Unmet needs and social challenges for seniors during and after the COVID-19 pandemic: an opportunity to improve care - GEDC (2023)

Many older adults in the United States are affected by unmet needs and social challenges that have a negative impact on their health and well-being. These include social isolation, inadequate care, inability to carry out daily activities, food insecurity, housing insecurity, poverty and abuse/neglect/exploitation. Such challenges make it difficult to obtain medical and dental care and manage vision/hearing problems. Affected patients have problems obtaining medications and adhering to medication regimens. These problems can compromise the nutrition of the elderly. They can contribute to anxiety, depression and loneliness, which in turn can also negatively affect a person's health and physical functioning.

Unmet needs and societal challenges intersect with the emergency department (ED) visit in two ways. First, they often contribute to a senior's decision to seek emergency department care. They are often a causative factor in an injury or the trigger for an illness.¹Second, a visit to the emergency department may be one of the few times seniors leave the house or interact with a medical professional. This makes the visit to the SU a critical opportunity to identify and improve these issues. Sixty percent of cognitively intact seniors who present to the emergency department report ongoing nonmedical problems²; these problems may be even more common among older adults with cognitive impairment. Older adults report that they would like their non-medical issues addressed during an emergency room visit, yet these issues are rarely identified, much less addressed.³

The COVID-19 pandemic and its public health response have highlighted the burden of unmet needs and social challenges for older adults. This document offers the opportunity to create a change in ED systems to better identify and improve linkages of services to deal with these issues. Emergency service providers should systematically screen older adults for unmet needs and social challenges as part of the emergency assessment. If available in the emergency department, a social worker, care manager, or care coordinator may be the ideal team member to detect these problems.⁴

The assessment typically involves asking a patient about his daily activities and functioning, his home environment, his medication regimen, and how he receives care. An alternative approach is to ask a more limited set of questions (eg, vital signs of hunger) and, if these initial questions are positive, to assess a broader range of issues.⁵Connecting an elderly patient with appropriate community services and resources can be very helpful.⁶Linking to adult day care or seniors services can also provide the elderly patient with necessary supports.^7-10

Providing meals at home can sometimes delay the need for admission to a nursing home.¹¹However, timely linkage to support services can be problematic depending on local resources. Sometimes family members or caregivers can help during the time until services can be provided.¹²While not ideal, hospitalization may be necessary for seniors for whom emergency care providers feel a safe discharge plan cannot be established.^13,14Below, we discuss in more detail several unmet needs and societal challenges and recommend specific assessment and intervention strategies.

Even in the absence of a pandemic, an estimated 43% of seniors experience social isolation.¹⁵This disconnect can lead to loneliness, decreased quality of life and depression, and is associated with medical consequences including falls, cognitive decline and mortality.^15,16The public health response to COVID-19, including stay-at-home orders and social distancing measures, has dramatically increased the prevalence of social isolation in older adults and exacerbated the problem for those already isolated. Gathering places such as senior centers and places of worship were closed. Social supports, including family and friends, may feel uncomfortable visiting or may be formally prohibited from visiting due to concerns of infecting an older adult or contracting COVID-19 itself. And while some studies suggest that older adults are more comfortable using technology as a platform for medical appointments than previously thought,¹⁷many seniors do not have internet access or cannot use the technology needed to conduct video chats. This last problem can be partially solved with the use of age-friendly technology that employs large icons and pre-programmed communication methods.¹⁸

The pandemic also presents significant transportation challenges, as seniors may rely on social supports or public transport to get to appointments and carry out essential errands. Without access to safe transportation, seniors cannot receive regular outpatient medical care or obtain prescription drugs. As a result, chronic health conditions can be exacerbated, which can lead to presentation and hospitalization in the emergency department.

Socially isolated seniors visit emergency services more often than those who feel connected,¹⁵This suggests that a visit to the emergency department can be an opportunity to identify this problem and initiate intervention with appropriate referrals. To assess social isolation in the ED, providers should explore the patient's social support network. Questions that focus on perceptions of loneliness, including how connected an older adult feels to friends and family or whether they have people they can talk to or depend on, can be particularly helpful.¹⁹

Many communities have recognized the importance of reducing seniors' social isolation amidst COVID-19 and have developed creative solutions to improve connectivity. In New York City, the Department of Aging has developed virtual centers for seniors and New York Connects has created a Friendship Line for seniors who may feel lonely. A large cable TV and Internet company in the New York area has created an affordable Internet option for seniors. Community-based counseling programs offer support via telephone or video conference. In Detroit, Michigan, an innovative telephone outreach program was established.¹⁹A senior travel program in Virginia offers private travel to and from medical appointments for seniors with chronic health conditions with frequent disinfection to reduce the transmission of infections.²⁰It is essential to know and use local resources to provide assistance and referrals to the elderly in this difficult time.

