Tag Archives: Telehealth

Doctors Open Doors To Sick Punjabi Truckers

The doctor leaned over Jitamber Singh Bedi and inserted the needle of the injection into his eyeball. Jitamber had a blockage in his vein that was causing his eyesight to cloud up. Vision problems are a side effect of diabetes. Like eighty-eight percent of truck drivers, Jitamber Singh Bedi too had Type 2 diabetes. 

In order to operate a commercial vehicle on the road, a driver must be able to prove they are maintaining stable blood sugars. Jitamber medical exam report is part of his driving record. It is filed electronically by the Medical Examiner (ME) with the US Department of Transportation (DOT) bi-annually. Any drop in health indices would mean he loses his license or at best, gets recertified every year. 

Over half of all long haul truck drivers suffer from hypertension and/or diabetes. These comorbidities put them at a higher risk for COVID.

“Sedentary lifestyle and erratic sleep gets you, if bad food on the road doesn’t,” says Jitamber Singh Bedi. “Sitting for ten hours a day for ten days at a stretch, the truck driver is a sitting duck for diseases like diabetes. And when they do take a break it is easy to pull out a cigarette.”

“At every rest stop I ended up smoking,” says Jitamber. 

Irregular eating habits and dehydration further strain the system. Jitamber is always worried about taking restroom breaks and therefore restricts the intake of fluids and food which can lead to the taxi cab syndrome. The inability of drivers to relieve themselves regularly throughout the workday leads to voiding dysfunction, infertility, urolithiasis, bladder cancer, and urinary infections as compared with nonprofessional drivers wrote Alon Y Mass, MD, David S Goldfarb, MD, and Ojas Shah, MD. from the Department of Urology, NYU Langone Medical Center. Paid by the mile, every restroom stop costs precious time.

“Sssssslow suicide behind the wheel,” says Jitamber, “with the pandemic that could take a quick turn for the worst.”

Jitamber graduated from Mayo College, where he went to school with the sons of India’s upper classes, princes, and nobles. After immigrating to the US, he worked for ten years as the Assistant Manager, Special Reporter and Editor for India Post, a California publication. Jitamber started driving a truck in the US in 2012.  

Jitamber & his wife Lisa

He still maintains his A1 license to drive a truck and is married to Lisa, a librarian at the county library. Jitamber is on his wife’s medical plan. Kaiser is their health insurer. Kaiser, a California company, has agreements with other providers to provide coverage all over the US thinks Jitamber. He does not really know how his health insurance will play out if he falls sick on the road.

Raman Dhillon of the North American Punjabi Trucking Association (NAPTA) has negotiated a health plan that truckers can buy into. Portability of insurance plans from one state to the other has been a bottleneck to seamless healthcare access. NAPTA wants to ensure that the trucker has access to pharmacy anywhere and medication can be prescribed to and picked up by the driver from the pharmacy closest to him. 

President Trump’s Emergency Order in the face of the COVID pandemic opened up anywhere anytime access to healthcare.

Anywhere Anytime Access 

Of the 1.5 million truck drivers on US highways, says the Punjab Truck Association, about 150,000 Punjabis are working in the trucking industry. The South Asian gene makes the Punjabi drivers more vulnerable to acute myocardial infarction (MI). Studies by UCSF, Stanford and El Camino hospital’s South Asia Heart Center, show that heart disease strikes South Asians at a younger age and more malignantly than the general population. “South Asians represent approximately 17 percent of the world’s population – yet they account for 60 percent of the world’s heart disease patients,” says Anita Sathe of the South Asian Heart Center which runs a program to help South Asians manage their heart risk.

The ability to access and monitor healthcare on the road is crucial to the health of Punjabi truckers.

COVID-19 opened the door for truckers to access technology-based ubiquitous healthcare. Under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, the incorporation of telemedicine into routine medical care on a temporary and emergency basis, has lightened the burden on truckers. The waiver has loosened former requirements that the patient and provider be in the same state or that the patient must be in physician shortage areas to access telemedicine; so a doctor in New York now can be reimbursed for consulting with a patient out of California. 

The rule that a new patient could not use telehealth and must have an established relationship with the doctor has been relaxed as have some of the HIPAA requirements like data transfer and storage. The new criteria allow the use of tablets or smartphones, so a driver can call a nearby doctor from his smartphone. However, all calls must be video calls;  audio-only calls may not be made. 

“From March 6, 2020, a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, offered telehealth to all patients,” says Apexon Healthcare executive Siva Sundar. “Meeting the doctor through zoom or Facetime has become the norm for everyone during the quarantine.” 

