Chronic Disease, Isolation, COVID-19, and Mental Health: How Telehealth and Remote Patient Monitoring Can Help

By Wayne Meng

It would come as no surprise to anyone living with chronic disease that there’s a correlation between depression/anxiety and chronic disease. According to the National Institutes of Health, depression is common among people with conditions including cancer, coronary heart disease, diabetes, multiple sclerosis, HIV/AIDS, rheumatoid arthritis, and more.1 These issues have been further compounded lately by increased social isolation resulting from COVID-19 and the added fact that older adults with chronic conditions are at highest risk for severe illness if they contract the disease.

However, one unintended consequence of COVID-19 has been the rise of telehealth and remote patient monitoring (RPM) and the promise of hope they deliver to this patient population.

“It is estimated that up to one-third of individuals with a serious medical condition have symptoms of depression,” according to an article from the Cleveland Clinic. “Depression is especially likely to occur when the illness causes pain, disability, or social isolation.” What’s more, “depression caused by chronic illness can aggravate the illness, causing a vicious cycle to develop.”2

Geriatric patients are also at increased risk for these kinds of mental health challenges because they are disproportionately affected by chronic disease. Approximately 80% of older adults have at least one chronic disease, and 77% have at least two, according to the National Council on Aging.3 Diabetes alone affects 23% of Americans older than age 60, and 90% of Americans aged 55 and older are at risk for developing hypertension. The National Council on Aging also notes that 1 in 4 older adults experience some mental disorder, including depression and anxiety, and that people aged 85 and older have the highest suicide rate of any group.

Social Isolation and COVID-19
Compounding the challenges of chronic disease and mental health in aging populations are other social determinants of health, including lack of transportation, a fixed income that may not have much buffer for acute events and health care costs relating to chronic illnesses, and lack of a strong social support network.

That lack of social support can have a big impact on both physical and mental health. “Loneliness and social isolation in older adults are serious public health risks, affecting a significant number of people in the United States and putting them at risk for dementia and other serious medical conditions,” according to the Centers for Disease Control and Prevention. “Nearly one-fourth of adults aged 65 and older are considered to be socially isolated.”4

The Centers for Disease Control and Prevention goes on to note that loneliness and social isolation increase a person’s risk of dying prematurely from all causes; are associated with a 50% increased risk of dementia, 29% increased risk of heart disease, and 32% increased risk of stroke; and lead to higher rates of depression, anxiety, and suicide.

Facing this perfect storm of physical and mental health risk factors, geriatric patients have now been confronted with the additional and unprecedented challenges brought on by COVID-19. The pandemic has increased isolation for all of us to some degree, and older people and those with chronic diseases must isolate more than most groups because of their higher risk for severe illness if infected.

A Kaiser Family Foundation poll conducted in March found that 45% of adults say the pandemic has affected their mental health, and 19% say it has had a “major impact,” the Washington Post reported.5 A later Washington Post article, published May 4, reported that “a federal emergency hotline for people in emotional distress registered a more than 1,000% increase in April compared with the same time last year,” and that one online therapy company reported a 65% jump in clients from mid-February to early May.6

All this data paints a bleak picture, especially for older populations suffering from chronic disease. What can we do about it?

Bringing Health Care Home
The good news is that telehealth has become something of a beacon of hope during the COVID-19 crisis, especially for those who are older, have chronic disease, or who are otherwise high-risk.

“For years, telehealth has been considered the future of medicine—it just never became the present. Then, as the COVID-19 pandemic shut down doctors’ offices and clinics across the country, telemedicine suddenly became the only way patients could see their doctors and vice versa,” according to a USA Today article.7 “Telehealth use surged from 8% of Americans in December to 29% in May as primary care and mental health physicians and specialists turned to remote care out of necessity during the COVID-19 pandemic,” the article says.

Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, said of telehealth, “There’s a consensus that this is a silver lining” to the pandemic.

Virtual Visits Alone Aren’t Enough
While telehealth has no doubt helped doctors stay connected to their patients for purposes such as chronic disease management and assessing potential COVID-19 symptoms, sometimes a chat over videoconference isn’t enough.