Many elderly people experience functional decline and need assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include bathing, grooming, toileting, transferring, and self-feeding; IADLs include cleaning the house, managing money, preparing meals, shopping for groceries and necessities, taking prescription medications, and using the phone to communicate. Receiving inadequate care or assistance with these ADLs and IADLs is a critical unmet need21 that can dramatically affect an elderly person's health and increase their mortality.²²Prior to COVID-19, research showed that 75% of seniors presenting to the ER reported a decrease in ADLs and 65% reported a decrease in IADLs.²³

The COVID-19 pandemic has likely increased the prevalence of unresolved functional challenges among older adults. Family members and friends who have already cared for an elderly person and, therefore, may have identified functional impairment, may not do so during a pandemic for fear of exposing themselves or the elderly person to the virus. Home-based care workers may no longer provide services due to personal concerns or agency policy, leading to inadequate care and worsening of existing health problems. An older adult may not be able to get the necessary prescription medications or take them properly. They may have difficulty purchasing assistive devices, such as canes, walkers, hearing aids or eyeglasses, and may not be able to adjust current devices as needed.

Also, your own functional deficiencies can affect the ability of individuals to access the necessary medical care for the emergency department. As outpatient providers rely on telemedicine to care for patients during the pandemic, older adults with hearing loss or fine motor skill deficits may face increasing challenges getting the care they need without access to technology. Easy to use.^sixteenWhile it is an important public health behavior, the use of masks by others makes it difficult for people with hearing or visual impairments to communicate.²⁴

Emergency service providers must recognize these challenges and proactively assess an older adult's functional status and the care/assistance they are receiving. Emergency personnel can educate family members or other informal caregivers on how to provide appropriate care. When appropriate, social workers and care managers should be involved to help establish or modify home care during the pandemic. Assistive devices must be delivered to the patient or delivery must be scheduled.²⁵

Many elderly people experience food insecurity, defined as the lack of access to nutritionally adequate food due to limited resources, such as financial resources, availability of healthy foods and transportation.⁵Food-insecure seniors are at greater risk not only for malnutrition, but also for heart disease, diabetes, depression, and ADL dependence.^5,26,27Before COVID-19, 8.7% of seniors living alone and 7.2% of seniors living with others were food insecure.²⁸Up to 15% of seniors presenting to the emergency room were malnourished and, of these patients, food insecurity was a contributing factor in over 25%.⁵

The COVID-19 pandemic has dramatically increased the risk of food insecurity among seniors. Meal delivery services such as Meals on Wheels have had to suspend operations. Senior centers, where many seniors received meals, were closed. Many seniors cannot go to the grocery store due to functional limitations, transportation issues, or fear of exposure to COVID-19. Online grocery services have replaced in-person shopping for many, but they can be difficult to navigate for some older adults who have established routines and are inexperienced in using technology. Financial issues due to the economic impact of COVID-19, which will be discussed below, may affect food purchases for seniors, their families and caregivers.

Existing screening tools such as the malnutrition screening tool²⁹and the Hunger Vital Sign (HVS)³⁰ED providers can use the food insecurity screen to assess this critical issue. For patients who test positive, referrals can be made to local service providers as well as the Federal Supplemental Nutrition Assistance Program.³¹The use of HVS to identify older emergency room patients with unmet non-medical needs and refer them to community-based services was recently piloted in a US emergency department;⁵Unpublished results support the feasibility of this approach.

Housing insecurity, which includes low-quality housing, homelessness, overcrowding and lack of affordability, is an increasingly common problem for older people.³²Housing-insecure seniors, particularly the homeless, have increased health care needs related to geriatric conditions, along with functional and cognitive decline.³³Homeless people often visit the emergency room for care³⁴but they show improvement in depressive symptoms and use less acute care after obtaining housing.³³

Older adults with unsafe housing are likely to be at greater risk of exposure and illness from COVID-19. Homeless shelters have been a nesting place for the spread of COVID-19.³⁵People living in homelessness and substandard housing may not be able to properly quarantine if exposed or socially isolated if they develop symptoms and therefore may become vectors for further spread. Also, they may not be able to take care of themselves if they get sick.

