Introduction
The COVID-19 epidemic has led to an increase of remote healthcare services. The delay in development of effective and safe vaccines, social distancing, and quarantine have created an environment in which the search for alternatives to person-to-person care is a priority1. Different strategies such as remote consultations, remote monitoring, and home delivery of medications were implemented to supply medical care2. In the disruptive scenario caused by COVID-19, along with medical care, the need for social and emotional support, possibly in remote ways, has emerged as a crucial service as well.
The health and needs of the elderly were especially affected by COVID19 since they are at higher risk of progression to severe disease and mortality from it3. COVID19 may also exacerbate problems of isolation, loneliness, and anxious and depressive disorders as a consequence of social distance measures4. High prevalence of anxiety disorders (up to 49.7%) and depression (up to 47.2%), plus an increase of sleep disturbances and psychological stress have been reported due to COVID195. Being female, having family members with COVID-19, having negative feelings, and lack of resources seem to act as potential risk factors5.
The need to provide new forms of health care to elderly led to the creation of programs such as CCARRE Coordinated Care At Risk/Remote Elderly in New York6, which focused on older adults with cognitive impairment and provided services through videos and calls in which a comprehensive care plan was developed for patients. Spain and Romania assessed the effectiveness of a TV-based platform service for physical and mental health and wellbeing in older people with mild cognitive impairment or mild dementia7. These programs address physical and mental health issues of the elderly but they did not address their social issues.
In the case of our country, the Regulation of Law No. 30421, considers different service modalities for the remote approach of people, such as telemonitoring, teleorientation, teleconsultation, among others; which can be used taking advantage of information technologies8. It should be noted that it is necessary to take into consideration the literacy of older adults, internet connectivity, among other aspects, for its deployment in this population9.
Peruvian Social Security (EsSalud) is responsible for the care of almost 30% of Peruvian Population. It is organized in health networks, which are administrative units distributed at national level. In total there are 29 care networks, three of which are located in Lima (Peru’s capital) and the others in the remaining regions10.
EsSalud delivered social services for elderly nationwide before the COVID-19 pandemic; since the lockdown began, it has implemented a strategy for telemonitoring and teletorientation for older people. Health professionals such as social workers and psychologists, who used to provide preventive and recreational activities for elderly in senior center through the face-to-face modality, began to carry them out remotely, including active listening active listening sessions, social and emotional counseling, social-family support actions, social-health orientation, and follow-up for suspected cases of COVID-199. We describe the experience of implementing psychosocial remote care sessions for elderly patients of the Peruvian Social Security during COVID-19 pandemic.
A previous experience in Lambayeque Region, was developed for emotional support through teleconsultation in order to minimize avoidant symptoms; this study was developed in a population with suspected or confirmed diagnosis of COVID-1911.
Methods
Description of Psychosocial telemonitoring and teleorientation for older adults in EsSalud
EsSalud is the second largest public health provider in Peru, insuring all the formal employed population and their families12. EsSalud has 126 senior centers nationwide that develop and provide preventive and recreational activities. They have the aim to improve quality of life for older adults through the development of family integrative, intergenerational, sociocultural, recreational, productive, and lifestyle programs for active aging13. Due to the measures adopted for the pandemic, the senior centers have started to provide services remotely through telephone calls or video calls for their users. Thus, after the start of the pandemic, they implemented a Psychosocial Telemonitoring and Teleorientation Program with the objective of providing emotional and social support to older adults. In Figura 1, you can see how the intervention was deployed.
Methods
We performed a secondary data analysis of records generated by the teams of the senior centers at the national level during the first six month of operation, between May to October 2020. The database of Psychosocial telemonitoring and teleorientation program for older adults contains the senior center, the healthcare network to which they belong and the name of the center. It also contains the self-report sociodemographic data of the elderly such as age, number living at home, food availability, presence of violence, the need for medication, and self-report of COVID-19 infection. We also registered the method of communication and the type of intervention provided. The data are presented descriptively in frequencies and percentages. We analyzed the data using STATA v.16 statistical software (StataCorp, TX, US) and graphics were created using Excel Spreadsheet.
Results
Characteristics of psychosocial remote program
Between May 1 and October 31, 2020, 154 280 remote monitoring and care were provided to 36 492 older adults. The number of encounters per month is shown in Figura 2.
The healthcare networks that provided the greatest number of remote care sessions were Lima-Rebagliati (27174), Cusco (13029) and Lima-Sabogal (13029); the number of remote care sessions provided by each healthcare network is shown in Figura 3. The healthcare networks with the largest number of older adults who received remote care sessions were those located in Lima.
Characteristics of older adults in the first psychosocial session
At the first remote care sessions, 71.5% of older adults reported living with two or more people at home and only 6.5% reported living alone. The majority of the attendees (90.0%) had no problems with food availability and 0.7 % reported presence of violence at home. Regarding the need of medications, 13.7 % had prescriptions pending and 14.5 % reported lack of prescription and need of medicines (See Table 1).
