Running head: NUCLEUSCARE PILOT STUDY 1

Pilot Study Examining the Outcomes of Seniors Who Use Telehealth Technology to Reduce

Social Isolation and Improve Medication Adherence

Karen Huacasi, BSN, RN and Nicole Smith, BSN, RN

Faculty Advisor: Brenda Boone, PhD, RN

Faculty Advisor: Jonathan Mack, PhD, RN, NP

University of San Diego

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Executive Summary

This pilot study seeks to determine the impact of the use of telehealth technology in older

adults living in affordable, supportive senior housing. For this project, at-risk seniors are defined

as individuals over the age of 62 who are at risk for social isolation and medication

nonadherence. Participants enrolled in this study will use the NucleusCare™ device to engage in

telehealth visits from nurse case managers (NCMs), community volunteers (CVs), and family

members for a duration of 3 months. A total of three participants were studied to understand the

outcomes of seniors before use of telehealth technology compared to outcomes after use. After

results are obtained from the pilot study, changes will be made to the study design to address

issues or challenges that arise during the pilot study.

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Pilot Study Examining the Outcomes of Seniors Who Use Telehealth Technology to Reduce

Social Isolation and Improve Medication Adherence

The adult aging (senior) population is subject to many health and social conditions that

may be mitigated with telehealth. Social isolation and poor medication adherence are major

health problems among older adults (Elder & Retrum, 2012; Marcum, Hanlon, & Murray, 2017).

Medication non-adherence contributes to costly emergency department visits and

hospitalizations, while social isolation appears to predict increased Medicare expenditure

(Roebuck, Liberman, Gemmill-Toyama, & Brennan, 2011; Shaw et al., 2017). Telehealth is

defined as “the use of electronic information and telecommunications technologies to support

and promote long-distance clinical healthcare, patient and professional health-related education,

public health and health administration” (“Telemedicine and Telehealth,” 2017, para. 1) by the

U.S. Department of Health and Human Services. Telehealth applications include live

videoconferencing, store-and-forward videoconferencing, remote patient monitoring, and mobile

health (“Telemedicine and Telehealth,” 2017). Telehealth technology that creates access for

seniors to their family, caregivers, and other support systems may help improve social isolation

(Van Der Heide, Willems, Spreeuwenberg, Rietman, & De Witte, 2012). Telehealth may also

help improve medication adherence (Kvedar, Coye, & Everett, 2014). Telehealth supports face-

to-face interaction with healthcare providers and family members who can provide medication

reminders and visually assess changes in cognitive function that may impede medical

compliance.

The telehealth device employed in this study is called the NucleusCare™ device.

NucleusCare™ is a tablet-based video conference tool that allows loved ones and care providers

one button access to seniors without the use of smart-phones or complex tablet based operating
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systems. NucleusCare™ also has a function that allows care providers to send text messages to

seniors and allows seniors to respond to the text messages. During this study, NCMs and CVs

visited seniors on a scheduled basis to assess social isolation, medication compliance, ongoing

risks, and provide healthcare prompts to improve plan of care adherence. The role of NCM was

fulfilled by a registered nurse employed as a case manager for the senior community center and

the CV was any member of the community that had received training on how to carry-out basic

telehealth visits with project participants. The purpose of this pilot study was to determine the

feasibility for a telehealth device to reduce social isolation and improve medication adherence in

an at-risk senior population.

Literature Review

Social isolation and medication nonadherence have a harmful effect on the health of older

adults in the United States (Elder & Retrum, 2012; Marcum et al., 2017). Low-income older

adults are a unique population group that typically frequents the emergency room as a result of

chronic health conditions in combination with stressors due to limited funds, lack of access to

care, and low health literacy (Counsell et al., 2007). Telehealth technologies can facilitate

increased engagement with a clinician via video conferencing, which can help improve the

management of complex treatment plans of older adults with multiple chronic conditions (Quinn,

O’Brien, & Springan, 2018). Daily video recorded health data by the patient provides clinicians

with a more complete understanding of a patient’s condition, which can result in proactive care

(Quinn et al., 2018). Telehealth studies have even demonstrated that seniors can experience a

reduction in emergency room visits and hospitalization using telehealth strategies, which have

demonstrated early detection and intervention of declining health status compared with usual

care (Gellis et al., 2012).

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The senior population is negatively affected by diminished cognitive abilities, limited

access to transportation, difficulty with advanced technology, and lack of access to a personal

phone. With these challenges, many seniors do not receive sufficient care to support their

declining health and functional status and are not capable of following through with treatment

plans developed by a primary care practitioner (Coe et al., 2018). Videoconferencing has been

shown to lessen these issues by improving access to a provider and alternative services (Kvedar

et al., 2014; Quinn et al., 2018). Use of telehealth technology to perform visits would eliminate

the need for travel, especially for those with disabilities, who are unable to participate in a

physical appointment (Newbould, Mountain, Hawley, & Ariss, 2017).

Telehealth technology such as the NucleusCare™ device can provide increased access to

care for seniors. Improved medication adherence and improved follow-up appointment

attendance may lead to improved management of chronic conditions. Without adequate

management of medical conditions, patients may experience worsening health conditions,

declining social and physical functioning, and more problems relating to mental health status and

re-hospitalization (Gellis et al., 2012). Research suggests that the use of video-conferencing

technology through which clients receive social and medication support can help decrease

feelings of loneliness among the senior population (Van Der Heide et al., 2012). Telehealth may

provide a solution to expanding access to care and lower the cost of care by improving

medication adherence and reducing social isolation.