Telemedicine and walk-in medical clinics located at truck stops and Pilot and Flying J Travel Centers proliferated with the advent of COVID. For the sake of the truckers, these new rules must outlast the pandemic and become the new normal. 

Checking For Sugar On The Road

Jitamber Singh Bedi would find it useful to wear body sensors that alert him, his family, and his doctor to potentially serious changes in his health status. 

Continuous glucose monitoring devices to monitor the driver’s blood sugar – motivates healthy behaviors says Rajeev Sehgal, Jitamber’s classmate from Mayo College, who has been wearing the Dexcom 6 device for over 6 months. “In the same way that wearing a Fitbit can be motivational for meeting daily fitness goals, real-time monitoring of blood sugar levels might reinforce good behaviors around eating and exercise,” he says. 

The tiny sensor he wears on his stomach sends real-time reading of his blood sugar levels to his phone every 5 minutes.  “It is extremely comfortable to wear. I can swim with it. I change the device every ten days,” says Sehgal who highly advocates its use by drivers. The device allows quick remedial actions for timely diabetes management and the information can be kept private or shared with family members when the driver is on the road.

If the sensor indicates high sugar and blood pressure levels, the trucker can consult with a doctor by teleconference over Facetime. If they’ve embarked on a trip without getting a refill or forgetting to pack their meds Telemedicine can get them their meds at a pharmacy close to where they are. 

“At present, the sensor is prescribed and covered by insurance for people who have uncontrolled type 2 diabetes but it should be authorized for truck drivers who are managing their diabetes,” says Sehgal. 

Monitoring blood sugar levels on the go will allow the trucker to take immediate remedial action. A brisk walk could fix a spike in blood sugar levels following a sugary lunch or in case of a drop in sugar levels, a quick pop of sugar will prevent deterioration in vision like the one Jitamber had to face. A year ago he noticed he couldn’t read street signs. Retinal vein occlusion and macular edema caused big brown blobs to float in front of his eyes. After a series of shots at regular intervals, Dr. An Ngoc Huynh, MD at Kaiser Irwindale California declared his vision to be 20:25.

“The main thing I want to better understand is, how different things I do affect my glucose levels,” says Jitamber. “I will track my blood sugar levels to see how it responds to food, sleep, and exercise. Fasting, exercise, stress, or sleep can be tweaked to get the marker to the right place. Precision in targeting our health issues can prevent shots in eyeballs,” said Jitamber.

Read other articles in this series:

Road Warrior

Punjabi Truckers Find A Warm Welcome At US Highway Dhabas


Ritu Marwah wrote this series while participating in the USC Center for Health Journalism‘s California Fellowship.

 

The New Digital World Can Give Seniors A Hard Time

Family gatherings on Zoom and FaceTime. Online orders from grocery stores and pharmacies. Telehealth appointments with physicians.

These have been lifesavers for many older adults staying at home during the coronavirus pandemic. But an unprecedented shift to virtual interactions has a downside: Large numbers of seniors are unable to participate.

Among them are older adults with dementia (14% of those 71 and older), hearing loss (nearly two-thirds of those 70 and older) and impaired vision (13.5% of those 65 and older), who can have a hard time using digital devices and programs designed without their needs in mind. (Think small icons, difficult-to-read typefaces, inadequate captioning among the hurdles.)

Many older adults with limited financial resources also may not be able to afford devices or the associated internet service fees. (Half of seniors living alone and 23% of those in two-person households are unable to afford basic necessities.) Others are not adept at using technology and lack the assistance to learn.

During the pandemic, which has hit older adults especially hard, this divide between technology “haves” and “have-nots” has serious consequences.

Older adults in the “haves” group have more access to virtual social interactions and telehealth services, and more opportunities to secure essential supplies online. Meanwhile, the “have-nots” are at greater risk of social isolation, forgoing medical care and being without food or other necessary items.

Dr. Charlotte Yeh, chief medical officer for AARP Services, observed difficulties associated with technology this year when trying to remotely teach her 92-year-old father how to use an iPhone. She lives in Boston; her father lives in Pittsburgh.

Yeh’s mother had always handled communication for the couple, but she was in a nursing home after being hospitalized for pneumonia. Because of the pandemic, the home had closed to visitors. To talk to her and other family members, Yeh’s father had to resort to technology.

But various impairments got in the way: Yeh’s father is blind in one eye, with severe hearing loss and a cochlear implant, and he had trouble hearing conversations over the iPhone. And it was more difficult than Yeh expected to find an easy-to-use iPhone app that accurately translates speech into captions.

