Telehealth provides for the promotion of health care, health education, and public health through the use of electronic information and telecommunication technologies (Health Resources and Services Administration, 2020). Telehealth may include a mixture of telephonic, video, and remote monitoring technologies that can perform subjective (e.g., patient/caregiver–reported symptoms) and objective (e.g., weight, blood pressure, medication adherence) functions. In response to the COVID-19 pandemic, and particularly in response to care for high-risk individuals such as older adults, health providers have sought practical ways to use telehealth to deliver person- and family-centered care.
Although telehealth has long been used in the United States, its availability has been substantially limited due to stringent regulatory requirements (Dorsey & Topol, 2016). The greatest limitation is reimbursement, which is only provided in rural areas and to physicians and advanced practice providers. Furthermore, individuals have not been allowed to receive telehealth within their home. Although accountable care organizations were recently provided greater leeway, a minimal proportion of older adults are enrolled in these organizations, limiting its reach.
Limitations on billing have restricted the spread of telehealth adoption despite the fact that telehealth can be provided safely and effectively in primary and subspecialty care (Shigekawa et al., 2018). Thus, the majority of telehealth in the United States has been provided through health plans and health systems seeking to reduce high-cost care. These programs that provide telehealth to the home have largely been nurse-driven and have shown high rates of success in improving quality and reducing costs in chronic disease management, palliative care, behavioral health, and rehabilitation (Speyer et al., 2018).
Given the strengths and limitations of currently available telehealth options and opportunities to expand telehealth in the wake of COVID-19, the current article seeks, under the framework of person-centered care (PCC) for the older adult, to describe: (a) existing effective models of telehealth; (b) current or potential integration of key functions of telehealth for older adults and their caregivers; (c) current limitations of telehealth; and (d) the shifting landscape and telehealth opportunities for nurses and other health disciplines following the onset of the COVID-19 pandemic.
Key Integrations of Telehealth and Other Existing Models
Telehealth, in and of itself, is broad and can be delivered in many different ways. The wide-ranging components of telehealth are recognized in The Telehealth Research and Policy Framework backed by multiple stakeholders, with service delivery as the centerpiece (Edmunds et al., 2017). The model focuses on policy and payment, service delivery, and outcomes, and forms a good base for exploring telehealth. However, although this model focuses on the macro level, it does not focus on concepts of how this care should be delivered, thus requiring additional development.
Integration of Person- and Family-Centered Care
Person- and family-centered care is defined as care that is individualized to the person and family, focusing on being respectful of and responsive to preferences, needs, and values. This care places the person and family at the center of decision making and is compassionate and coordinated (Barnsteiner et al., 2014). The model has been extended by nurses with a specific focus on cultural sensitivity and social justice (Lor et al., 2016). Person- and family-centered care, although a goal for all, is especially important with older adults given the substantial variation that exists in physical and cognitive function, treatment goals and preferences, and the more frequent need to interact with informal and formal caregivers. However, this heterogeneity makes providing PCC complicated, requiring targeted strategies to ensure older adults' preferences are aligned with the care provided (Wolff & Boyd, 2015).
Telehealth strategies may help move forward a vision for PCC as they can be personalized for the older adult and caregiver while also allowing for effective communication across the health care continuum. For instance, the Care Ecosystem Model successfully uses a telephonic and internet-based system for lay care navigators to work as part of an interdisciplinary team to care for persons with dementia and their caregivers using PCC strategies (Possin et al., 2019).
Self and Family Management. Several models of PCC exist, including the Self and Family Management Framework, which is well-suited for older adults, as it focuses on self and family management of health and illness (Grey et al., 2015). In this framework, facilitators and barriers are presented related to personal and lifestyle factors, health status, resources, environment, and effects of the health care system. The framework presents processes that focus on the needs of older adults, matching them with the resources necessary to manage and live successfully with their conditions.
One key factor of this framework, especially relevant to older adults and their caregivers, is that it can help clinicians think through the various factors that need to be addressed in care processes. Addressing issues in processes of care is essential to ensure PCC occurs in a way that allows for effective self and family management. As the clinician is not physically present, most telehealth interventions require a high level of self-care and/or family care.