A gap in large controlled telehealth studies exists worldwide (Newbould et al., 2017). In

particular, there is a lack of studies that examine how telehealth might differ among different

populations of care home residents (Newbould et al., 2017). Upon completing this literature

review, the researchers of this pilot study observed that there is a lack of studies exploring the
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effectiveness of telehealth on specifically improving medication adherence and reducing social

isolation in older adults living in a community setting. This pilot study seeks to fill that gap.

Methods

This pilot study sought to determine the outcomes of seniors who use telehealth as

compared to baseline status prior to the regular use of telehealth. A small cohort of three

participants were enrolled in a 90-day pilot study to assess feasibility and benefits and make

improvements to the study design as needed prior to a larger, long-term study.

Participants

Senior housing site. Study participants were 62 years or older and residents of one of

two supportive housing properties owned by a local senior community center. The senior

community center is a nonprofit organization that provides a variety of services to seniors, the

majority of which are low income and/or homeless. Some of these services include nutritious

meals, social services, nurse case management, and fun activities. The two housing buildings are

located in Downtown San Diego, CA and in the City Heights neighborhood of San Diego. These

buildings encompass 350 units and provide support services to the residents to assist them in

maintaining independent housing.

Recruitment method. Feedback was elicited from support service coordinators within

the senior community center including a Home-Delivered Meals Case Manager and the Director

of Supportive Housing Services. These clinicians provided a list of potential participants who

might benefit from the study, including seniors receiving home-delivered meals and seniors who

are medically fragile. Seniors who are either completely home-bound or mostly home-bound and

receive home-delivered meals are at risk for social isolation due to their sensory or mobility

impairment and inability to leave their home (Elder & Retrum, 2012). Seniors were considered
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medically fragile if they had at least two comorbid conditions and more than three prescribed

medications as that, in combination with social factors related to lower income levels, puts older

adults at higher risk for frequent emergency room visits (Coe et al., 2018). The NCM contacted

each senior on the list to provide information about the study and identify interested participants.

Additional details were provided to those who were interested in participating in the study as

they were recruited and continued with enrollment. The goal was for five participants to be

enrolled, however, due to external issues and lack of follow through with the vulnerable

population, this was not feasible.

Inclusion and enrollment. Study group participants were 62 years or older, living in one

of the supportive housing buildings, capable of understanding English, able to comprehend and

sign research consents, and able to carry out basic operations of the NucleusCare™ device.

Participants were excluded if they were currently using telehealth services, however they were

not excluded if they had used telehealth services in the past. Participants were also excluded if

they did not meet inclusion requirements or exhibited untreated behavioral health or complex

medical conditions. These participants were not included in this study due to the potential for

needing a higher level of care than could be provided through the telehealth intervention. This

study was a convenience sample with enrollees recruited as volunteers. Study participants will be

provided with a small monetary token, in the form of a $10.00 gift card, for their participation at

the end of the study.

Consent and study enrollment of participants. Individuals who agreed to participate in

the study were asked to sign a research consent showing that they understood what was expected

of them during the study period and potential risks to them for participating (see Appendix A).
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Approval for the study was obtained through the Institutional Review Board by other members

of the research team.

Evaluation tools. All study participants received a clinical assessment, Mini-Mental

State Examination (MMSE), to detect cognitive impairment and ability to complete the

requirements of the study (Arevalo-Rodriguez et al., 2015; see Appendix B). Study participants

also completed a pre- and post-intake assessment to establish baseline status and post

intervention comparison data (see Appendix C). The pre-intake assessment was performed

before telehealth interventions began and the post-intake was completed after the 90 days of

study participation. The intake included the following evaluation tools: UCLA Loneliness Scale

Version 3 (UCLA LS3; see Appendix D) and Morisky Medication Adherence Scale (see

Appendix E).

The UCLA LS3 is a valid and reliable scale used to assess subjective feelings of

loneliness across a variety of populations including the elderly (Russell, 1996). It is a 20-item

questionnaire with nine positively (non-lonely) worded items and 11 negatively (lonely) worded

items (Russell, 1996). Every question begins with the statement “How often do you feel…,” so

that personal or telephone interviews can be conducted more smoothly (Russell, 1996). The

participant responds to each question with the statement Never, Rarely, Sometimes, or Always.

Each response is assigned a number. The numbers associated with each response are summed

together at the end of the interview. According to the author, “Higher scores indicate greater

degrees of loneliness” (Russell, 1996, p. 23).

All clients were also assessed using the Morisky Medication Adherence Scale, which is a

validated scale used to measure adherence to taking medications (Morisky, Ang, Krousel-Wood,

& Ward, 2008). This scale consists of eight items pertaining to adherence with taking
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medications as prescribed. It has been validated in low-income patients, proving to be a reliable

and valid screening tool for assessing medication adherence (Morisky et al., 2008). This tool is

therefore appropriate for the current study as the population’s income source is social security

benefits, which puts them at or less than 100% of the federal poverty line. Based on this self-

report tool, participants who have difficulty taking their medications can be identified for

intervention as they would be at risk for uncontrolled conditions (Morisky et al., 2008). The

questions are worded to identify several reasons one might have difficulty remembering their

medications. To avoid “yes-saying,” questions are reversely worded to prevent the respondent

from simply answering positively as they may feel obliged to do (Morisky et al., 2008). Each of

the eight questions determines a behavior of taking medication opposed to adherent behavior that

provides results on how well the participant is taking their medication regimen instead of why

they are not taking medication (Morisky et al., 2008).

