Barriers to Telehealth Access Among Homebound Older Adults

Alexander V. Kalicki BS; Kate A. Moody BS; Emily Franzosa DrPH; Peter M. Gliatto MD; Katherine A. Ornstein PhD, MPH


J Am Geriatr Soc. 2021;69(9):2404-2411. 

In This Article

Abstract and Introduction


Background/Objectives: To identify major barriers to video-based telehealth use among homebound older adults.

Design: Cross-sectional survey.

Setting: A large home-based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community.

Participants: Sixteen primary care physicians.

Measurements: An 11-item assessment of provider perceptions of patients' experience with and barriers to telehealth.

Results: According to physicians in the HBPC program, more than one-third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first-time video-based telehealth encounters between April and June 2020 during the first COVID-19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) "unable to interact over video" for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video-capable device access.

Conclusion: The COVID-19 pandemic resulted in a large and dramatic shift to video-based telehealth use in home-based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video-based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video-based telehealth use.


More older adults in the United States become homebound (never or rarely leave home) each year than enter nursing homes.[1] As such, home-based primary care (HBPC) is an increasingly adopted approach to delivering health care to older patients in the home,[2–4] particularly those of whom experience disability, multimorbidity, cognitive impairment, and high rates of hospitalization.[5] Video-based telehealth has emerged as an important care-delivery innovation within HBPC, especially during the COVID-19 pandemic. Not only does telehealth reduce costs, transportation, and time on the part of the patient, but the pandemic also has highlighted additional benefits such as reduced infection exposures.[6,7] The federal government has recognized these benefits and implemented regulatory waivers and rule changes aimed at increasing telehealth accessibility, facilitating its rapid uptake since early 2020.[8–11]

Video-based telehealth has been shown to be feasible within HBPC, and many different HBPC programs have increased telehealth utilization substantially since the start of the pandemic.[11–14] Studies of telehealth adoption among HBPC patients have demonstrated the complex interplay of patient-level barriers to access, such as individual interest, self-confidence, and technology access, and macro-level barriers to access, such as policy standards (e.g., HIPAA compliant platforms), software access, funding, and personnel.[13]

Although demand for video-based telehealth services is now high, adoption has been limited by disparities in access that can present obstacles to specific demographic groups. In 2017, 42% of New York City (NYC) adults over 65 lacked broadband internet access, compared to only 23% of adults aged 18 to 64. This disparity in internet access tracked closely with factors such as poverty, unemployment, and geographic location,[15] indicating that older age may compound other drivers of inequality in access to telehealth.[16]

Older adults with broadband access may still struggle to use mobile devices, as vision, dexterity, and cognition slowly decline with age. Small font size, poor color contrast, and the requirement of fine motor skills when navigating devices used for video-based telehealth encounters can be challenging. As such, programs aiming to expand telehealth services to an older population may benefit from the use of devices with assistive qualities such as fewer buttons, automatic information transmission, and joint visual/audio guidance.[17] But even with access to an appropriate device, some older adults may struggle from difficulty hearing, seeing, or speaking, and the lack of a consistently available caregiver to assist with a telehealth visit.[18]

The Mount Sinai Visiting Doctors Program (MSVD), a large HBPC program based in Manhattan, received a grant from the Federal Communications Commission (FCC) in April 2020 to distribute video-based telehealth devices to patients without telehealth access. To better target device distribution, we rapidly assessed the provider-perceived telehealth capabilities, barriers, and needs of MSVD's homebound population. Our survey focused on video-based rather than telephone-based telehealth because MSVD physicians provided telephone-based care extensively even before the COVID-19 pandemic,[19] and because our grant was focused on the provision of video-based devices. Moreover, video-based telehealth has been shown to be feasible, and in some cases preferable, to the provision of healthcare services by telephone in older adults with mild cognitive impairment.[20] Our aims were to understand existing video-based telehealth usage and capability among MSVD's patients and to determine which patients might be most likely to benefit from receiving a new video-based telehealth device. Querying MSVD providers, who often have long-term relationships with patients and unique insight into their resources, allowed for rapid collection of patient information to accelerate appropriate device dissemination.