What’s missing is the data. Especially for older patients and those with chronic diseases, information such as blood pressure, blood sugar, weight, heart rate, oxygen level, and lung function can be crucial for prescribing the right treatments and avoiding costly acute events. For a truly complete picture of a patient’s health, pairing RPM devices with telehealth is key.

In a November 2019 survey from Spyglass Consulting Group, 88% of respondents “have invested or are evaluating investments in RPM technologies to support high-risk chronically ill patients whose conditions are considered unstable and at-risk for hospital readmissions.”8

“As the country begins to emerge from the COVID-19 pandemic, these virtual tools, including telehealth, remote monitoring technologies, and wearables, will become a way of life for patients,” according to an article from FierceHealthcare published in May. Providence St. Joseph Health in Seattle set up an RPM program within 72 hours of realizing the demand from COVID-19, according to the article. “Since it launched in late March, the platform has been used to monitor 2,400 patients that were either confirmed COVID-positive or under investigation, with 1,000 patients currently being monitored through remote devices. The use of technology enables clinicians to ‘check-in’ on patients daily and monitor symptoms, which is key with an unpredictable virus such as COVID.”9

“What we know about remote patient monitoring and why it works is that when you are making more contact with a chronically ill individual, when you are watching them more closely, you pick up on things more easily,” said David Putrino, PhD, director of rehabilitation innovation at Mount Sinai Health System, also cited in the article.9

Old Dogs and New Tricks
But will older adults really use this kind of technology? Several studies have shown that, contrary to popular belief, they will. In a study published in the International Journal of Emerging Medicine, researchers wrote, “When we established a program to see low acuity patients in the NewYork Presbyterian-Weill Cornell Emergency Department [ED] by telemedicine, we assumed the majority of older patients who presented to the ED and who fit our inclusion criteria would choose not to be seen by telemedicine and that the vast majority of our telemedicine patients would be younger adults who we assumed would be more comfortable with the technology.”10 But what they found was quite different.

Of the 1,052 patients, 355 were 60 or older (median age for patients older than 60 was 72) and two patients were 99 years old. The study found that “older patients were no more likely to return to the ED within 72 hours than younger patients, and they had very high levels of satisfaction with their visits (98th percentile as measured by Press Ganey).”10

“Our observations and data have refuted our initial assumption that this program would be most appropriate for the young. Many of the older patients we have cared for have demonstrated flexibility and interest in the novel use of technology,” study authors wrote. “Our thoughts regarding the way the program would be received by older adults was based on ignorant, and even ageist, misconceptions,” they concluded.10

“Perhaps, the older population has intuitively understood some of the paradoxical virtues and power of technology in the form of a telemedicine encounter, namely, that the essence of care is the basic connectivity with another human being,” they concluded.10

Government Gets on Board
For hospitals and home health agencies, an integrated RPM/telehealth model allows patients who are discharged and those sent home from the ED to be monitored for worsening symptoms. For physicians and medical groups, it enables continuity of care and chronic disease management for high-risk patients who can’t—or won’t—return to traditional office visits yet. And earlier this year, the Centers for Medicare & Medicaid Services (CMS) began removing major reimbursement barriers to the adoption of telehealth/RPM care.

On March 30, CMS released what it called “a sweeping array of new rules and waivers of federal requirements to ensure that local hospitals and health systems have the capacity to absorb and effectively manage potential surges of COVID-19 patients.”11 Part of that effort was an expansion of telehealth.

“CMS will now pay for more than 80 additional services when furnished via telehealth. These include emergency department visits, initial nursing facility and discharge visits, and home visits, which must be provided by a clinician that is allowed to provide telehealth,” the agency said at the time. RPM was also a key part of this effort. “Clinicians can provide remote patient monitoring services for patients, no matter if it is for the COVID-19 disease or a chronic condition,” according to the agency.