Additional history collected from each participant included demographic, health, and

medical insurance information. The questionnaire used to collect this information was created

specifically for use in this study based on questions deemed necessary by the study team

members. To understand each participant’s use of emergency services and health status prior to

using telehealth, questions were asked to determine the participant’s last primary care visit,

urgent care visit, emergency room visit, and 911 call prior to the initiation of the study. This data

was again collected post 90-day pilot study to assess the effect of telehealth visits on reducing

unnecessary 911 calls and emergency room visits. A list of current medications was collected for

each participant along with clinical data, including self-reported height, weight, blood pressure,

and heart rate at time of pre-intake. All of this information was recorded on paper forms and kept

secure in a locked cabinet within a locked office. The answers were uploaded to Google Forms
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for future data analysis. Access to the Google Form was only provided to the NCM, CV, and

other participating project team members participating in data analysis. Each client was assigned

a unique, randomized identification number that was used on the Google Forms to prevent

privacy violations. Using a randomized identification number allowed the data to be collected

and analyzed without any identifying information attached.

NucleusCare™ devices. The NucleusCare™ devices used in this study were donated by

NucleusCare™ to assess the benefits of utilizing a tablet device for telehealth visits specific to the

senior population. The NucleusCare™ device is a communication device that allows users to

connect with their care providers and loved ones with a simple touch of a button (“NucleusCare,”

2019). The NucleusCare™ device has many features available for use. The select features used in

this study are as follows: live video-conferencing for clients and care coordinators, text-

messaging for clients and care coordinators, web portal for care coordinators, and a family

mobile app for clients’ friends and family members (“NucleusCare Suite,” n.d.).

The NucleusCare™ website describes various use cases for the device, one of them is

“Senior Living.” One stated benefit is that the device allows family and care providers to “check

in on senior living patients, while allowing them to maintain the independence they value”

(“Senior Living,” n.d., para. 1). These increased check ins can “reduce readmissions” and

“increase patient’s quality of life and overall satisfaction by allowing them to stay in touch with .

. . friends and family” (“Home Care,” n.d., para. 1). This study explored the use of the

NucleusCare™ device in a senior living setting.

Procedure
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This study applied telehealth technology using the NucleusCare™ device. The NCMs and

CVs performed scheduled weekly visits with study enrollees starting on February 1, 2019. In

addition, family and friends were encouraged to make unscheduled telehealth visits with the

enrollees. The additional visits with family and friends allowed the participant to experience

increased social interactions with loved ones as convenient for them. This study is divided into

two parts: Phase 1 and Phase 2.

Device install and technical support. The NucleusCare™ Device was managed and

supported by the University of San Diego Hahn School of Nursing and Health Science. Graduate

students installed the devices from January 21-31, 2019. The NucleusCare™ devices were

installed in the home of each participant. Each participant was trained on the use of the

NucleusCare™ device and received a learning guide/tip sheet (see Appendix F). It contained

information about the setup overview, maintenance and support, privacy and security, and device

interface. It also contained instructions on how to make an instant video and audio call, respond

to text messaging, and troubleshoot. Graduate students also trained clinical staff and study

enrollees and provided ongoing technical support. During each telehealth visit the NCM or CV

inquired about technical difficulties and provided technical support as needed. Study participants

had a technical support contact for communicating issues and questions. NCMs and CVs

forwarded additional technical issues to the NucleusCare™ technical support team.

Phase 1. Clinical staff, participants, and family used the NucleusCare™ device for a 90-

day period during Phase 1 of the study. This period began on February 1, 2019 and ended on

May 1, 2019. Participants, clinical, and technical staff were interviewed at the completion of the
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90-day period to determine if any issues, trends, or device failures occurred prior to Phase 2

enrollment. The following provides a brief detail of the Phase 1 activities:

1. Three participants were enrolled.

2. NCM contacted participants once a week to perform a video-based visit.

3. CV contacted study participants once a week to perform a video-based visit.

4. Text messages were sent to participants two times a week in the form of questions

and reminders. Participants were randomly divided into a control and intervention

group to determine how the text messages are delivered. The control group received

messages displayed on the device only. The intervention group received messages

that were displayed and read out loud by the device. The text message response rates

and times for both the control and intervention groups will be compared to identify

which method worked the best for the participants.

5. Family members and friends were provided training and instructions on the use of the

NucleusCare™ device. By downloading the accompanying NucleusCare™ application

on their smartphone or other device, they were able to engage in video visits with the

participants. In this way, participants were able to contact their family members in

addition to scheduled telehealth visits with the NCM and CV. These contacts were

not scheduled but were tracked throughout the study to evaluate their effect on self-

reported feelings of loneliness.

Telehealth Visits. Telehealth visits were conducted 2 times per week. Each participant

received one 10- to 20-minute visit per week from the NCM and one 5- to 10-minute visit per

week from the CV.

