A Hybrid Model of Outpatient Memory Care in the COVID Era

INTRODUCTION: The coronavirus pandemic has drastically affected day-to-day life, including the way healthcare is provided. An emphasis is placed on the need to transition to telemedicine to reduce exposure rates. The effects of the pandemic have been especially significant in the geriatric population, which is at increased risk of hospital mortality with infection: 35% mortality for patients aged 70 to 79 years and greater than 60% mortality for patients aged 80 to 89 years (Gómez-Belda et all., 2020, Wiersinga et al., 2020). Physicians, as well as patients, have had to quickly adapt to telemedicine for outpatient services to reduce rates of transmission and infection. However, the barriers to telemedicine are also higher in the geriatric population. The lack of smart devices with cameras, microphones, internet, and the lack of ability and comfort in using these are some of the barriers in which the older population face (Hawley, et al. 2020). With confounding factors of dementia limiting instrumental activities of daily living, learning new technology can also be an additional burden to this population. This can lead to unwillingness or hesitation in participation of telehealth visits by both the patient and the caretaker. An increase in caregiver burden has also been shown secondary to the coronavirus pandemic and the increased isolation (Alexopoulos et al., 2020). METHODS: At the Banner Alzheimer's Institute, the needs of this population led to the development of the Hybrid model of care, which allows some patients to be present in person at the office but distanced in a separate room from the providers. In a separate room, a screen with a camera is set up so the appointment can occur as a “remote” visit. When indicated, short direct contact is made to complete a physical exam. This reduced time of close contact is important for infection control, especially when as testing prior to visits is not widespread for outpatient services. Prolonged exposure is defined as within 6 feet of contact with infected persons for at least 15 minutes (Wiersinga et al., 2020). This hybrid model allows for decreased time of contact, and therefore decreases exposure risk while removing the initial barrier of access to and difficulty navigating technology in this population. With more hybrid visits, patients may even develop more comfort and confidence in technology use for fully remote visits. We analyzed data routinely collected by the department regarding patient and provider satisfaction. We analyzed ratings on front desk interactions, provider interactions, ease of care, office net promoter score (NPS), and provider NPS. We compared the ratings from June to October of 2020, when the hybrid model was in use, to the ratings from June to October of 2019 using a paired t-test. RESULTS: None of the measures analyzed showed any statistically significant difference between the scores. CONCLUSIONS: To provide care to the high-risk geriatric population, we developed this hybrid model of treatment. A key concern was the potential for patient dissatisfaction with not being able to see the provider in person. However, this was not seen on the patient satisfaction survey results. One reason could be related to increased flexibility from patients considering the pandemic, the quality of video visits, and a perception of valuing safety over in person visits. In the evaluation of this model, using the typical measure of patient and provider satisfaction, we did not see significant differences between the previous and new models of care. This is an encouraging result and argues for the increased use of this hybrid model in the future to optimize infection prevention while maintaining patient satisfaction. With the use of the hybrid model, geriatric patients can be partially exposed to use of technology first in the office and be provided with in person tutorials on video use. This can normalize the use of video visits with time and practice and therefore lead to more confidence when applying the use of technology at home. The hybrid model can also mitigate concern over continuous exposure, and therefore address the wellbeing of physicians. FUNDING: Not applicable