Many communities have recognized the importance of addressing housing insecurity as a way to contain the COVID-19 pandemic. One approach has been to convert abandoned hotel rooms into housing for the homeless. Emergency service providers should ask older adults about their home environment to assess their safety and security. They should explore the possibility of an older adult living with a relative or friend if their current living situation is unsafe. Emergency service providers should consider admitting patients if they have questions about their ability to safely care for themselves or receive care from others in their home environment. Patients facing this societal challenge are likely to be at much greater risk of re-presenting to the ER and having poor outcomes if released back into the same living environment during the pandemic.

Financial insecurity was a reality for many seniors before the COVID-19 outbreak, and 9.2% of American seniors had incomes below the poverty line.³⁶The poverty rate among older adults is highest among the elderly (≥65 years) and among blacks and Hispanics.³⁷

COVID-19 has been financially devastating, causing massive job losses as well as temporary but dramatic drops in the stock market and retirement investment accounts. COVID-19 related deaths among older adults are likely to lead to an increase in financially vulnerable elderly families, with the surviving spouse struggling with money.³⁸Financial insecurity can cause and exacerbate other unmet needs and social challenges described above, as older people may not have the necessary resources to pay for care, medication, transportation, food and housing. Furthermore, unpaid utility bills can lead to service interruptions that create an unsafe living environment. COVID-19 also presents other financial challenges. Seniors receiving a fixed income through checks in the mail may be reluctant or have difficulty depositing or cashing these checks during the pandemic. Online banking and bill paying has become more common during the pandemic. While many seniors are comfortable using them, others may need training and assistance.

While emergency service providers may not be able to address COVID-19-related financial insecurity in elderly patients, they should be aware of its potential importance and relevance to acute issues that precipitate presentation to the ER. Community services, including the local or regional Agency on Aging, can provide resources to pay for necessary expenses and help with financial management and paying bills. Additionally, older patients can be directed to resources at financial institutions that offer online financial management training.

Elder abuse, which includes physical abuse, neglect, sexual abuse, verbal abuse, emotional abuse, psychological abuse and financial exploitation, is a serious problem that is critical to identify in the ED. Elder abuse occurs frequently, affecting 5 to 10% of seniors living in the community and over 20% of those living in long-term care facilities.³⁹Elder abuse has medical consequences, with victims having much higher mortality than other older adults and higher rates of depression and exacerbation of chronic illnesses.³⁹Victims of elder abuse are less likely to see a primary care provider than other older adults and are more likely to go to the emergency department.³⁹Research has shown that 7% of elderly patients with cognitively intact erectile dysfunction report abuse if asked,²but emergency professionals rarely identify or address this issue during an emergency consultation.^39,40

The COVID-19 pandemic and the public health response have likely increased the frequency and severity of elder abuse.⁴¹Stay-at-home orders or a period of quarantine can be disastrous for a victim who is now trapped at home with an abuser. Unemployment, decreased income and increased stress for family caregivers, all known risk factors for elder abuse, are more common during the pandemic. Rising rates of substance abuse and mental illness among caregivers may also contribute to the rise in elder abuse during the pandemic. Access to community support services and senior centers, as well as interactions with family and friends who can prevent abuse or intervene, can be severely limited.⁴¹Nursing homes and assisted living residents may also be in greater danger. Restricting family visits, while necessary to reduce the transmission of infections, reduces facility liability and eliminates opportunities to identify problems with the care provided to residents.

Because an emergency room visit for an acute illness or injury may be the only time an elderly victim leaves home during the pandemic, emergency care providers must make identifying elder abuse a priority. The incorporation of protocols for the detection of elder abuse should be considered,⁴²how many cases are subtle and involve various types of abuse. Social workers can take the lead in ED assessment when available. Several ED-specific tools have recently been developed and tested: the ED Senior Abuse Identification Tool (ED Senior AID);⁴³a multi-step screening approach that incorporates the ED Senior AID tool,⁴², and the Emergency Department Elder Abuse Assessment Tool for Social Workers (ED-EMATS).⁴⁴The last of these is designed specifically for social workers.

