outline and discuss the problems in this field and make recommendations
for future discussion.
ICT Use in Long-Term Care Facilities
While modern ICT use (such as the use of the internet, smartphones, and tablets) in
healthy older adults has increased precipitously in recent years, the situation differs
for those with multiple medical comorbidities and functional impairments and those
with advanced age who are the primary residents of LTCFs (19–23). Seifert and Cotten
(19) showed in their 2019 study that 21% of retirement home residents used the internet,
13% used a smartphone, and 5% used a tablet. Compared with non-users, internet users
within LTCFs were more likely to be younger, healthier, and more functionally unimpaired
(23, 24). The residents in this study (19) were also asked about their difficulties
with modern technology with the statement, “Do you have difficulty operating modern
technical devices?” Respondents rated the statement based on a 5-point Likert scale
format (1 = “No, not at all” to 5 = “Yes, very much”). Among the respondents, 6.3%
answered “No, not at all,” 10.1% answered “Not very much,” 26.9% answered “Partly,”
34.3% answered “Yes, somewhat,” and 22.5% answered “Yes, very much.” Schlomann et
al. (22) recently conducted a study using data from North-Rhine–Westphalia, Germany,
involving people aged 80 years and older living in private households and LTCFs. The
researchers found that fewer than 3% of people in LTCFs used internet-connected ICT
devices. ICT-device adoption was associated with the living environment and individual
characteristics, including functional health, chronological age, education, and technology
interest (22). These results indicate that individual characteristics and the living
environment are both related to technology usage among the oldest age groups (21,
24).
Telemedicine and Digital Infrastructure in Long-Term Care
Whether LTCF residents have access to using telemedicine is highly dependent on an
underlying telemedicine infrastructure (e.g., internet availability, ICT access, telemedicine
tools/software, ICT skills). The availability of modern ICT is limited within LTCFs,
thus highlighting a significant deficiency in ICT infrastructure (25, 26). This deficit,
in part, also includes a lack of technical skills among LTCF staff and potentially
their apprehension of using technology within care facilities (27, 28), all inhibiting
opportunities for telemedicine. The ongoing COVID-19 pandemic has prompted discussions
of the positive outcomes of telemedicine for residents of LTCFs (29, 30). However,
these discussions have also created awareness of the existing limitations of these
facilities' current telemedicine infrastructures (11, 31).
Based on a Swiss representative national study (32) among managers of 466 LTCFs conducted
in winter 2019, 14.6% of the LTCFs in Switzerland did not provide internet access
to their residents. The survey was carried out as a standardized online survey of
inpatient old-age homes throughout Switzerland. The respective managers were interviewed
(32). Of the institutions that provided internet access, 66.3% offered residents an
internet connection for free. The results show that basic internet access is not provided
by every LTCF; however, Switzerland's ICT infrastructure and internet use of people
aged 65 years and older are more equipped than other countries where individual residents
need to pay for such services (33). Nevertheless, the results also show the degree
of missing infrastructure for widespread telemedicine solutions within LTCFs (e.g.,
free internet access or mobile devices to use telemedicine apps privately).
The above-mentioned study (32) also asked the LTCF managers if they already used telemedicine
(teleconsultation of doctors and/or health practitioners) within their facilities;
only 3.9% of all 466 participating LTCFs used telemedicine. When asked if the managers
evaluated telemedicine as useful for their facilities, 21.7% found it “rather useful”
and 14.5% found it “very useful”; the rest (63.8%) found it rather not so useful or
very non-useful. For this study, the authors did not have information related to the
barriers or attitudes toward telemedicine; nevertheless, the authors demonstrated
that telemedicine solutions were available in the minority among LTCFs in Switzerland,
with few managers (36.2%) finding telemedicine useful. Only 11.1% of the managers
in this study (32) said they involved their residents in decision-making about purchasing
new technology for the institution. This corroborates the assumption that LTCFs are
contextual settings with potential elements of a self-contained institution (34) with
modest participation of residents in the process of initiating new technology solutions
such as telemedicine.
Recommendations
Based on the presented data, we recommend (1) education and training of staff and
residents, (2) a solid telemedicine infrastructure, and (3) a system that promotes
and integrates telemedicine in daily workflows within LTCFs.
First, given the rapid expansion of telemedicine, it is paramount to educate both
LTCF staff and residents about how to use telemedicine, which could be useful in their
daily lives during and beyond the current pandemic. The LTCF staffs are the coordinators
and attend consultations with the patient; therefore, they are very important to include
in all learning settings of telemedicine. It would be helpful to offer support and
training to these people to increase their digital literacy skills. Establishing a
workforce within LTCF environments with telemedicine competencies is important; this
has not yet been anchored in education or evidence-based training (35). Learning new
technical skills can even foster a certain sense of competence and autonomy (36) within
older adults that can encourage the efficient use of other digital interventions.