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Telehealth visit with nurse case manager. During the NCM telehealth visit, information

was obtained from the participants on current status and any changes or issues since the last visit.

The NCM asked the participant set questions to review medication adherence and risk for social

isolation and was available for education, referrals, and support (see Appendix G).

Telehealth visit with community volunteer. During this telehealth visit, a CV collected

information from the participant regarding current physical and emotional wellbeing and any

changes or issues since the last visit. CV identified if the participant had used the NucleusCare™

device to communicate with family, friends, or another provider. The CV also encouraged the

participant to attend upcoming group activities hosted by the supportive housing buildings as

well as the senior community center. Words such as “alone,” “lonely,” and “isolated” were

avoided during the videoconference visit to avoid bringing up feelings of loneliness or isolation.

The CV determined how the participant was doing and communicated with the NCM on each

participant’s status. Interventions included referral to primary care provider, referral to NCM,

emergency services contact, or referral for family contact (see Appendix H).

Text messaging. Participants received messages through the NucleusCare™ device two

times per week from either the NCM or the CV depending on individual status. Participants were

randomly and evenly divided into a control group and an intervention group to assess the effect

of delivery method for a text message. The control group received the standard of messages

displayed on the device. The intervention group received the message displayed on the device

but also utilized the read out loud feature for the messages. With this feature, participants had the

message read out loud to them as they visualized it on the device. Text messages were sent as

quick reminders or check-ins regarding the participants medical and psychosocial status.
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Responses to the messages will be measured for both groups to identify the most effective

method for messaging.

Post-pilot study evaluation. Now that the Phase 1 90-day pilot is complete, study results

will be reviewed for potential opportunities and improvements that can be made to improve the

study. The data obtained from the pre- and post-intakes, text message responses, and answers to

telehealth visit questions will be analyzed to identify project outcomes. Based on the success of

Phase 1, there will be a longer study, Phase 2, involving a larger cohort over a period of 9

months. The study will evolve from Phase 1 to include elements that worked well and changes

based on technical or other issues.

Deliverables

● Initiation, set up, and launch of a pilot study

● Additional documents

o Gantt chart and timeline

o NucleusCare™ Learning Guide (Tip Sheet)

o Participant Intake

o Consent to Participate/Agreement Form

o Telehealth Visit Questions

o Telehealth Visit Escalation Plan

Conclusion

This study ended on May 1, 2019 and post collection data has not yet been obtained.

With a small cohort of only 3 participants, results are not anticipated to provide meaningful

results and outcomes. Rather, results will be used to identify the feasibility and use of these

devices for this population and to alter the study design based on feedback and issues identified
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during Phase I. Several limitations have impacted this phase including recruitment and internet

challenges. Due to the target population’s limited income, wireless internet was not a luxury

many had, which inhibited participation in the study. However, once initial setup was completed,

participants had no difficulty with the device or telehealth visits. So far, participant and end-user

feedback is positive. The value of the telehealth visits has been recognized by the participants

thus far as a means for increasing social connections and offering support for health and medical

needs.
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Giannakou, A., . . . Cullum, S. (2015). Mini-Mental State Examination (MMSE) for the

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Coe, A. B., Moczygemba, L. R., Ogbonna, K. C., Parsons, P. L., Slattum, P. W., & Mazmanian,

P. E. (2018). Low-income senior housing residents’ emergency department use and care

transition problems. Journal of Pharmacy Practice, 31, 610-616.

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Counsell, S. R., Callahan, C. M., Clark, D. O., Tu, W., Buttar, A. B., Stump, T. E., & Ricketts,

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American Medical Association, 298, 2623-2633. doi:10.1001/jama.298.22.2623

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Kvedar, J., Coye, M. J., & Everett, W. (2014). Connected health: A review of technologies and

strategies to improve patient care with telemedicine and telehealth. Health Affairs, 33,

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older adults and family caregivers. Insight on the Issues, 135. Retrieved from the AARP

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Appendix A

Participant Informed Consent Form

Study Title
Pilot Study Examining the Outcomes of Seniors who Utilize Telehealth Technology to Reduce
Social Isolation and Improve Medication Adherence
Researchers
Jonathan Mack, PhD, RN, NP Nicole Smith, BSN, RN
Karen Huacasi, BSN, RN Rachel Gerard-Buonomo, BSN, RN, DNP-S
Michelle L. Jackson, MSN, RN, ANP-BC James Mangapit
Purpose of the Study
The purpose of this study is to determine the ability for Telehealth technology to reduce social
isolation and improve medication adherence, thereby reducing emergency room visits and
hospital admissions for a high-risk senior population.
Description of Study and Procedures

