Skilled Nursing Telehealth Adoption Not Without Challenges — But COVID-19 Changes Likely Here to Stay

About a month after COVID-19 first arrived on America’s radar, the federal government continues to tear down the dense web of regulations surrounding all aspects of the health care continuum in an attempt to fight back against the coronavirus pandemic.

As health care providers and officials look to prevent all non-emergency visits to nursing homes, telehealth has formed a key pillar of the regulatory relief efforts in the post-acute and long-term care space. Rules previously considered sacrosanct — from HIPAA requirements that prevented clinicians from providing services over consumer apps like Skype and FaceTime, to the need for in-person consultations before telehealth could be be used as a replacement — disappeared overnight.

Just this week, Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma announced yet another round of telehealth expansions, including the approval of virtual visits for nursing facility and discharge visits, as well as coverage for remote patient monitoring.

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That latter move, according to AMDA, the Society for Post-Acute and Long-Term Care Medicine, represented the completion of the provider group’s goal of “essentially eliminating all barriers and adding services in other sites of care to the telehealth list.”

But that doesn’t mean the road to telehealth adoption has been smooth, especially in the early days of the crisis. Staff buy-in has always been an issue when rolling out new telehealth programs, even in normal times — and unlike in many other care settings, nursing home residents’ unique set of comorbidities can make virtual communication difficult for patient and provider alike.

SNN called Dr. Grace Terrell, CEO of the skilled nursing-focused physician group Eventus WholeHealth, to learn how her company has been rolling out telehealth programs throughout the 500 facilities where the North Carolina-based company provides care.

Though Eventus and its partners have run into some growing pains, Terrell shared stories of telehealth success in the early days of this crisis. And Terrell also predicted that the COVID-19 pandemic — which she described as “the largest unplanned experiment in history at so many levels in health care” — will bring about permanent change in the industry.

“I don’t think you’re going to be able to put the toothpaste back in the tube,” Terrell said. “We’re not going to go back; things will change.”

Please note that SNN spoke with Terrell on Friday, March 27; this interview thus reflects the situation at that time.

What are you seeing on the ground right now?

The skilled nursing industry is really quite diverse with respect to how it’s governed, and who’s making decisions. We, Eventus, are in 500 facilities in five states, and have a little over 200 providers providing services. Some of those have a corporate structure with governance at the top, and some of them are little mom-and-pop places. As a result of that, it’s not easy, per se, to basically say that there’s going to be one approach to how we’re going to do things.

We have to really adapt to our partners and customers and say: “What will be the most useful way of addressing what the issues are?”

We had planned for a long time — it was part of our strategy, a strategic action we had already planned on this year — to have telemedicine. We didn’t know we were going to put it in place in one week, because we had a larger strategic plan. But what we’ve tried to do is reach out to all of our facilities and say: “What is the way that we can do this that will be most useful for you all?”

Before there was even a declaration at the national level, we sent out to all of our skilled nursing facility partners some information that said that we would have — for every one of our providers that go to the building — they would attest every morning with a document that they had taken their temperature, that they didn’t have any symptoms, and that they had not traveled into the areas at the time that were considered high-risk, and they’ve not been exposed to anybody with COVID-19. And we’re still doing that.

So that was the first thing we did, which is to say: “We take this seriously. We’re going to work with you all. And then we’re going to also try to create strategies for reducing the number of individuals that are in the building, and how we actually actually provide services” — hence, telemedicine, reduction in some of the services that we’ve provided before, such as nail care, for example, in the short run. Any screening exams that were occurring, for our vision care, is not appropriate care during thsi situation and we’ve stopped it. So that was reassuring.

We’ve had some facilities that, interestingly, initially did not want any of our mental health providers or psychotherapy in the facility. So we were working on some telehealth strategies with them, and then they’ve come right back and said, “Oh, no, that was a huge mistake. We’re having all sorts of anxiety and we need you guys.” And so we’ve worked with them to do that.

Most of the SNFs, at least at this point, have had personal protective equipment — but not all of them. So we’ve come up with some creative ways of having our PPE in the short run, and then we have what we believe is going to be a larger national supply coming in next week.

