The what, why and how of “real” telehealth

During the COVID-19 public health emergency, the Medicare 1135 waiver immediately expanded the use of telehealth and bypassed HIPAA requirements, allowing essentially any video chat application to be used for remote patient visits.

Within days, free video chat apps of all sorts became widely used by skilled nursing facilities and practically all other healthcare provider organizations to provide some semblance of telehealth — and over the following six months, telehealth has moved to the center of how SNF patients and residents receive care.

However, the anticipated removal of the HIPAA waiver after the conclusion of the public health emergency will leave many SNFs uncertain about how to replace non-compliant apps, now that clinicians, patients, residents and families are expecting virtual care to persist. In addition, SNF clinicians see the flaws of these apps and how they are implemented into clinical workflows and wonder, “Is this what telehealth is?”

What is real telehealth?

Real telehealth is not merely adding video chat to a patient visit, it encompasses a host of integrated capabilities coupled with thoughtful implementation, communication and training. Real telehealth has at least four key characteristics:

1. It enables preferred physicians: A patient’s own physicians know them best, are familiar with SNF staff caring for that patient and understand the unique characteristics of the particular facility. Third-party clinicians assigned to deliver only telehealth visits without past interactions with the patient — nor full access to the medical record — miss important details and do not gain the trust of patients and their families. Real telehealth allows patients to choose familiar and trusted physicians to care for them.
2. Integrated access to the full medical record: Care quality is improved and errors reduced if the remote physician has immediate access to the electronic health record during a telehealth session without having to toggle between the EHR and a video chat application, particularly when using mobile devices. Physicians want easy access using a single login that allows them to view critical EHR information, such as lab results, alongside the video session and enter notes that can be routed back to the EHR to avoid double entry.
3. Optimized for SNF clinical workflows: SNF clinical workflows present unique telehealth challenges and needs not directly addressed by video chat alone. For example, a remote physician assessing a patient’s change in condition can make better decisions by receiving streamed audio from a bedside stethoscope placed on the patient’s chest. There is also the need to communicate and coordinate with a broader care team including the primary care physician, family members, medical director, therapists and the patient.
4. HIPAA-compliant messaging: Scheduling and coordinating telehealth sessions involving the patient, bedside nurse, remote clinician and, increasingly, family members is challenging in a SNF environment. Secure text-based messaging among staff and clinicians increases the value and satisfaction of virtual visits, while supporting patient-centered communication and engagement.

Why is real telehealth important financially?

COVID-19 telehealth reimbursement policies have been critical to supporting SNFs with visitation restrictions whose patients can’t see their physicians in person. Separate from these policies, real telehealth delivers mission-criticality that justifies implementation for sustainable success, rather than using ad hoc approaches. Three long-standing sources of return on investment for SNFs are:

1. Protecting revenue: A real telehealth program that breeds confidence among clinicians and families can greatly assist in bringing patients back to the facility, in light of COVID-19 concerns, and retain them there as appropriate to their care. Telehealth also enables remote physicians to manage patient change-in-condition occurrences, prevent avoidable transfers back to the hospital, and preserve SNF revenue by treating those patients in place according to the Medicare reimbursement “midnight rule.” 
2. Maximizing quality incentives and avoiding penalties: There is a growing array of value-based care programs instituting quality incentives and penalties for SNFs, such as SNF Value-Based Purchasing, the Hospital Readmission Reduction Program, Medicare accountable care organizations, and Institutional Special Needs Plans. Real telehealth’s attributes, such as patients being able to select personal physicians or other clinicians to easily access the EHR during a remote visit, enable the high quality of care and comprehensive clinician satisfaction to excel in these programs.
3. Expanding care delivery to increase revenue: Real telehealth enables a SNF to more efficiently expand workflows to participate in new revenue opportunities. For instance, ACOs and I-SNPs can provide assistance from their advanced care teams to SNF partners through telehealth, thereby reducing payer costs and increasing shared savings. 

In this era of tight budgets, it is important for SNFs to run their own return on investment calculations and plan the right levels of investments into real telehealth for achieving sustainable, positive financial outcomes.

How to plan for real telehealth

Beyond examining the financial case, additional steps can help facilities determine the right approach for real telehealth. Start with surveying staff, physicians, families and patients to gather feedback on their experience with telehealth during COVID-19. Design the survey to ask about different types of telehealth sessions, such as beside-staff-to-remote-physician and remote-family-initiated sessions with the patient and clinician. If a facility was forced to adopt ad hoc telehealth approaches due to the public health emergency, it is very likely that major gaps and opportunities for improvement will be discovered.