The second round of such announcements, on April 30, made physical and occupational therapists eligible for the reimbursements, allowed hospitals to bill for outpatient services furnished remotely by hospital-based practitioners, sped up the process by which it adds new services to the list of reimbursable telehealth services, and more.12

“I can’t imagine going back,” CMS Administrator Seema Verma told STAT News during a live virtual event in June. “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.” She also noted that weekly telemedicine visits jumped to more than 1 million a week, compared with about 12,000 before coronavirus began to spread in the United States in March.13

According to Emily Yoder, an analyst in the division of practitioner services at CMS, “Health providers should watch for the agency’s annual proposed Physician Fee Schedule rule, which typically publishes in July,” FierceHealthcare reported.14 And on July 16, the House announced a bipartisan bill, the Protecting Access to Post-COVID-19 Telehealth Act, which seeks to push forward wider access to and use of telehealth.15

“There is no going back,” says Will Brady, who serves as chief of staff to the deputy secretary and senior adviser to HHS Secretary Alex Azar, echoing Verma’s earlier comments. “Telehealth is now the preferred method.”

— Wayne Meng is founder and CEO of RemetricHealth.

References
1. Chronic illness & mental health. National Institute of Mental Health website. https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index.shtml. Accessed July 16, 2020.

2. Chronic illness and depression. Cleveland Clinic website. https://my.clevelandclinic.org/health/articles/9288-chronic-illness-and-depression. Updated January 17, 2017. Accessed July 16, 2020.

3. Facts about healthy aging. National Council on Aging website. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/. Published June 12, 2018. Accessed July 16, 2020.

4. Loneliness and social isolation linked to serious health conditions. Centers for Disease Control and Prevention website. https://www.cdc.gov/aging/publications/features/lonely-older-adults.html. Published May 26, 2020. Accessed July 16, 2020.

5. Achenbach J. Coronavirus is harming the mental health of tens of millions of people in U.S., new poll finds. The Washington Post. April 2, 2020. https://www.washingtonpost.com/health/coronavirus-is-harming-the-mental-health-of-tens-of-millions-of-people-in-us-new-poll-finds/2020/04/02/565e6744-74ee-11ea-85cb-8670579b863d_story.html. Accessed July 16, 2020.

6. Wan W. The coronavirus pandemic is pushing America into a mental health crisis. The Washington Post. May 4, 2020. https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/. Accessed July 16, 2020.

7. Alltucker K, Weintraub K. Telehealth called a ‘silver lining’ of the COVID-19 pandemic. This time, it might stick. USA Today. July 6, 2020. https://www.usatoday.com/story/news/health/2020/07/02/telehealth-soars-covid-19-shutdown-limits-doctor-visits/5355739002/. Accessed July 16, 2020.

8. Malkary G. Trends in remote patient monitoring 2019. http://www.spyglass-consulting.com/wp_RPM_2019.html. Published October 2019. Accessed July 16, 2020.

9. Landi H. Tech experts: widespread adoption of telemedicine, remote monitoring ‘here to stay.’ FierceHealthcare. May 7, 2020. https://www.fiercehealthcare.com/tech/technology-experts-virtual-care-has-hit-a-turning-point. Accessed July 16, 2020.

10. Greenwald P, Stern ME, Clark S, Sharma R. Older adults and technology: in telehealth, they may not be who you think they are. Int J Emerg Med. 2018;11:2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752645/.

11. Additional background: sweeping regulatory changes to help U.S. healthcare system address COVID-19 patient surge. Centers for Medicare & Medicaid Services website. https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient. Published March 30, 2020. Accessed July 16, 2020.

12. Trump administration issues second round of sweeping changes to support U.S. healthcare system during COVID-19 pandemic. Centers for Medicare & Medicaid Services website. https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid. Published April 30, 2020. Accessed July 16, 2020.

13. Re’em Y, Dratman R, Bowen S. My Covid-19 symptoms have lasted 100-plus days. I’m not alone. STAT website. https://www.statnews.com/2020/07/08/my-covid-19-symptoms-lasted-100-plus-days/. Published July 8, 2020. Accessed July 16, 2020.

14. Landi H. CMS: Upcoming Medicare payment rule to include permanent telehealth expansions. FierceHealthcare. June 25, 2020. https://www.fiercehealthcare.com/practices/cms-upcoming-medicare-payment-rule-to-include-proposals-to-expand-telehealth. Accessed July 16, 2020.

15. Protecting Access to Post–COVID-19 Telehealth Act of 2020, HR 7663, 116th Cong, 2nd Sess (2020). https://mikethompson.house.gov/sites/mikethompson.house.gov/files/2020-07-15ProtectingAccessToPost-COVID19TelehealthAct.pdf