During the COVID-19 pandemic, providers are trying to limit face-to-face visits so that patients can avoid travel and possible exposure to the coronavirus. In many circumstances — for well visits, wellness checks, and non-urgent elective concerns — telehealth appointments can be as effective as in-person visits.
Through telehealth wellness checks, providers can reassure patients that they are staying connected during this time of limited physical contact. During these wellness checks with older adults, the Age-Friendly Health Systems 4Ms Framework (What Matters, Medication, Mentation, Mobility; see Figure 1) provides an excellent structure for these calls:
- Ask What Matters most — This will help to convey that what matters is important to the provider.
- Medications check — Does the older adult have enough of each medication, or need refills? Do they understand how and why they are taking the medications? Are there medications that can be discontinued?
- Remember, before a new medication is added to work in conjunction with a current medication, consider gradually increasing the current medication to the maximum dosage to avoid polypharmacy.
- When prescribing a medication that’s new for the patient, remember to consider starting with a lower dose and gradually increasing as needed.
- Mentation check — Conduct a brief delirium screening and ask 1) the current day of the week; and 2) the months of the year backwards, starting with December. The Montreal Cognitive Assessment (MoCA) has been validated for remote administration, leaving out the visual items. If you have a video connection, you could also do a Mini-Cog screening, which is a three-item recall and a clock drawing test, or the longer MoCA test.
- Mobility check — Ask what the older adult is doing to keep moving inside or around their home. Suggest a plan to do steps or laps around a room or join an online exercise class. Also suggest 5-10 sit-to-stand repetitions 3-4 times a day. Stress the importance of remaining active even while staying home.
Figure 1 — The Age-Friendly Health Systems 4Ms Framework
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Here is a suggested script to follow for a telehealth visit using the 4Ms:
What Matters — Hello, (Mr./Mrs./Ms.) Smith, this is Dr. Blue, your primary care doctor. (If you’re calling from the primary care office but to a patient who is not in your panel, you can say, This is Dr. Blue calling from the office of Dr. Jones, your primary care doctor.) I am calling to check in with you. We know that this can be a challenging time, with the coronavirus limiting our abilities to go out and interact with others, so I wanted to see if you are doing okay. How are you doing?
Many people may be scared or anxious during this time, so I want to reassure you that we are here for you and able to continue providing you with the best care possible. In order to provide that care, I would like to ask you what matters most to you at this time? Knowing what matters most to you will allow us to refine your care plan together, as a team, to meet your needs and address all your concerns.
Medications — Let’s do a review of your current medications. How do you organize your medications? Who manages your medications? Please pick up each pill bottle and tell me the name and how often you are taking it, such as daily or twice a day, etc. If you know what each medication is for, please tell me that as well. If you are not sure, I will tell you, and if you want to write it down, I will help you with that. [After reviewing each medication] Now I want to make sure that you have enough of each medication. If you need refills on anything, let me know so we can get everything called in to your pharmacy.
Thank you for completing such a thorough review of your medications. If there are any medications that I think you can stop taking, I will let you know.
Mentation — Now, this can be a stressful time, and sometimes under stress we have difficulties with our memory, especially short-term memory. Have you had any episodes of forgetfulness or confusion lately? It is understandable if you have, given these trying times. Let me check your thinking with a quick test. I am going to ask you two questions: What is the day of the week? Can you name for me the months of the year backwards, starting with December? Thank you for doing that with me.
Mobility — Now, I would like to talk about how you are getting around at home. Have you had any falls in the last week? Are you able to stand up from the chair without help? If you are, I want you to stand up and sit down in the chair, 4 times in a row, without using your arms to help push you up. Any dizziness or lightheadedness?
This is a great exercise to do 4 times a day. It’s called a sit-to-stand exercise, and it helps keep your leg muscles from getting weak. This and walking around your home, even for a short time, will help. Especially with our current situation of physical distancing and stay-at-home orders. If you are weak or unsteady, we can get a physical therapist to come to your home and treat you, to help you regain your strength. We can make a brief exercise plan now together. [Outline a plan to do steps or laps around a room, and to do 5-10 sit-to-stand repetitions 3-4 times a day. Stress the importance of maintaining activity even while staying home.]
Remote visits have certain limitations, but by using the Age-Friendly Health Systems 4Ms Framework to guide your interactions with older adults, you can maintain your connection with your patients, reassure them during this difficult time, and help identify issues that may require more attention.
Dr. Laurence M. Solberg, MD, is a geriatrician in the Geriatric Research, Education, and Clinical Center (GRECC) at the Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, in Gainesville Florida.
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