Emergency service providers must report all potential cases of elder abuse to the appropriate authorities. Health professionals are mandatory whistleblowers for elder abuse in most, but not all US states, and in many, elder abuse must be reported even if the victim does not want a report to be made. Requirements vary by state and information can be obtained from the state Department of Health website.

Alyssa Elman LMSW¹, Daniel Baek MPH¹, Elaine Gottesman LMSW¹, Michael E. Stern MD¹, María R. Mulcare MD¹, Amy Shaw MD², Morgan Pearman PA-C¹, Michelle Sullivan PA-C¹, Domingo Clark ScD MPH³, Timothy F. Platts-Mills MD MSPH⁴, Rahul Sharma MD MBA¹, Tony Rosen MD MPH¹

1. Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York
2. Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York
3. Boston Trauma Institute, Department of Surgery, Boston University School of Medicine
4. Quantworks, Inc. Carrboro, Carolina do Norte

Autor para correspondência: Tony Rosen MD MPH, Department of Emergency Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, 525 East 68th Street, Room M130, New York, NY 10065,aer2006@med.cornell.edu, 212-746-0780 (phone), 212-746-4883 (fax)

Funding: Tony Rosen's participation was supported by a Paul B. Beeson Emerging Leaders in Aging Career Development Award (K76 AG054866) from the National Institute on Aging. The content is the sole responsibility of the authors and does not necessarily represent the official opinion of the National Institutes of Health.

1. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a review of the literature on trends, appropriateness, and consequences of unmet health needs. MedCare Res Rev 2011;68(2):131-155. doi:10.1177/1077558710379422

2. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of non-medical problems among older adults presenting to the emergency department. Acad Emerge Med 2014;21(6):651-658. doi:10.1111/acem.12395

3. Shankar KN, Bhatia BK, Schuur JD. Towards patient-centered care: a systematic review of seniors' views on quality emergency care. Ann Emerg Med 2014;63(5):529-550.e521. doi: 10.1016/j.annemerged.2013.07.509

4. Hamilton C, Ronda L, Hwang U, et al. The evolving role of geriatric emergency department social work in the era of health care reform. Soc Work Health 2015;54:849-68.

5. Morris AM, Engelberg Anderson JK, Schmitthenner B, et al. Leveraging emergency department visits to connect seniors at risk of malnutrition and food insecurity with community resources: design and development of protocols for the BRIDGE study. Pilot Bolt Feasibility 2020;6:36. doi:10.1186/s40814-020-00576-3

6. Siegler EL, Lama SD, Knight MG, Laureano E, Reid MC. Community supports and services for seniors: a basic handbook for clinicians. J Geriatric 2015;2015. Doi: 10.1155/2015/678625.

7. Pardasani M, Thompson P. Centers for the elderly: innovative and emerging models. J Appl Gerontol 2012;31:52-77. Doi: 10.1177/0733464810380545.

8. About Adult Day Services. National Association of Adult Day Services 2013. Available at https://www.nadsa.org/learn-more/about-adult-day-services/. Accessed June 1, 2021.

9. Dabelko-Schoeny H, Anderson KA, Guada J. Adult day services: a service platform for mental health care delivery. Aging Ment Health 2013;17:207-14. Doi: 10.1080/13607863.2012.724653.

10. The MetLife National Study of Adult Day Jobs. New York, NY: MetLife Mature Market Institute (MMI); 2010. Accessed June 7, 2021.

11. Thomas KS, Mor V. Providing more meals at home is one way to keep seniors with low care needs out of nursing homes. Health Affairs 2013;32:1796-802. Doi: 10/1377/hlthaff.2013.0390.

12. Involving family caregivers reduces hospital readmissions by 25%. 2017. Available at https://patientengagementhit.com/news/family-caregiver-engagement-cuts-hospital-readmissions-by-25. Accessed June 1, 2021.

13. McCusker J, Roberge D. Safe discharge of seniors from the emergency department to the community. Montreal, Canada: St. Mary's Hospital - Department of Clinical Epidemiology and Community Studies; 2008.

14. Salentiny-Wrobleski D. Safe discharge from the Emergency Department. Emergency Nurses Association 2019. Available at: https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/safedischargefromed.pdf?sfvrsn=998ee45f_12. Accessed June 1, 2021.

