Telehealth Best Practices: Dr. Liron Sinvani of The Feinstein Institutes for Medical Research On How To Best Care For Your Patients When They Are Not Physically In Front Of You

…Geriatrician shortage. While older adults make up the fastest-growing segment of the population, the number of geriatricians stays constant. Telehealth allows patients who live in areas with no geriatricians to benefit from the skill-set and comprehensive assessment required to care for medically complex older adults.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Liron Sinvani.

Liron Sinvani, MD, is an assistant professor in the Institute of Health System Science at the Feinstein Institutes for Medical Research and the director, Geriatric Hospitalist Service at Northwell Health, New York’s largest health system. As a hospitalist with geriatrics training, Dr. Sinvani is passionate about improving the management of care for older adults. Dr. Sinvani has been drawn to the complex nature of caring for the frail elderly during hospitalization, a most vulnerable time for adverse outcomes. Her overall goal is to develop and test interventions to prevent and mitigate functional and cognitive decline in older adults during hospitalization.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory,’ and how you got started?

As a hospitalist with a geriatrics focus, I am passionate about improving care for older adults during their most vulnerable state, namely, during hospitalization. Currently, my roles include being an assistant professor at the Feinstein Institutes for Medical Research, the science arm of Northwell Health, as well as an associate professor of medicine at the Zucker School of Medicine at Hofstra/Northwell and the director of research for Hospital Medicine.

Since starting medical school, I have always loved the hospital setting in which multidisciplinary teams work together to optimize care. Growing up, my four grandparents were instrumental in raising me and were really my inspiration to become a geriatrician. During my geriatrics fellowship, I met my mentors, Dr. Gisele Wolf-Klein and Dr. Renee Pekmezaris, who introduced me to research. After completing my geriatrics fellowship and joining the Division of Hospital Medicine, I experienced firsthand the devastating consequences of hospitalization in older adults which consist of functional and cognitive decline. Therefore, my goal was to develop and study innovative programs that integrate geriatrics into hospital medicine.

Can you share the most interesting story that happened to you since you began your career?

As a geriatrician-hospitalist, COVID-19 has had a disproportionate and unbearable impact on my patients and my colleagues. During this time, I have many unforgettable and painful stories of fear and death. However, as healthcare providers, this experience has also been met with many important lessons of resilience. As hospital workers, we learned how to adapt on the fly to the constantly changing conditions. We learned to work better together to care for our patients despite our physical distance and anticipate their needs. Most importantly, how to face all the odds head-first and emerge even stronger. As our studies continue, we are more determined than ever to improve the care of hospitalized older adults with dementia and their caregivers.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that is relevant to you in your life?

“If we knew what it is we were doing, it would not be called research. Would it?” -Albert Einstein.

Early in my career, my mentors challenged me to ask questions and change the status quo. Although we may not always know the correct answer, I learned that it is always important to ask the question.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

I have been incredibly privileged to have strong female mentors who have helped guide and mold my career and become my friends.

In medical school, while I was a top resident in my class, I struggled to decide on a career path in which I could balance a successful academic career while still raising a family. During my first week back as a third-year resident following my maternity leave, I had just finished rounds when my phone rang; it was the chief of the Division of Geriatrics asking me if I would want to meet the fellowship director for an interview. While I loved my grandparents dearly, I had never considered a career in geriatrics.

The next day, I met Dr. Gisele Wolf-Klein, and I like to think that it was “love at first sight.” Dr. Wolf-Klein was highly energetic and electric. Her first question to me was about research. She was not fazed at all when I told her I had never done research before. She promised that she would teach me everything she knew about geriatrics, research and life for as long as I had questions to ask. Dr. Wolf-Klein retired two years ago, but we still talk multiple times a week about life, research and everything in between. She is the true definition of a mentor.

Ok, wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them, of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can, of course, be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

As a geriatrician, most functional, cognitive and psychosocial assessments rely on patient observation. How does the patient enter the room, sit down, stand up? Can the patient pay attention to the surrounding conversation? The physical examination, a critical component of the assessment, necessitates evaluating the skin, the way the extremities move and the resistance the patient can provide when challenged.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

While technology literacy has improved drastically among older adults, there are still many who struggle. This obstacle was most recently highlighted by the struggle of many older adults to gain access and make appointments for COVID-19 vaccinations. Therefore, for many older adults, using technology relies on caregivers (for those that have them readily available). In addition, similarly to the strength of in-person meetings, by not having a patient in the same space, one could miss subtle and important signs of impairment, whether in cognition or function.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You”?

