Overcoming Telehealth Barriers and Engaging Older Adults in Virtual Care

Laura M. Cascella, MA, CPHRM

If the COVID-19 pandemic offered any silver lining at all for healthcare, one could easily argue that it was telehealth. During the public health crisis, telehealth offered a virtual gateway that became instrumental to continuity of care for patients and economic viability for practices.

Although the use of telehealth has receded from its peak during the pandemic, it almost certainly will remain a critical tool in healthcare delivery — particularly since access to care and provider shortages remain top concerns.

Yet, despite it benefits, telehealth mirrors other aspects of healthcare in creating disparities. Certain populations have not been able to take advantage of virtual care in the same way as others for numerous reasons. Older adults are one of the groups at a disadvantage. This article examines the barriers that prevent many older adults from participating fully in telehealth and offers practical strategies that healthcare providers can implement to address these issues.

Telehealth Barriers for Older Adults

Various factors have been identified as potential telehealth utilization barriers for older adults. These barriers range from technological issues to medical conditions to life circumstances, and — whether alone or combined — they may put older patients at a digital disadvantage.

Lack of Access to Technology

Telehealth relies on technology for the transfer of information between parties, which can be problematic for older adults who might not have access to the necessary electronic devices and services.

A study of Medicare beneficiaries showed that 41 percent of participants did not have access to a desktop or laptop computer with high-speed internet, and 40 percent did not have a smartphone with a wireless data plan. About a quarter of the participants did not have either form of digital access.¹

In the absence of these technologies, telehealth is limited to phone calls, which might work for simple services (such as medication refills) but has limitations for more in-depth care.

Lack of Experience With Technology

Even when older adults have access to technology, problems can arise if they are not experienced using it, are unable to troubleshoot problems that arise, or cannot adapt to digital communication.

A physician survey on the impact of telehealth noted that patients’ lack of digital literacy was a major telehealth barrier.² Further, a study on telehealth readiness in adults older than 65 showed that 30 percent were not ready for telehealth encounters because of inexperience with technology.³

Hearing, Vision, and/or Communication Impairments

Gradual deterioration in hearing and vision are normal processes in aging, but they can make communicating via technology difficult. An article in the Annals of Internal Medicine notes that hearing loss is almost universal among older adults, and “Approximately two thirds of persons aged 70 years or older have clinically significant hearing loss.”⁴

Additionally, because telehealth encounters occur outside of the controlled setting of the exam room, the potential for noise, distractions, and missed visual cues might increase, further impeding both patient and provider comprehension.

Cognitive Issues

Unfortunately, cognitive impairment is a reality for many older adults. The Centers for Disease Control and Prevention estimates that 5.1 million Americans aged 65 years or older may currently have Alzheimer’s disease, the most well-known form of cognitive impairment.⁵

The aforementioned study on telehealth readiness in adults older than 65 states that for individuals with cognitive disabilities “in-person visits are already difficult and telemedicine may be impossible.”⁶ However, the American Psychological Association explains that the minor cognitive changes that naturally occur with aging should not prevent older adults from using telehealth services, and even individuals who have mild cognitive impairment “can successfully learn new skills, especially if they use compensatory strategies.”⁷ Such strategies might include appointment reminders, notes for operating technology, or seeking a family member’s help with using telehealth applications.

Socioeconomic Factors

Older adults’ socioeconomic status can affect their willingness or ability to participate in telehealth encounters. For example, income and education level might play a role in whether patients have access to technology or experience using it. Older adults who have concerns about costs associated with cellphone plans and data charges might prefer telephone-only appointments, which can limit the provision of care and take away key aspects of visual communication that assist with comprehension.

Socioeconomic status also can affect other barriers that contribute to telehealth difficulties, such as hearing and vision loss, if patients lack access to care and/or cannot afford assistive products or devices.⁸

Telehealth Strategies for Older Adults

Although not all older adults experience telehealth barriers, those that do are not able to reap the full benefits — or any benefits — of virtual care. The result of this disparity is not yet fully known, but the consequences could be significant. Serious health conditions might go undetected, delayed diagnoses might occur, and necessary treatment might be delayed or never provided.

Many of the issues related to telehealth disparities are complex and require broad public health approaches and systemic solutions. However, healthcare providers who treat older adults also can implement meaningful strategies⁹ to help these individuals have successful experiences with virtual care. These strategies can occur before, during, and after telehealth encounters.