15. Kandasamy D, Platts-Mills TF, Shah MN, Van Orden KA, Betz ME. Social disconnection among elderly people treated at the emergency service. West J Emerg Med 2018;19(6):919-925. doi:10.5811/westjem.2018.9.38784

16. Steinman MA, Perry L, Perissinotto CM. Addressing the care needs of elderly people isolated at home during the COVID-19 pandemic. JAMA Intern Med 2020;180(6):819-820. doi:10.1001/jamainternmed.2020.1661

17. Greenwald PW, Stern M, Clark S, et al. A new emergency department-based telemedicine program: How are elderly patients doing? Telemed JE Saúde 2019;25(10):966-972. doi:10.1089/tmj.2018.0162

18. Tsai H-yS, Shillair R, Cotten SR, Winstead V, Yost E. Getting Grandma Online: Are tablets the answer to increasing digital inclusion for older adults in the US? Educ Gerontol 2015;41:695-709. doi:10.1080/03601277.2015.1048165

19. Rorai V, Perry TE. An innovative phone answering program for seniors in Detroit, a city facing dire consequences from COVID-19. J Gerontol Soc Labor 2020:1-4. doi:10.1080/01634372.2020.1793254

20. EngAGED: The National Resource Center for Senior Adult Engagement. The impact of COVID-19 on access to transport and social isolation. Available at: https://us5.campaign-archive.com/?u=8e5a58f0539f4d7433f4faafc&id=f878b8a7ad. Accessed June 1, 2021.

21. Iliffe S, Lenihan P, Orrell M, Walters K, Drennan V, Tai SS. The development of a brief instrument to identify common unmet needs in older adults in general practice. Br J Gen Pract 2004;54:914-8.

22. He S, Craig BA, Xu H, et al. The unmet need for ADL assistance is associated with mortality among elderly people with mild disabilities. J Gerontol A Biol Sci Med Sci 2015;70:1128-32. doi:10.1093/gerona/glv028

23. Wilber ST, Blanda M, Gerson LW. Does functional decline lead to emergency room visits and hospitalization in elderly patients? Acad Emerg Med 2006;13:680-2. doi:10.1197/j.aem.2006.01.006

24. Marchini L, Ettinger RL. COVID-19 Pandemics and Oral Health Care for the Elderly. Spec Care Dentist 2020;40:329-31. doi:10.1111/scd.12465

25. Fareed N, Southerland LT, Rao BM, Sieck CJ. Geriatric assistive devices improve older patient engagement and clinical care in an emergency department. Am J Emerg Med 2020. Doi:10.1016/j.ajem.2020.07.073

26. Burks CE, Jones CW, Braz VA, et al. Malnutrition risk factors in the elderly in the emergency department: a multicenter study. J Am Geriatric Soc 2017;65:1741-7. doi:10.1111/jgs.14862

27. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Affairs (Millwood) 2015;34:1830-9. doi:10.1377/hlthaff.2015.0645

28. Coleman-Jenson AR, Matthew P.; Gregory, Christian A.; Singh, Anita. Home Food Security in the United States 2019. United States Department of Agriculture (online). Available at: https://www.ers.usda.gov/webdocs/publications/99282/err-275.pdf?v=8980.1. Accessed on January 19, 2021.

29. Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: comparison with two validated nutritional assessment methods in hospitalized elderly patients. Nutrition 2013;29:101-6. doi:10.1016/j.nut.2012.04.007

30. Makelarski JA, Abramsohn E, Benjamin JH, Du S, Lindau ST. Diagnostic accuracy of two food insecurity detectors recommended for use in healthcare settings. Am J Public Health 2017;107(11):1812-1817. doi:10.2105/AJPH.2017.304033

31. Pooler JA, Hartline-Grafton H, DeBor M, Sudore RL, Seligman HK. Food insecurity: a key social determinant of elderly health. J Am Geriatric Soc 2019;67:421-4. doi:10.1111/jgs.15736

32. Brown RT, Lori Thomas M, Cutler DF, Hinderlie M. Meeting the housing and care needs of homeless seniors: an ongoing housing support program for homeless seniors. Caring for the elderly J 2013;21:126-35.

