Telehealth, COVID and Long Term Care
The society-wide physical isolation strategies adopted in response to COVID-19 has given rise to a broad surge in virtual interactions, from FaceTime family reunions to a steady drumbeat of Zoom meetings. Healthcare is no different: the number of telehealth visits this year is expected to reach one billion, according to research firm Forrester—and 900 million of those will be related to COVID-19.
The rise in telehealth is especially relevant to long-term care facilities, where residents have proven to be particularly vulnerable, and have accounted for an outsized portion of COVID fatalities in the United States. One-third of skilled-nursing facilities in America have COVID-positive patients, according to the American Health Care Association and National Center for Assisted Living (AHCA/NCAL).
“Every building, whether it has COVID or not, has been impacted,” said former Kansas Governor Mark Parkinson, CEO of AHCA/NCAL, during a May webcast sponsored by HPS Advise’s affiliated law firm, Hall Prangle + Schoonveld.
Long-term care providers have responded to the threat of COVID infection by isolating residents from one another within their facilities, and also by limiting interaction between residents and and people outside their buildings—a group that includes friends and family, as well as many healthcare professionals. That means fewer in-person visits with doctors, nurses and other clinicians and specialists, despite the fact that frequent, personalized care is especially critical during this pandemic.
“Telehealth becomes the only opportunity they may have to be able to take continue to take care of patients, and, at the same time, keep COVID away from the facility,” said Alex Bardakh, director of public policy and advocacy at AMDA, the Society for Post-Acute and Long-Term Care Medicine.
Telehealth services have surged in response, because tech-enabled virtual visits put patients and practitioners together while minimizing the exposure and transmission risk for patient and clinician alike.
As the COVID lockdown took effect this spring, lawmakers and healthcare regulators made a series of temporary changes to the requirements for telehealth visits, as well as the ways in which providers and facilities are reimbursed for telehealth services. For example:
The Department of Health & Human Services (HHS) relaxed its HIPAA-related privacy requirements around telehealth to allow virtual visits on popular but noncompliant apps such as Zoom and Google Hangouts.
The Centers for Medicare & Medicaid Services (CMS) relaxed its requirements for approved telehealth visits to include remote care across state lines, as well as intake and discharge visits at long-term care facilities.
CMS also began to allow service providers to conduct telehealth visits via audio only, and to bill for all telehealth visits (both video and audio) at in-person rates.
As long-term providers embrace telehealth, they also face daunting uncertainties. Among them: the current relaxation of telehealth requirements is temporary, and it’s unclear which, if any, changes will be permanently adopted, and when other requirements might revert to their previous states. HPS Advise’s April Walkup suspects that the current requirements will remain in place throughout most of 2020, both because of the threat of a second COVID wave, and because lawmakers are likely to be reluctant to make big changes just before a presidential election.
“Nobody is going to feel comfortable rolling these things back,” Walkup said.
The other cloud hanging over telehealth’s expansion at long-term care facilities is the threat of COVID-related lawsuits.
“There's going to be a cascade of litigation related to these wrongful death cases, and we need to brace for the impact of that,” said Laura Ginett, a partner at Hall Prangle + Schoonveld.
Some states have adopted measures to shield long-term care facilities against such litigation, but Ginett cautioned that those protections may not be puncture-proof. She suggests that providers take extra precautions relating to telehealth documentation and communication, which she called “the usual suspects” in litigation suits against long-term care facilities.
Specifically, Ginett advises that facilities use nurse providers as the telehealth presenters who must be present along with the patient during a telehealth visit, and that those presenters bring baseline health information about the patient to the telehealth. Ginett says it’s essential for the telehealth presenter to create a formal record of each virtual visit that includes details such as the names of each individual participating—the clinician, the patient and also the presenter—as well as a timeline of care.
COVID-19 has forced many long-term care facilities and other healthcare providers to accelerate their adoption of telehealth. Rolling it out successfully requires careful planning and implementation—not to mention down-the-road flexibility based on regulatory uncertainties—but healthcare leaders say its potential makes the effort well worthwhile.
Telehealth is “one of the real pluses that had come out of this whole crisis,” said AHCA/NCAL’s Parkinson. “It's been a godsend in our buildings.”