Before Telehealth Encounters

• Make older adult patients aware of the availability of telehealth services, and talk to them about the benefits and limitations of virtual visits. Assure them that the practice is dedicated to providing high-quality care during telehealth encounters.
• Consider contacting, or having a staff member contact, patients before telehealth appointments to walk them through the process of using the telehealth application, test their ability to connect, and answer any questions the patient might have.
• Develop clearly written, step-by-step instructions for using the telehealth application. Including screenshots associated with each step can assist with comprehension.
• Evaluate the space in which you conduct telehealth visits to ensure it has adequate lighting, is devoid of distracting items, offers privacy, and minimizes the potential for noise and disruptions.
• Invest in quality telehealth equipment, such as cameras and microphones, to optimize communication with patients. Consider using a headset with microphone to improve audio quality and reduce background noise.
• Select HIPAA-compliant technology, and explain to patients the safeguards that have been put in place to protect them and their health information. A survey of older adults that focused on telehealth use before and during the COVID-19 pandemic showed that about 1 in 4 participants had privacy concerns.¹⁰

During Telehealth Encounters

• For wellness visits, consider using a framework — such as the Age-Friendly Health Systems 4Ms — to help guide appointments, engage patients, and ensure consistency in care.
• When possible, encourage patients to use video to maximize the benefits of telehealth encounters. However, be cognizant and respectful of patients’ limitations and preferences. Additionally, if video is used, determine whether captioning is available to enhance communication.
• Confirm that patients are in a quiet and private location at the beginning of the telehealth appointment, and ask if they can hear you and see your face.
• Acknowledge that telehealth encounters can seem awkward and unnatural, and let patients know that you might verbally verify their understanding of information or clarify any visual cues that indicate misunderstanding, frustration, and so on.
• Suggest that patients use a headset or headphones to improve their ability to hear. For patients who have hearing aids, confirm that they are using them.
• Speak clearly and concisely while looking into the camera. Do not raise your voice or yell, as the technology might distort the sound.
• Watch for signs that patients are not following the conversation or do not understand you. Address these issues early to avoid confusion and misunderstanding. For example, encourage patients to increase speaker volume, put on their glasses, or use an available headset. Repeat information as needed, or rephrase what you’re saying if patients still seem confused.
• Consider recommending an interpreter if short-term solutions do not improve patients’ ability to see, hear, or understand what you’re saying.
• Use a comprehension technique, such as teach-back, to confirm that patients understand the information you have conveyed.

After the Telehealth Encounter

• Provide a written summary of the telehealth appointment that includes key points, treatment recommendations, and instructions. Make sure the summary is clear, concise, and easy to read and understand.
• Ask older patients (and other patients as well) to provide feedback on their telehealth experience. Constructive feedback can help identify potential issues with the platform, the process, and communication. The provider and staff members can then use this information as the basis for quality improvement initiatives.

In Summary

Telehealth is an important tool in the future of healthcare delivery. However, older adults may experience barriers to telehealth, including lack of access to technology; inexperience with technology; hearing, vision, and/or communication impairments; cognitive issues; and socioeconomic factors. These barriers can hinder care and treatment, putting older adults at a disadvantage.

Healthcare providers who have geriatric patient populations can address some of these issues using strategies before, during, and after patient encounters. Proactive approaches to identify and resolve telehealth barriers can optimize virtual interactions for patients and help address disparities in care.

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¹ Roberts, E. T., & Mehrotra, A. (2020). Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine. JAMA Internal Medicine, 180(10), 1386–1389. doi:10.1001/jamainternmed.2020.2666

² COVID-19 Healthcare Coalition. (2020). Telehealth impact study: Physician survey. Retrieved from https://c19hcc.org/telehealth/physician-survey-analysis/

³ Lam, K., Lu, A. D., Shi, Y., & Covinsky, K. E. (2020). Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Internal Medicine, 180(10), 1389–1391. doi:10.1001/jamainternmed.2020.2671

⁴ Nieman, C. L., & Oh, E. S. (2020, August 11). Connecting with older adults via telemedicine. Annals of Internal Medicine, 173, 831-832. doi:10.7326/M20-1322

⁵ Alzheimer’s Association. (n.d.). Alzheimer’s disease facts and figures. Retrieved from www.alz.org/alzheimers-dementia/facts-figures; Centers for Disease Control and Prevention. (2011). Cognitive impairment: A call for action now! Retrieved from https://www.cdc.gov/aging/pdf/cognitive_impairment/cogimp_poilicy_final.pdf

⁶ Lam, et al., Assessing telemedicine unreadiness among older adults.

⁷ APA Committee on Aging. (2020, August 13). How to provide telehealth to older adults. Retrieved from https://www.apaservices.org/practice/clinic/telehealth-older-adults

⁸ Nieman, Connecting with older adults via telemedicine; National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. (2016). Understanding the epidemiology of vision loss and impairment in the United States. In A. Welp, R. B. Woodbury, M. A. McCoy, et al. (Eds.), Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK402366/

⁹ Nieman, Connecting with older adults via telemedicine; APA Committee on Aging, How to provide telehealth to older adults; Cascella, L. (2023 [last updated]). Bridging the digital divide: Creating a personalized telehealth experience. MedPro Group. Retrieved from https://www.medpro.com/bridging-digital-divide-telehealth

¹⁰ National Poll on Healthy Aging, University of Michigan. (2020, August). Telehealth use among older adults before and during COVID-19. Retrieved from https://www.healthyagingpoll.org/report/telehealth-use-among-older-adults-and-during-covid-19

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