So we’ve had to be real partners. But it really has been at the level of being able to be adaptive on the ground and partner with them in ways that we can just solve whatever makes sense. We’ve had some — without naming the facilities — we’ve had some situations recently where their non-Eventus medical directors have just quit in the midst of all this. So we’ve been there to step in and be able to provide some of those services.

Like everybody else, we’re taking it day to day.

Tell me about the telehealth implementation. Are your partners really embracing it? Has the transition been smooth? Are there already interventions being conducted on the ground?

We take — even though it’s been within a week — a fairly deliberate approach, because our behavioral therapists were some of the first of our physicians to [indicate] they were wanting to decrease the number of visits. We trained them, we created documents that would train our skilled nursing facility administration and nursing staff with what the technology would do and how to use it. And then we rolled it out in some places that wanted it to begin with, and we’re going to … offer it everywhere.

We’ve learned along the way. One of the biggest issues for telemedicine that’s happening in the community: You typically may have somebody that’s fairly savvy in the community setting and can have an interaction with a clinician face-to-face without any trouble. But you know and I know that the individuals that are in skilled nursing facilities quite often have all sorts of disabilities, and it really requires someone at the field facility to be there to help with the technology — to make sure that it’s not just the patient and the clinician interacting, but that the technology is set up and done in an appropriate way.

So that puts strain on the part of the nursing staff and the facilities. In one strategic approach we have, we can have one of our medical assistants go into the building and provide telehealth services for all of our clinicians — whether it’s a primary care clinician or a psych med or behavioral therapist — and that limits the number of people in the building, and actually frees up the nursing staff at the SNF to not have to be involved with it.

But some of them haven’t wanted that — they don’t want anybody in the building that doesn’t need to be there. So in that situation, if you’re going to use telehealth, you’re going to have to have the resources on the other side to host it, if you will.

We’re still learning. We’re very early in the process, but there is significant types of work that may need to be done — because, as this situation changes in real time, they’re going to be short-staffed themselves.

Are you seeing staffing shortages at these facilities? How is morale?

We’re not hearing of staffing shortages much yet in our areas. We’re not in some of the high-incidence areas like New York or California or Washington right now. There is — I believe on the part of all of the health care industry — a lot of anxiety about what’s getting ready to hit us, because there has been a reduction in admissions to many of the skilled facilities in the short run as a result of a reduction in elective procedures in the hospital. I think for a little while, we’re in the calm before the storm. I think that that may well get worse.

We’ve had one of our providers that was COVID-positive. We immediately quarantined her; we informed the facility. There’s been no cases in those facilities that have occurred. But we worked and partnered with them with respect to making sure that all those residents were being monitored on a regular basis.

When things like that happen — and it’s going to be more of that — there’s just going to be a lot of fear and a lot of anxiety. So what we’re trying to do is be the best partners we can to our SNF partners.

How do you think this is going to permanently change the post acute and long term care landscape? Obviously in the matter of two weeks, CMS has erased a lot of regulations and a lot of long-standing rules that had been in place for decades in some cases.

I don’t think you’re going to be able to put the toothpaste back in the tube. We’re not going to go back; things will change. We’ve got the largest unplanned experiment in history at so many levels in health care — around the world in so many different ways. There will be many things that we will learn about it.

HIPAA is based on things that still need to be true, which is respect for privacy, respect for the security of patient information. But one of the things that that particular regulation has always done — possibly it was a barrier to certain types of technology innovation.

So now that we have that, in the short run, stopped, then there will be the opportunity to see the results of the lack of regulation, and there’ll be innovation that comes out of it, I believe, on the technology side. One of the things that is true with clinicians in the community that have not had the experience of telemedicine — I’m hearing from many of my colleagues they never want to go back. They’re enjoying it.

I’m a clinician. I’m an internist, and in the past, I did some work for Teladoc, including about 5,000 telemedicine visits; I’ve written a white paper on telemedicine in the past. I think that this is an industry that was ready to be transformative, but we had these barriers in place — and now that they’ve been removed, there will be the opportunity to learn from that, and then you’ll see some real redesign of the way a lot of care is provided.

This interview has been condensed and edited for clarity.

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