● Recruitment: Study group participants are 62 years or older, living in the Potiker Family
Senior Residence or Potiker City Heights Square, capable of understanding English, able
to comprehend and sign research consents, and able to carry out basic operations of a
technology device. Five participants will be selected for the pilot study.
● Study Description: This study will consist of telehealth visits with each participant aimed
at reducing social isolation through frequent contact and improving medication
adherence/reducing emergency room visits via video conferencing using the
NucleusCare™ device.
● Pre-Study Evaluation: All study participants will receive a clinical assessment to
determine absence of cognitive deficits, risk for isolation, risk for medication non-
adherence, and risk for inadequate nutrient intake. Participants will be asked questions
from the Mini Mental State Examination (MMSE), UCLA Loneliness Scale Version 3,
Morisky Medication Adherence Scale, and the Mini-Nutritional Assessment (MNA)
before introduction of the NucleusCare™ Device. Additional history from each subject
includes frequency of hospital and emergency department usage and contact with 911
services and a brief health history.
● Phase I: 90-day Pilot study (February 1, 2019-May 1, 2019).
o Nurse case managers (NCMs) will schedule one 10- to 20-minute visit per week
for each participant. During this visit, the nurse will perform a brief assessment
and offer any case management services, as needed. The nurse will also review
participant’s medications and their overall well-being.
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o Community volunteers (CVs) will contact study participants one time each week
through the NucleusCare™ device. CVs will provide brief conversations consisting
of reminders for social activities, medications, and nutrition adherence. They may
determine if any other interventions are needed, including referral Nurse Case
Manager, emergency services, or family contact.
o Text Messaging: Participants will receive messages through the NucleusCare™
device 2 times per week, from either the NCM or the CV. Participants are
expected to respond to messages regarding their overall well-being or medication
and nutrition adherence. Messages may also be sent as reminders and do not
require a response.
o The nurse case manager and community volunteer will only be available at pre-
established days/times during the pilot study. Participants are expected to use that
time as there is no guarantee a nurse or community volunteer will be available at
other times when the participant calls.
o Participant Expectations: We will preschedule all Telehealth visits with the
participant for consistency. We expect participants to be present for each
scheduled visit or contact the Nurse Case Manager (619-487-0616) to reschedule.
o Post-Study Evaluation: Participants will again be asked questions from the initial
intake and questionnaires at the completion of 90 days. Participants will also be
asked survey questions relating to their experience with the technology and
Telehealth visits and the impact on their health and well-being.

Risks
We do not anticipate any risks to you during this study. A possible, but unlikely, risk is the loss
of privacy as a result of the collection of your data. All data and answers to survey questions will
be kept secure and de-identified to prevent the loss of confidential information.

Benefits
Results of this study will help determine the benefits of a Telehealth intervention on social
isolation, medication adherence, and reduced 911 calls/ER visits. The benefits to you as a result
of your participation could include: reduced social isolation/depression, increased
awareness/participation in social activities, better medication adherence, lower blood pressure,
better management of chronic diseases, and proactive care opposed to ER visits. There is a
possibility you may experience no benefit as a result of this study.
Costs of Participating in the Study
There will be no cost to you for participating in this study. All participants will receive a $10 gift
card for participating after the completion of the study.
Data Collection
We will record your responses to the Intake, Ongoing Visit, and Survey questions in a secure
data file. All data and information disclosed by the client and collected by a research member
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will be de-identified for future data analysis and publication. You will be given a unique
participant ID that will be within the data file and we will maintain a separate file that contains
your participant ID and your identifying information for use during the study period. This file
with confidential identifying information will only be accessed by the study research members
and the Institutional Review Board. Your privacy will be protected when your personal
information is reviewed.
Confidentiality
All information and records obtained in the course of the Pilot study shall be subject to
confidentiality and disclosure provisions of applicable Federal and State statutes. Disclosure of
this information to anyone outside of the study research team is made only by the participant’s
written consent or in an emergency, as required by law. If you inform any member of the study
research team of your intent to harm yourself or others, we must report that to authorities and/or
trained professionals.
Release of Liability
Through my participation in this Pilot study, I waive any and all claim I may have, and release
from all liability: participating senior center, CloudTalk Inc. d/b/a NucleusCare™ and the
University of San Diego, including all entities, employees, volunteers, and agents.
Participation Agreement
I have read the above statements or have had them read and explained to me in a language which
I understand. I hereby voluntarily consent to participate in this study. I understand that the
NucleusCare™ device is not a medical or emergency device and I should not attempt to use it in
case of sickness or emergency. I understand that I will be contacted by the Nurse Case Manager
or Community Health Worker for my pre-determined scheduled visits. If I attempt to call the
Nurse or Health Worker outside of my scheduled visit time, I understand that my call may not be
answered and I should seek alternative resources for urgent or emergent situations. If I have any
further questions I can contact Nicole Smith, Nurse Case Manager at 619-487-0616. If I have
questions about my rights as a research subject, I can call the Institutional Review Board at (206)
543-0098. I give permission to the researchers to use my previous data/information and access to
future clinical data I provide. I will receive a copy of this consent form.

Participant Name Witness Name/Title

Participant Signature Date Witness Signature Date

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Appendix B

Mini-Mental State Examination

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Appendix C

Participant Intake

Demographics

First Name: __________________________________________________________________

Middle Initial: _________________________________________________________________

Last Name: __________________________________________________________________

Date of Birth: _________________________________________________________________

Supportive Housing Building:

☐ Potiker Family Senior Residence (Downtown)

☐ Potiker City Heights Square

Address Line 1: _______________________________________________________________

Address Line 2: _______________________________________________________________

City, State, Zip: _______________________________________________________________

