Eldercare Voices is an occasional feature of the Center’s monthly newsletter, Health Innovation Highlights, inviting guest commentators directly involved in care delivery to older adults to share their perspectives from the field. This is the fifth in a special series of interviews on their experiences with older adults during the pandemic.
Interview with Gregg Warshaw, MD, Professor, Departments of Internal Medicine (Geriatrics Division) and Family Medicine, University of North Carolina-Chapel Hill
Gregg Warshaw, MD, an academic family physician/geriatrician, is senior advisor to the Geriatrics Provider Collaboration within the Center for Consumer Engagement in Health Innovation. He is a professor in the Departments of Internal Medicine (Geriatrics Division) and Family Medicine, School of Medicine, at the University of North Carolina-Chapel Hill. Dr. Warshaw was previously the director of the Geriatric Medicine Program at the University of Cincinnati College of Medicine from 1987 - 2015. He is a past president of the American Geriatrics Society and the Association of Directors of Geriatric Academic Programs. Dr. Warshaw was a 2013-2014 Atlantic Philanthropies Health and Aging Policy Fellow/American Political Science Association Congressional Fellow.
Center: How are the older adults you work with doing?
Gregg Warshaw: I’ve been impressed with people’s resilience in a difficult time. Most people are taking the risk of the virus quite seriously and doing their best to stay safe. The challenge has been for those who have ongoing medical problems: their needs have to be addressed, but they have been reluctant to seek care. The situation in March was very confusing, but in April and May we started to get a handle on treating patients for COVID-19 and those with non-COVID health problems, as well.
I currently work in an ambulatory setting with a diverse patient population. However, I have seen that in North Carolina, like rest of country, nursing homes have had the worst problems – especially smaller, traditional nursing homes. These nursing homes do not have the resources to adequately respond to the pandemic. The staff and residents, and their families, have suffered greatly. The privately owned, for-profit nursing homes are mostly funded through the Medicaid program. Their staffs and patient populations include large numbers of lower-income people of color. I’ve seen some improvements over the course of the pandemic as relationships have developed between nursing homes and larger health care systems.
We learned from COVID that there are great differences in capability and resources among long-term care facilities. We’ve known that many nursing homes, especially those dependent on Medicaid funding, have long been underfunded. I really hadn’t recognized just how vulnerable these nursing homes really were. Previously, our worst fear was an influenza outbreak, but COVID-19 is proving to be a much greater challenge. I’m hoping that we’ve learned lessons about what needs to be improved.
It’s been very difficult to convince older adults and their caregivers to accept in-home care. Families are also reluctant to have their relatives move into assisted living settings, since these care facilities are in lockdown and family visits are prohibited. That has meant that family caregivers are doing it all themselves. Another problem is that many home care workers, often immigrants or people of color, frequently live with people who work in other settings. That means that if the family members they live with have an exposure to COVID, the home care worker cannot go back to work and the older adult may have weeks without help.
Center: And, how are you doing?
GW: As an older geriatrician, I’m certainly concerned about my own safety. By April, my practice had created a robust video and telephone visit system so I did only virtual visits in April and May. In June, we started opening our offices, and at this point about 75 percent of my visits are now face-to-face. We have systems set up to keep the environment safe: pre-screening, screening at the time of entering and mask requirements. We’ve also set up an outdoor drive up testing center for people with any respiratory symptoms. Staff who run these centers wear full hospital PPE.
Center: What do you think older adults most need right now?
GW: There are a variety of needs. People are isolated and crave connection. Often times, we find that it’s hard to end a virtual health care visit, the patients are so glad to have someone to talk with.
People are not getting enough physical exercise. I had several patients who were gym goers, but I really don’t encourage them to do that anymore. Some people are willing to have home physical therapy, but not everyone. I have encouraged walking outdoors when that is possible. My patients who have been more active are no longer traveling. For some, it’s just another loss among many. But for my oldest patients, the horizon of their lives is shorter, and it’s even more disappointing that delayed travel may not ever happen.
One of the biggest challenges for my older adult patients is the inability to be with their family. I’m frequently asked, “can I let my kids come and visit?” We have to balance the need for family connection with the need for safety.
Center: What are you learning now that signals the direction for care in the future?
GW: Video-telehealth visits are now built into secure medical systems and they can work if someone has adequate broadband. But service deteriorates quickly as you move away from urban areas. A cell phone can also work, for a video or phone visit. Some older adults don’t own a cellphone and some that have them don’t know how to use them. Family members – especially grandchildren! – can assist, and they’ve been helpful in assisting with tele-health visits. These kinds of visits have been reassuring for patients, and I’m finding that, generally speaking, people are more confident about it now than early in the pandemic.
CMS and private insurer reimbursements for telehealth has been helpful, and I’m hopeful that CMS will take lead to continue reasonable reimbursement for this service. There are many patient visits that don’t require coming into the office, and transportation can be a limitation, even in the best of times.
Large health care systems have also learned a lot about how to organize themselves in order to provide routine care at the same time they are coping with the pandemic. My practice has created additional pathways to entry, e.g., outdoor screening and conducting COVID testing before procedures. In our local health system, we have two hospitals about 10 miles apart, so one has been the COVID treatment center and another has been devoted to non-COVID care. This has kept people safer.
We’re also learning about training doctors. When the pandemic began, we pulled medical students off of clinical services in order to conserve PPE. Instead, we encouraged other activities that did not require face-to-face patient care. Among these activities, they made calls to check on isolated older patients. This was a great service during May and June.
Center: What's been most surprising to you about the experience of older adults during this pandemic?
GW: People have been truly creative and resourceful. I’ve had patients who have made trips to see their children and grandchildren. They’ll take road trip after quarantining, not stop along the way and then be able to spend time with their family.
I expected more people to develop depression and anxiety, but people have been really resilient. They’ve accepted the fact that their activities are limited, but they’re being proactive about staying safe. They will use delivery services, family or friends for their groceries, or wear PPE if they go to the grocery store.
That said, there’s plenty of anxiety. The number one recommendation I give to patients is to avoid watching cable television news!
Center: If you could wave a magic wand, what would you wish for to improve the lives of older adults?
GW: So much of what needs to be done (for everyone) is obtaining control over the amount of virus in the community. We need to lower the testing positivity rate down to 3 percent or so using basic principles of public health. The vaccines will help greatly. If we can get there, so many other things can happen. Facilities can re-open. Older adults can have in-home care. Community based organizations can continue to provide services. The senior center system is so important to older adults and is so well-run in our area. The pandemic has had a negative impact on their ability to provide services. It’s been a huge loss.