Characteristics | n = 36492 | (%) |
---|---|---|
Age [mean (Standard deviation) | 73.5 | (SD: 7.7) |
Number of people living at home | ||
Alone | 2375 | (6.5 %) |
With one person | 8023 | (22.0 %) |
With two or more people | 26094 | (71.5 %) |
Food availability | ||
No | 3647 | (10.0 %) |
Yes | 32845 | (90.0 %) |
Need of medicine | ||
Do not need medicine | 26192 | (71.8%) |
Prescription pending | 5012 | (13.7 %) |
Do not have prescription and need medicines | 5288 | (14.5 %) |
Presence of violence | ||
Yes | 253 | (0.7 %) |
No | 36239 | (99.3 %) |
COVID-19 infection | ||
Positive | 461 | (1.3 %) |
Negative/Do not know | 36031 | (98.7 %) |
Care provided in psychosocial program
Table 2 shows the characteristics of interventions provided in remote care sessions. The main method of communication with patients was through cell phone calls 70.7%, the main intervention provided was emotional support (75.5%), followed by social counseling (53.8%). 41.5% of the remote care sessions were follow-ups and the main reason for follow-up was for emotional aspects (49.3%) and for prescriptions (25.4%). (See Table 2).
Characteristics | n | % |
---|---|---|
Method of communication | ||
Cell phone calls | 109059 | 70.7% |
Landline phone calls | 32593 | 21.1% |
10346 | 6.7% | |
Others | 2282 | 1.5% |
Type of intervention* | ||
Emotional support | 116503 | 75.5% |
Social counseling | 82930 | 53.8% |
Social and health orientation | 66307 | 43.0% |
Accompaniment | 26536 | 17.2% |
Social and family support | 21491 | 13.9% |
Others | 18593 | 12.1% |
Reason of follow-up* | ||
Emotional | 75995 | 49.3% |
Prescription | 39137 | 25.4% |
Presence of violence | 1112 | 0.7% |
Health | 1099 | 0.7% |
Food Availability | 87 | 0.1% |
* The sum of the values does not add up to 100% because the categories are not mutually exclusive
The most recorded mood were calmness and worry, although in different proportions between cases with and without COVID-19 infection. In addition, feelings of worry, stress, sadness and fear are higher in those with COVID-19 compared to those without COVID-19 (See Table 3).
Characteristics | without Covid-19 | with Covid-19 | ||
---|---|---|---|---|
n (%) = 151101 (97.9%) | n (%) = 3179 (2.1%) | |||
Feelings* | ||||
Calm | 75490 | 50.0% | 1063 | 33.4% |
Worry | 49112 | 32.5% | 1606 | 50.5% |
Stressed | 20070 | 13.3% | 585 | 18.4% |
Optimistic | 16302 | 10.8% | 184 | 5.8% |
Sad | 14690 | 9.7% | 562 | 18.7% |
Fear | 12.146 | 8.0% | 592 | 18.6% |
* The sum of the values does not add up to 100% because the categories are not mutually exclusive
Discussion
Although the service provided in the care centers was not labeled “social prescribing”, most of the components address similar benefits as social prescribing models in other countries. Initiatives on social prescribing have been introduced in Netherlands, Canada, Australia and the United States, but is a common practice in the United Kingdom14. Social prescription is the process by which a person is referred to community resources, can be done by any primary care professional, and will address emotional or practical needs, for example, housing or employment advice, bereavement support, health behavior counselling, spaces for arts, sport or creative activities(9, 15). Some case-studies suggest that social prescribing in older adults experiencing social isolation and mild-to-moderate mental health problems cause positive effects on self-esteem, mental wellbeing, reduce loneliness and reduce health service use(9, 16). In addition, in other studies, it has been shown that the social prescription service allows people to participate in the community, generating more optimistic feelings about life17.
The COVID-19 pandemic have increased existing emotional, social, and economic challenges in population health that social prescribing may address. A social prescribing model that involves workers from the primary care and include principles of universality, comprehensiveness, and integration presents an opportunity to improve people wellbeing in the COVID-19 era18.
Regarding the provision of care through remote services, implementation of remote services is challenging not only for users, but also for healthcare providers. In Brazil, it is reported that the implementation of a remote care sessions program, the difficulties of health personnel in the early stages, was reflected in low adherence to services, as professionals gained more experience, adherence and fidelity to the service improved19. We cannot affirm this with our data because we worked with secondary data and did not collect healthcare professional perceptions.
In spite of the benefits offered by technology and remote care, it is necessary to reflect on some of its limitations, such as lack of access, distrust and technological literacy6 which are higher among older adults; this is consistent with a study where it was found that a third of older adults did not adapt to the use of telemedicine, plus the use of the telephone was an important option, especially for people with disabilities20. That is not just a problem for users, also for providers, since health professionals also experienced problems adapting to the use of technology, which was overcome over time21.
Despite the resistance and lack of thrust regarding the use of technology, healthcare workers and older adults gradually adapted to the use of new means of care delivery; this is an indicator about the necessity to focus public health policies on capability approach as an ultimate goal22, recognize the digital gap, and contextualize strategies to the reality of people20.
The impossibility of some older adults to have a telephone at home, cell phone or internet, or to have them but not know how to use them, indicates that those who have had access to remote services are probably a privileged group. According to our study, the least amount of telemonitoring was carried out in Huancavelica, which is the region with a 60.5% rural population, 80% speaks Quechua, 17.7% of its population is illiterate and very few have access to higher education23.
The information from this study is descriptive and it has not been possible to measure the effect of remote care on the quality of life of older adults. However, in the experience of CARE, one benefit could be that caregivers and patients improve their mood and decrease their symptoms of depression and anxiety6. We hope that to some extent this has happened with older adults in Social Security.
Senior Centers through their Psychosocial telemonitoring and teleorientation have been carrying out an important task of health, emotional and social assistance to the elderly. During the first 6 months of this remote assistance, more than 150 thousand remote care sessions were carried out for the benefit of around 36 thousand elderly people. The main services offered have been emotional support, social counseling and social and health orientation.
This experience shows the need to articulate health and social services in favor of the well-being of older adults, through strategies such as social prescription.