1) Pre-visit work — technology can be very tricky and challenging, especially for older adults. A pre-visit technology check — which may require a caregiver — is essential to ensure an efficient and high-quality visit.

2) Be mindful of the surrounding environment. While telehealth visits can limit the ability to make physical observations, it does open a window into the patient’s living conditions, which are crucial to good health.

3) Ask open-ended questions. One of the disadvantages of a telehealth visit is that providers seem to do more talking than listening. Asking open-ended questions and giving the patients and caregivers time to speak can encourage more participation.

4) Make a connection. While making a personal connection through telehealth is more challenging, it is even more important. Make sure to connect with the patient through questions and stories.

5) Engage caregivers. Older adults may be more dependent on caregivers for their healthcare. Make sure to discuss the healthcare plan with the caregiver team who provides care for the patient to ensure increased compliance.

Can you share a few ways that telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Here are a few ways in which we have used telehealth to improve patient care and research.

1. Geriatrician shortage. While older adults make up the fastest-growing segment of the population, the number of geriatricians stays constant. Telehealth allows patients who live in areas with no geriatricians to benefit from the skill-set and comprehensive assessment required to care for medically complex older adults.
2. Tele-physical therapy. During the COVID-19 pandemic, due to strict isolation precautions and visitation restrictions, older adults were often in their room, in bed and alone. This isolation led to significant weakness and deconditioning. Therefore, we needed to find innovative ways to engage our patients. Our research team partnered with physical therapists to establish a tele-rehabilitation program in which physical therapists engaged hospitalized older adults in tele-physical therapy two times a day. Our research found that most patients experienced improved function.
3. Staff training. Only five percent of hospital personnel receive training in dementia care. However, older adults make up over 50 percent of hospital beds. While in-person training on improving geriatrics assessment for nursing and physician staff can be effective, it is also highly time-consuming. Telehealth allows for improving accessibility and efficiency in providing specialized training for healthcare staff that can improve care for older adults.
4. Outpatient visits. While an in-person visit is highly valuable, it is well known that older adults have a more challenging time getting to appointments. The difficulty can be due to dementia, debility, or dependence on caregivers to get to appointments. Therefore, telehealth improved accessibility for many patients.
5. Recruitment into clinical trials. Telehealth has been increasingly used for patient recruitment as well as study implementation. This has allowed for greater participation by older adults and those in underserved populations.

Let’s zoom in a bit. Many tools have been developed to help facilitate telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

Practical smart devices, such as smart home devices, have expanded the ability of older adults to engage in telehealth and healthcare services in general. You can use smart home devices for reminders regarding medications, appointments, healthy eating and exercises. In addition, smart devices can connect patients, their caregivers and healthcare professionals, who may all be located at different sites, all in one call or visit.

If you could design the perfect telehealth feature or system to help your patients, what would it be?

The perfect telehealth system would be one that could integrate different platforms. For example, a system that can connect information from the primary care doctor, the consultants, the pharmacy, and the physical therapist all in one. This system can then generate a report that can be referenced by the patient, caregiver or healthcare team.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Having a good visit, whether it be in the office or on telehealth, requires preparatory work from the patient and caregiver. Before engaging in a telehealth visit, be sure to have an updated list of your medications ready, as well as a list of things you would like to discuss. In addition, it is very common for patients to forget things that were said during the visit, which can be especially true during telehealth. Therefore, make sure you take notes or ask a caregiver, family member or friend to take notes.

The technology is rapidly evolving and new tools like VR, AR and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

Care robots for older adults are a fascinating field in geriatrics and can address critical gaps in quality of care.

Is there a part of this future vision that concerns you? Can you explain?

Technology has generally targeted those that are younger. Older adults usually have been excluded from trials that predominantly use technology for healthcare. Therefore, the information we have is limited as to the applicability of the findings for older adults. More technology needs to be adapted for older adults who can significantly benefit from these devices and services.

Ok, wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

While older adults have been slower to adopt the use of technology, this is rapidly changing. The COVID-19 pandemic has dramatically increased the use of technology and telehealth by older adults. More research is needed to understand better facilitators and barriers to telehealth and technology for this population.

How can our readers further follow your work online?

People can check out my Feinstein Institutes profile page here and also follow be on Twitter @LSinvani

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.