33. Brown RT, Miao Y, Mitchell SL, et al. Health outcomes of housing acquisition among homeless older adults. Am J Public Health 2015;105(7):1482-1488. doi:10.2105/AJPH.2014.302539

34. Lin WC, Bharel M, Zhang J, O'Connell E, Clark RE. Frequent emergency department visits and hospitalizations among homeless people on Medicaid: Implications for Medicaid expansion. Am J Public Health 2015;105 Suppl 5(Suppl 5):S716-722. doi:10.2105/AJPH.2015.302693

[PubMed] 35. Rogers JH, Link AC, McCulloch D, et al. Characteristics of COVID-19 in homeless shelters: a community-based surveillance study. Ann Intern Med 2020. doi:10.7326/M20-3799

36. Romig K. Poverty among Americans age 65 and older. In: USCR Service, ed. 2019:1-19. Available at: https://fas.org/sgp/crs/misc/R45791.pdf. Accessed June 1, 2021.

37. Cubanski J, Koma W, Damico A, Neuman T. How many elderly people live in poverty? Kaiser Family Foundation, 2018. Available at https://www.kff.org/report-section/how-many-seniors-live-in-poverty-issue-brief/. Accessed on January 19, 2021.

38. Cohen M, Tavares J, Silberman S, Popham L. Potential financial impacts of the COVID-19 pandemic on older single families. National Council on Aging. Available at: https://d2mkcg26uvg1cz.cloudfront.net/wp-content/uploads/2020-C19-DG19_COVID-19-Issue-Brief_Older-Single-Householders_7-24.pdf. Accessed on January 19, 2021.

39. Rosen T, Stern ME, Elman A, Mulcare MR. Identify and initiate intervention for elder abuse and neglect in the emergency department. Clin Geriatric Med 2018;34:435-51. doi:10.1016/j.cger.2018.04.007

40. Evans CS, Hunold KM, Rosen T, Platts-Mills TF. Diagnosis of Elder Abuse in US Emergency Departments J Am Geriatr Soc 2017;65:91-7. Doi:10.1111/jgs.14480.

41. Elman A, Breckman R, Clark S, et al. Effects of the COVID-19 outbreak on elder abuse and response in New York City: early lessons. J Appl Gerontol 2020;39(7). doi:10.1177/0733464820924853

42. Rosen T, Platts-Mills TF, Fulmer T. Detection of elder abuse in emergency departments: current progress and recommendations for next steps. J Elder Abuse Negl 2020;32(3):295-315. Doi:10.1080/08946566.2020.1768997.

43. Platts-Mills TF, Hurka-Richardson K, Shams RB, et al. Multicenter validation of an emergency department-based screening tool to identify elder abuse. Ann Emerge Med 2020;76(3):280-290. doi:10.1016/j.anneemergmed.2020.07.005

44. Elman A, Rosselli S, Burnes D, et al. Development of emergency department elder abuse assessment tool for social workers using a modified Delphi technique. Social Work in Health 2020;45(2). doi:10.1093/hsw/hlz040.

45. Henning-Smith C. The unique impact of COVID-19 on older people in rural areas. J Aging Soc Policy 2020;32(4-5):396-402. Doi:10.1080/08959420.2020.1770036.

46. ​​Bains J, Greenwald PW, Mulcare MR, et al. Using telemedicine in a new approach to managing COVID-19 and the patient experience in the emergency department. Telemed JE Health 2020. Doi:10.1089/tmj.2020.0162.

47. Hollander JE, Carr BG. Practically perfect? Telemedicine for Covid-19. N Engl J Med 2020;382(18):1679-1681. doi:10.1056/NEJMp2003539

48. Shah MN, Wasserman EB, Wang H, et al. High-intensity telemedicine reduces emergency department use by elderly community residents. Telemed JE Saúde 2016;22(3):251-258. doi:10.1089/tmj.2015.0103

49. Brittain M, Michel C, Baranowski L, Armor R, Poll A, Helmer J. Community paramedicine in British Columbia: a virtual response to COVID-19. Australas J Paramedicina 2020;17. Doi: 10.33151/ajp.17.813

50. Daniels B, Greenwald P, Hsu H, et al. 284 Use of community-based teleparamedicine to reduce unnecessary emergency department visits and 30-day readmissions among high-risk patients with heart failure. Ann Emerg Med 2019;74(4):S112-S113. doi:10.1016/j.annemerged.2019.08.242