Phone: ______________________________________________________________________

Sex

☐ Male ☐ Female

☐ Transgender ☐ Other

Race

☐ White/Caucasian ☐ Black/African American ☐ American Indian

☐ Asian Indian ☐ Cambodian ☐ Chinese

☐ Filipino ☐ Guamanian ☐ Hawaiian

☐ Hmong ☐ Japanese ☐ Korean

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NUCLEUSCARE PILOT STUDY

☐ Other Asian ☐ Other Pacific Islander ☐ Samoan

☐ Vietnamese ☐ Other: _______________________________

Ethnicity

☐ Hispanic/Latino ☐ Non-Hispanic/Latino

☐ Other: _________________________________________________

Medical Information

Primary Medical Insurance

☐ Medicare (Part A only) ☐ Medicare (Part A and B)

☐ Medi-cal ☐ VA

☐ TRICARE ☐ Private: ____________________________

☐ None/Unknown ☐ Other: _____________________________

Secondary Medical Insurance

☐ Medi-cal ☐ None/Unknown

☐ TRICARE ☐ Private: ____________________________

☐ VA ☐ Other: _____________________________

Managed Care Plan

☐ Care 1st ☐ Community Health Group

☐ Health Net ☐ Molina

☐ Other: ________________________________________________________________

Primary Care Provider (PCP)

Name: ______________________________________________________________________
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NUCLEUSCARE PILOT STUDY
Clinic/Office Name: ____________________________________________________________

Address Line 1: _______________________________________________________________

Address Line 2: _______________________________________________________________

Phone: ______________________________________________________________________

If no PCP, what is the reason?

☐ Transportation ☐ Change in insurance

☐ Don’t want/need a PCP ☐ Don’t know how to get a PCP

☐ PCP just assigned by insurance ☐ In process of getting a new PCP

☐ Other: _________________________________________________________________

Health Information

When was the last time you saw a PCP?

☐ Less than 1 month ☐ 1-6 months ago

☐ 7 months- 1 year ago ☐ 1-2 years ago

☐ 2-5 years ago ☐ Over 5 years ago

How many times have you seen a PCP in the last three months?

☐ None ☐ Once

☐ 2-3 times ☐ 4-6 times

☐ More than 6 times

When was the last time you went to the Emergency Room?

☐ Within the last week (7 days) ☐ 7 days- 1 month ago

☐ 1 month- 3 months ago ☐ 3 months -6 months ago

☐ 6 months- 1 year ago ☐ 1-3 years ago

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NUCLEUSCARE PILOT STUDY

☐ More than 3 years ago ☐ Never

If you have gone to the Emergency Room within the last 3 months, how many times?

☐ Once ☐ 2-3 times

☐ 4-6 times ☐ More than 6 times

If you have gone to the Emergency Room in the last 3 months, what happened?

☐ Admitted to the hospital ☐ Labs and Tests completed

☐ Medications or treatment given ☐ Discharged with no intervention

☐ Follow-up instructions given ☐ Other: _____________________________

When was the last time you went to an Urgent Care?

☐ Within the last week (7 days) ☐ 7 days- 1 month ago

☐ 1 month- 3 months ago ☐ 3 months -6 months ago

☐ 6 months- 1 year ago ☐ 1-3 years ago

☐ More than 3 years ago ☐ Never

If you have gone to Urgent Care within the last 3 months, how many times?

☐ Once ☐ 2-3 times

☐ 4-6 times ☐ More than 6 times

If you have gone to Urgent Care within the last 3 months, what happened?

☐ Transferred to the hospital ☐ Labs and Tests completed

☐ Medications or treatment given ☐ Discharged with no intervention

☐ Follow-up instructions given ☐ N/A

When was the last time you made a 911 call?

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NUCLEUSCARE PILOT STUDY

☐ Within the last week (7 days) ☐ 7 days- 1 month ago

☐ 1 month- 3 months ago ☐ 3 months -6 months ago

☐ 6 months- 1 year ago ☐ 1-3 years ago

☐ More than 3 years ago ☐ Never

If you have called 911 within the last 3 months, how many times?

☐ Once ☐ 2-3 times

☐ 4-6 times ☐ More than 6 times

If you have called 911 within the last 3 months, what happened?

☐ Ambulance/Paramedics arrived but I did not go to the Hospital

☐ Ambulance/Paramedics arrived and took me to the Hospital or Emergency Room

☐ N/A

If you were taken to the Emergency room, what happened?

☐ Admitted to the hospital

☐ Discharged the same day

☐ Told you should be admitted but decide to leave (AMA)

☐ N/A

General Medication Information

How many medications do you take?

☐ None ☐ 1-2

☐ 3-5 ☐ 6 or more

Do you take any OTC (over-the-counter) medications or vitamins?

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NUCLEUSCARE PILOT STUDY

☐ None ☐ 1-2

☐ 3-5 ☐ 6 or more

Do you take your medications every day?

☐ Yes ☐ No

Do you use a pill organizer or other item for your medications?

☐ Yes ☐ No

Medications

Medication Name Dosage Route Frequency Side Effects?