Often, family members would try to arrange Zoom meetings. For these, Yeh’s father used a computer but still had problems because he could not read the very small captions on Zoom. A tech-savvy granddaughter solved that problem by connecting a tablet with a separate transcription program.

When Yeh’s mother, who was 90, came home in early April, physicians treating her for metastatic lung cancer wanted to arrange telehealth visits. But this could not occur via cellphone (the screen was too small) or her computer (too hard to move it around). Physicians could examine lesions around the older woman’s mouth only when a tablet was held at just the right angle, with a phone’s flashlight aimed at it for extra light.

“It was like a three-ring circus,” Yeh said. Her family had the resources needed to solve these problems; many do not, she noted. Yeh’s mother passed away in July; her father is now living alone, making him more dependent on technology than ever.

When SCAN Health Plan, a Medicare Advantage plan with 215,000 members in California, surveyed its most vulnerable members after the pandemic hit, it discovered that about one-third did not have access to the technology needed for a telehealth appointment. The Centers for Medicare & Medicaid Services had expanded the use of telehealth in March.

Other barriers also stood in the way of serving SCAN’s members remotely. Many people needed translation services, which are difficult to arrange for telehealth visits. “We realized language barriers are a big thing,” said Eve Gelb, SCAN’s senior vice president of health care services.

Nearly 40% of the plan’s members have vision issues that interfere with their ability to use digital devices; 28% have a clinically significant hearing impairment.

“We need to target interventions to help these people,” Gelb said. SCAN is considering sending community health workers into the homes of vulnerable members to help them conduct telehealth visits. Also, it may give members easy-to-use devices, with essential functions already set up, to keep at home, Gelb said.

Landmark Health serves a highly vulnerable group of 42,000 people in 14 states, bringing services into patients’ homes. Its average patient is nearly 80 years old, with eight medical conditions. After the first few weeks of the pandemic, Landmark halted in-person visits to homes because personal protective equipment, or PPE, was in short supply.

Instead, Landmark tried to deliver care remotely. It soon discovered that fewer than 25% of patients had appropriate technology and knew how to use it, according to Nick Loporcaro, the chief executive officer. “Telehealth is not the panacea, especially for this population,” he said.

Landmark plans to experiment with what he calls “facilitated telehealth”: nonmedical staff members bringing devices to patients’ homes and managing telehealth visits. (It now has enough PPE to make this possible.) And it, too, is looking at technology that it can give to members.

One alternative gaining attention is GrandPad, a tablet loaded with senior-friendly apps designed for adults 75 and older. In July, the National PACE Association, whose members run programs providing comprehensive services to frail seniors who live at home, announced a partnership with GrandPad to encourage adoption of this technology.

“Everyone is scrambling to move to this new remote care model and looking for options,” said Scott Lien, co-founder and chief executive officer of the company, which is headquartered in Orange County, California.

PACE Southeast Michigan purchased 125 GrandPads for highly vulnerable members after closing five centers in March where seniors receive services. The devices have been “remarkably successful” in facilitating video-streamed social and telehealth interactions and allowing nurses and social workers to address emerging needs, said Roger Anderson, senior director of operational support and innovation.

Another alternative is technology from iN2L (an acronym for It’s Never Too Late), a company that specializes in serving people with dementia. In Florida, under a new program sponsored by the state’s Department of Elder Affairs, iN2L tablets loaded with dementia-specific content have been distributed to 300 nursing homes and assisted living centers.

The goal is to help seniors with cognitive impairment connect virtually with friends and family and engage in online activities that ease social isolation, said Sam Fazio, senior director of quality care and psychosocial research at the Alzheimer’s Association, a partner in the effort. But because of budget constraints, only two tablets are being sent to each long-term care community.

Families report it can be difficult to schedule adequate time with loved ones when only a few devices are available. This happened to Maitely Weismann’s 77-year-old mother after she moved into a short-staffed Los Angeles memory care facility in March. After seeing how hard it was to connect, Weismann, who lives in Los Angeles, gave her mother an iPad and hired an aide to ensure that mother and daughter were able to talk each night.

Without the aide’s assistance, Weismann’s mother would end up accidentally pausing the video or turning off the device. “She probably wanted to reach out and touch me, and when she touched the screen it would go blank and she’d panic,” Weismann said.

What’s needed going forward? Laurie Orlov, founder of the blog Aging in Place Technology Watch, said nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services — something that many lack.

“We need to enable Zoom get-togethers. We need the ability to put voice technology in individual rooms, so people can access Amazon Alexa or Google products,” she said. “We need more group activities that enable multiple residents to communicate with each other virtually. And we need vendors to bundle connectivity, devices, training and service in packages designed for older adults.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.