The special learning needs and cognitive resources of older adults need to be considered
in these educational services, with attention paid to things such as the tempo of
the learning session and the technological skill background of the older participants
(37). These learning tools can be generally provided by LTCFs with the help of technical
and management experts in telemedicine.
Second, besides the user side of telemedicine, the results from Switzerland reveal
that LTCFs before, during, and probably beyond the COVID-19 pandemic have low levels
of telemedicine infrastructure. This situation has pointed out that although telemedicine
solutions would be ideal for medical treatments and consultations during physical
distancing; however LTCFs are not yet ready for this task. It is critical to motivate
developers and professional users (e.g., researchers, medical practitioners, and companies
within the health sector) of telemedicine to take a closer look at how different designs
and content can be tailored in a way that encourages trust and facilitates use among
older people and LTCF staff. All stakeholders are encouraged to address these challenges
and collaborate to promote the safe and evidence-based use of telemedicine during
the current pandemic and future outbreaks (38, 39). The integration of end-users into
workflows and the design process increases the usage and effectiveness of interventions,
particularly as a partner in community-based participatory research in advance of
developing a new digital intervention (40, 41). During any intervention, a real-time,
support hotline, and contact partner can be used to assist the older participants
when needed.
Third, telemedicine should not be system only used during a pandemic, but rather a
routine method of providing services in our health system (31, 38, 42), and especially
in LTCFs. We propose the following hurdles need to be overcome: (a) stable and high-performance
internet access in all areas (cities or rural areas), (b) computers or mobile devices
and software tools capable of engaging in telemedicine, (c) technical and software
skills and skills in managing telemedicine processes among all stakeholders (e.g.,
residents, LTCF staff, doctors, medical staff), (d) willingness of all stakeholders
to practice telemedicine, (e) interoperable communication systems and systems of exchange
of health-related information and data, (f) availability of telemedicine support for
staff or time for staff to do this within the daily business of care duties, (g) guidelines
regarding the appropriate use of telemedicine, and (h) clinical and economical evidence
from longitudinal studies within LTCF to support the effectiveness of the telemedicine
services. Also, user focused studies are needed to better understand practical experiences
from the perspective of resident and staff; and factors influencing uptake and acceptance
in the health system.
Telehealth can be considered a “disruptive innovation process” by implying changing
the way we provide service delivery. The importance of managing this change process
well cannot be overstated by including all of the stakeholders associated with successful
telehealth are accounted for. One way to further the “digital connection during physical
distancing” idea would be to not limit communication applications such as chatting
or video-calling to doctors, but to use such tools also for connecting with friends
and relatives. The pandemic has fostered the potential of those social tools for digital
connections within LTCFs (43), so why not also use those tools to help residents connect
with the world beyond LTCFs? Current projects (44) use Skype, for example, for telemedicine
under control for privacy and security requirements. However, also potential socio-economic
inequalities in the use of telemedicine (45–47) or technology in general among older
adults should be taken into account (15, 19, 33). Telemedicine enables cost savings
(e.g., no transfer to the doctors' office), but also causes additional costs for older
people (economical cost and acquired technical skills). Furthermore, potential barriers
for digital excluded groups, such as older adults in LTCF, should be discussed and
existing policy opinions should be considered when integrating telemedicine in everyday
practice (48).
Conclusions
The current pandemic highlights the challenges of providing LTCF residents with timely
medical treatment during physical distancing and the potential of routinely using
telemedicine in clinical care. Although the benefits of telemedicine have been widely
reported, its routine use and its systematic evaluation for residents in LTCFs has
been relatively limited. Integrating telemedicine is reliant on many complex and interrelated
factors which must be addressed for successful adoption. Aside from the technical
requirements, it is just as important to ensure that a supportive infrastructure are
in place to support telemedicine services, systems are interoperable between service
providers and recipients of care, staff are trained in its use, procedures are in
place to ensure the safe and effective delivery of care, responsibilities for telemedicine
care are clearly articulated, and funding is available to support the effort. The
current pandemic has reminded us that innovative models of care that include telemedicine
can be helpful, but organizational readiness to adopt telemedicine needs urgent attention.
Author Contributions
All authors provided substantial contributions to this article from conception to
final approval and share the same opinion.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.