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NUCLEUSCARE PILOT STUDY

Health conditions

☐ Alzheimer’s Disease ☐ Arthritis

☐ Atrial Fibrillation ☐ Asthma

☐ Back Problems ☐ Cancer: ____________________________

☐ COPD ☐ Congestive Heart Failure

☐ Diabetes Type I ☐ Diabetes Type II

☐ Diverticulosis ☐ GERD

☐ Gout ☐ Heart Disease

☐ Hypertension ☐ High Cholesterol

☐ Hyperthyroidism ☐ Hypothyroidism

☐ Irritable Bowel Syndrome ☐ Kidney Disease

☐ Kidney Stones ☐ Liver Disease

☐ Neuropathy ☐ Obesity

☐ Osteoporosis ☐ Malnutrition

☐ Traumatic Brain Injury ☐ Seizures or Epilepsy

☐ Urinary Tract Infection

☐ Other: _________________________________________________________________
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NUCLEUSCARE PILOT STUDY
Mental/Behavioral Health Conditions

☐ Alcohol/Substance Abuse ☐ Anxiety

☐ Bipolar Disorder ☐ Dementia

☐ Depression ☐ OCD

☐ Personality Disorder ☐ PTSD

☐ Schizophrenia ☐ Other: _____________________________

Clinical Data

Date: ______________________________________

Blood pressure (mmHg): _______________________

Weight (lbs): _________________________________

Self reported height (in): ________________________

Pulse (BPM): ________________________________

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NUCLEUSCARE PILOT STUDY
Appendix D

UCLA Loneliness Scale Version 3

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Appendix E

The Morisky Medication Adherence Scale

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Appendix F

NucleusCare™ Learning Guide (Tip Sheet)

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NUCLEUSCARE PILOT STUDY
Appendix G

Telehealth Visit Questions

Nurse Case Manager Visit Questions

Social Isolation Questions
How are you feeling today and since we last spoke with you?

Medication Adherence/Chronic Disease Management Questions

Have you been taking all of your medications as prescribed?
Have you called 911 for any reasons?
Have you been to the emergency room or urgent care for any reasons?
Have you been checking your blood pressure?

Nutrition Questions
How would you describe your appetite?
How many meals do you eat per day?
Do you have access to healthy foods (e.g., fresh fruits, vegetables)
Do you believe you are getting enough food to eat every day?

Community Volunteer Visit Questions

Social Isolation Questions
How have you been feeling today and since we last spoke with you?
Have you been in contact with any family or friends since our last visit?
Have you been to any events since our last visit?

Medication Adherence/Chronic Disease Management Questions

Have you been taking all of your medications as prescribed?

Nutrition Questions
Have you eaten today?
Have you had at least one meal today?

Miscellaneous
Have you had any technical difficulties/ do you have any concerns related to the NucleusCare
device?
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NUCLEUSCARE PILOT STUDY
Appendix H

Telehealth Visit Escalation Protocol- Nurse Case Manager

Nurse Case Manager

No answer from participant
● No answer for video call
○ Wait 1- 5 minutes and attempt to call participant again.
○ If participant answers, continue on.
○ If participant still doesn’t answer, send a text message (“Hello, you missed your
video visit call with the Nurse. Do you want to reschedule?”) with answer choices
(“Yes” or “No”)
○ If no answer to text message that day, attempt phone call to participant to check-
in.
● No answer for text message (not reminder message)
○ If participant doesn’t respond to text message within one day, re-send message
○ If participant still does not respond to message, make a note to review on next
video visit (participant may need to have it explained again)

Urgent Medical Need

● Client reports symptoms of urgent medical condition
○ Complete brief assessment: determine extent of symptoms, duration, severity
○ Determine if client able to go to PCP
○ Arrange transportation to PCP/Urgent Care/ER (as needed)
○ Alert supportive staff (staff information removed for privacy purposes)

● Nurse Case Manager informed of participant’s urgent need by Community Volunteer

○ Initiate video visit or send text message (as appropriate) to determine participant
status
○ Repeat steps listed above for Urgent Medical Need

Medical Emergency
● Call 911, provide participant information including address and unit number, phone
number, and description of emergency
○ Alert supportive staff
○ Follow up with client as condition warrants

Urgent Non-Medical Need

● Refer to senior community center based on need
○ Nutrition/Meals, Activities, General Information
■ Reception: 619-487-0720
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NUCLEUSCARE PILOT STUDY
○ Social Services, Dental, Nursing, Housing, or other service need
■ Intake and Referral: 619-487-0719
○ Home Delivered Meals
■ 619-487-0641

Suspected Abuse or Neglect

● For signs of emergent danger, abuse, or neglect that participant reports or is observed:
○ Ensure client is safe
○ If not, call 911 and request PERT (if needed)
○ Notify Supportive Staff (see previous)
○ For non-emergent danger, abuse, or neglect that participant reports or is observed:
○ File an APS report on behalf of client
■ https://www.aiswebreferral.org/Account/Login.aspx?ReturnUrl=%2f
■ 800-510-2020

Suicidal Thoughts or Ideations

● If participant makes any of these or other remarks suggesting suicidal tendencies, refer to
the Suicide Prevention Protocol and follow as directed below:
○ Ask, “Do you feel like hurting yourself?”
○ Ask, “Do you have a plan?” Do you intend to hurt yourself?”
■ NO: If the client has no intention or plan to harm themselves, offer crisis
line phone number (1-888-724-7240) and mental health resources.
Schedule follow up appt. if needed. (Consider getting release of
information and assist with scheduling doctor appt if needed). Document
the conversation and resources provided.
■ YES: Do not leave them alone, this must be taken seriously. The reality is
that every situation is different therefore follow through is a must, along
with documentation.
○ Let them know you are very concerned about them and tell them you think it is
important they speak with someone. If client has plan and intention to harm
themselves, call 911 and ask for PERT officer if available. **This can be done
with the client. Explain to them that the officer is here to help and will assess
them and provide resources to keep them safe.
○ If the client makes a suicidal statement but then leaves, call 911 immediately.
○ Notify Supportive Staff (see previous)
○ Follow-up with client as condition warrants

