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By Maggie Flynn | July 28, 2019

Skilled nursing providers are becoming increasingly interested in telehealth technology as a way of improving clinical outcomes and reducing care costs.

But systemic obstacles blocking capital investment — and SNFs’ generally narrow margins — and cultural resistance mean that it’s hard for providers to implement the technology, Lana Adzhigirey, care transformation manager at the health care system CHI Franciscan in Tacoma, Washington, told Skilled Nursing News.

The first question about telehealth will almost always relate to connectivity and the technological capabilities required, she noted. But beyond the basic tech issues, there is a deeper shift culturally that has to take place for SNFs to launch and use telehealth successfully.

“Besides the technical and potential connectivity infrastructure needs, the implementation challenges lie in the changes to the nursing role,” Adzhigirey, who also serves as chair of the American Telemedicine Association’s (ATA) Telehealth Nursing Special Interest Group, told SNN. “There is a difference in skill and comfort levels between making a call to a provider for a patient who spiked a fever and leading a virtual assessment when the provider is not there physically.”

States across the U.S. are increasingly turning to telehealth to address provider shortages and ensure access to specialty care, according to a report from the ATA that was released July 18.

The majority of states have adopted policies in which Medicaid, for coverage and/or payment purposes, will treat telehealth services and in-person services in the same, the report said.

Traditional Medicare, however, is another story.

Medicare Part B covers certain telehealth services, but only in some rural areas under certain conditions — such as when the session takes place in a SNF. But the Centers for Medicare & Medicaid Services (CMS) recently finalized the expansion of telehealth coverage for Medicare Advantage plans, which telehealth providers in the SNF space were optimistic about.

“The Medicare Advantage telehealth benefits are a welcome development that will resonate across the SNF sector,” Paul Cristiano, CEO of the Avon, Conn.-based TeleCare Partners Group, told SNN at the time.

Reimbursement laws play a major role in telehealth adoption, which means there might be more SNF interest in telehealth in the regions of the U.S. where there are telemedicine parity laws in place, Adzhigirey said. But when it comes to Medicaid, there are still 19 states that have not yet adopted parity policies, according to the ATA report.

In fact, reimbursement and the challenges of reimbursement were blamed in the downfall of Call9, a telehealth provider that embedded emergency personnel in nursing homes, while also connecting SNF staffers to remote physicians via iPads and other technology.

The company ended up suspending operations, and founder Tim Peck told SNN that the reimbursement landscape was a major factor.

“You can’t lean into fee-for-service in order to maximize the amount of cash that you’re getting in the short term, and keep the good graces of the payers and the world out there, who’s trying to work with you toward being a value-based company,” he told SNN.

But 36 states offer telehealth through an innovative payment model, making use of a variety of waivers: managed care organization, home and community-based services, or Medicare-Medicaid dual-eligibles.

Map showing the states that make use of waivers for telehealth in blue and the ones that do not in grey
Source: ATA 2019 State of the States Coverage and Reimbursement Report

Changing the culture

Post-acute facilities have a definite opportunity to make of telehealth, since they have provider coverage around the clock, Adzhigirey said. But capital investment remains a major challenge, particularly given that rural areas where telehealth is reimbursed are the same areas where the internet structure may not be optimal for bidirectional video exchange as used for virtual visits, she said.

But another key investment is the human one, in the changes to the nursing role and the different skills needed, Adzhigirey explained.

“The nurse takes on a role of a telepresenter where they partner with the provider to complete a thorough assessment and use technology such as a camera and an electronic stethoscope,” she noted. “This typically takes more nursing time and arrangements need to made to assure other patients are receiving adequate care.”

The change in role plays into the staffing issues around telehealth, which an anonymous telehealth provider told SNN earlier is a challenge when it comes to incorporating the tech in the SNF setting.

“The resistance is — I’m going to say — in a sense worse, because if it was just technology, you could fix for that,” the operator said. “The bigger issue is the willingness to up and change those care models, and bring them into what the new care levels are going to demand.”

But the benefits for patients are significant. Adzhigirey specifically cited a study in the American Journal of Managed Care that found avoidable hospitalizations were significantly reduced, with 259 patients
treated on-site, out of 313 cared for by telemedicine-enabled covering physicians during the year of service.

And though it takes time and effort to get nurses onboard, telehealth can be a major benefit for both patients and SNFs alike. The challenge and opportunity is in using the tools available to change care for the better,

“There are limitations with technology, and not all patients can be successfully seen virtually. But there’s also a lot of opportunity,” Adzhigirey said. “Reimbursement is very important; unfortunately, business case drives whether the program will survive or not.”

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