Telehealth Visit Escalation Protocol- Community Volunteer

Community Volunteer
● No answer from participant
○ No answer for visit call
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NUCLEUSCARE PILOT STUDY
■ Wait 5 minutes and attempt to call participant again.
■ If participant answers, continue on as normal.
■ If participant still doesn’t answer, send a text message (“Hello, you missed
your video visit call with the Volunteer. Do you want to reschedule?”)
with answer choices (“Yes” or “No”)
● If yes, offer available time options.
■ Inform Nurse Case Manager of missed visit
● Phone: 619-487-0616
○ No answer for text message (not reminder)
■ If participant doesn’t respond to text message within one day, re-send
message
■ If participant still does not respond to message, notify Nurse Case
Manager

Urgent Medical Need

● Client reports symptoms of urgent medical condition
○ Attempt to contact Nurse Case Manager, if during working hours
■ Phone: 619-487-0616
■ Phone: 619-487-0635
■ If Nurse Case Manager unable to be notified, alert Supportive Staff
● Phone: 619-804-7466

Medical Emergency
● Call 911, provide participant information including address and unit number, phone
number, and description of emergency
● Alert Nurse Case Manager (see above)
● Alert supportive staff (see above)

Urgent Non-Medical Need

● Contact Nurse Case Manager and inform of situation
● Refer to senior community center for social services, meals, housing, dental needs
● 1525 4th Avenue, San Diego CA 92101
● 619-487-0719

Suicidal Thoughts or Ideations

● If participant makes any of these or other remarks suggesting suicidal tendencies, refer to
the Suicide Prevention Protocol and follow as directed below:
○ Ask, “Do you feel like hurting yourself?”
○ Ask, “Do you have a plan?” Do you intend to hurt yourself?”
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NUCLEUSCARE PILOT STUDY
○ NO: If the client has no intention or plan to harm themselves, offer crisis line
phone number (1-888-724-7240) and mental health resources. Schedule follow up
appt. if needed. (Consider getting release of information and assist with
scheduling doctor appt if needed). Document the conversation and resources
provided.
○ YES: Do not leave them alone, this must be taken seriously. The reality is that
every situation is different therefore follow through is a must, along with
documentation.
○ Let them know you are very concerned about them and tell them you think it is
important they speak with someone. If client has plan and intention to harm
themselves, call 911 and ask for PERT officer if available. **This can be done
with the client. Explain to them that the officer is here to help and will assess
them and provide resources to keep them safe.
○ If the client makes a suicidal statement but then leaves, call 911 immediately.
○ Notify Nurse Case Manager
○ Notify Supportive Staff
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NUCLEUSCARE PILOT STUDY
Program Competencies: Karen Huacasi

All health care informatics program outcomes were met throughout the initiation, set up,

and launch of this pilot study. Each outcome addresses a different yet equally important aspect of

the role of a health care informaticist. The following paragraphs demonstrate how each

individual outcome was met.

Health Science Knowledge and Skills

Participants will be assessed for risk of social isolation and medication non-adherence

continuously throughout the study. With participant consent, the NCM and CV will provide

appropriate interventions. Concerns regarding patient reported symptoms and signs observed

through the videoconference will be communicated to the NCM and escalated as needed.

Assessments, interventions, and evaluations will be collected and documented throughout the

duration of the study

Leadership and Systems Management

This capstone project will involve designing, strategically planning, setting up, and

launching a pilot study. A five-person team was created, and a team leader was established.

Concepts of strategic planning, such as setting priorities and establishing agreement upon

intended outcomes, were applied in order to allow for smooth progression of the study. On an

individual level, each researcher will lead out a videoconference call with a participant. The

research team understands that it is their ethical and legal duty to protect all participant personal

health information collected throughout the study.

Systems Design and Management

Designing this pilot study involved exploring the different ways in which it might fail.

When a potential failure point was identified, the team acted to reduce the failure. This analysis
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NUCLEUSCARE PILOT STUDY
will be repeated throughout the study to allow for continuous improvement. At the end of Phase

1, all failure points will be analyzed in order to improve the design of Phase 2.

This project will involve training older adults on the use of a technology system that they

have never used before. The research team must utilize understanding of the human and

technology systems integration in order to successfully teach older adults how to use the

NucleusCare device.

Data and Knowledge Management

Data will be collected throughout this entire study. It will need to be gathered, formatted

and stored so that the researchers can further investigate the given problem. It will then need to

be statistically analyzed to evaluate the results of the study.

Quality and Regulatory Outcomes

All research team members understand and agree with the importance of the privacy and

security of protected health information. Information regarding the patient’s demographics,

health conditions, and emotional state will be collected. Appropriate precautions will be taken to

protect all collected information.

Social Justice and Community Activism

All study participants signed an informed consent form detailing data collection methods,

and how all information and records obtained in the course of the pilot study would be subject to

confidentiality and disclosure provisions. All research team members have been trained in the

importance of privacy and security of protected health information.

The target population of this study is low-income seniors, a vulnerable population. The

goal of the study is to find out if telehealth interventions can possibly reduce social isolation and

improve medication adherence, which are two big problems among senior populations today.