Caregiver Integrated Telehealth
Although many telehealth interventions have been developed specifically for caregivers (Chi & Demiris, 2015), they have largely focused on caregiver wellness, palliative care, or caring for individuals with cognitive impairment. However, this focus dis-associates the important role of the caregiver and older adult as a dyad and fails to address the role of the formal (paid) caregiver. As telehealth matures, further work, conceptually and operationally, is needed to understand how to best integrate the older adult, family, and paid caregivers into telehealth models. We know that older adults and family often work as gatekeepers to paid caregiver participation (Reckrey et al., 2020). Yet, paid caregiver insight is often valuable in understanding the older adult's clinical and social circumstances. Therefore, an intentional, inclusive, PCC approach needs to be developed that maintains the autonomy and values of the older adult, while ensuring that effective communication and information sharing can occur.
With the rapid advancement of technology, opportunities abound to support older adults and their caregivers in ensuring that telehealth-based PCC can be provided across settings. Technologies to support telehealth delivery across settings can provide ease of mind to older adults and family through remote monitoring of everything from falls to blood sugar levels, geolocation, and beyond (Bartz, 2017). However, these same advances lead to substantial ethical issues around privacy and safety (Klugman et al., 2018). These technologies also raise questions about how (and whether) they should be integrated into the health care system, and if so, how to pay for them and who should be monitoring them.
Health equity is also a concern, as underserved populations, whether low income or located in rural regions, are less likely to use these technologies (Park et al., 2018). However, telehealth can improve access, quality, and satisfaction for underserved rural populations (Khairat et al., 2019). The integration of health technologies must prioritize improving health access for underserved populations so that advancements do not widen the already significant health gap.
Most telehealth interventions have focused on either nurse-led case management or physician and advanced practice provider visits. Additional programs have been developed by or for other disciplines, including, but not limited to, social work (Cabacungan et al., 2019), pharmacy (Perdew et al., 2017), physical therapy (Lee et al., 2018), and occupational therapy (Renda & Lape, 2018). However, segmented, individual discipline telehealth is likely not adequate to meet all needs of older adults, particularly those living with complex care needs. Medicare allows reimbursement to providers for chronic care management performed by clinical staff in their offices; however, reimbursement is too low to provide this care in a truly interdisciplinary manner. True interdisciplinary telehealth research and models are still in their infancy, and further work is needed to assess the best ways to fully integrate an interdisciplinary approach.
Telehealth Changes During the COVID-19 Pandemic
Although it is clear that greater research and model development are needed to create robust telehealth programs, as is true in other parts of health care, policy, market, or environmental forces often cause change before fully developed and evidenced programs can be implemented. Due to the COVID-19 pandemic, telehealth use has exploded, and it is unlikely that the genie will be put back in the bottle, so to speak. Because of stay at home orders, the high risk to older adults of COVID-19, and Centers for Medicare & Medicaid Services issuance of public health emergency waivers that almost completely relaxed restrictions on telehealth use, older adults and health care providers had the opportunity to adopt telehealth (Young et al., 2020). Some barriers still remain: home health agencies cannot count telehealth visits toward billing, and hospices cannot include telehealth visits on their claims, making it appear that they are providing fewer services, which could potentially lead to audits. In addition, demographic and socioeconomic disparities have emerged, as those with poorer technology access and those who are older are less likely to choose telehealth (Reed et al., 2020). Therefore, further work is needed to introduce the technology and reduce the access disparities that exist. However, it is clear that telehealth, a PCC format that provides ease of access, was acceptable to a large number of older adults, and thus our system now needs to evolve to continue providing this care post-pandemic, but in an effective and efficient way.
The Next Phase of Telehealth
Current Policy Movement
Policymakers recognize that the United States cannot return to the pre-pandemic state. As of mid-June 2020, Lamar Alexander, the chairman of the U.S. Senate Health, Education, Labor and Pensions Committee recommended making many of the waivers issued due to COVID-19 permanent (Alexander, 2020). Other bills introduced in the 116th Congress require demonstration projects (S.773), expand telehealth services (H.R. 5257), allow telehealth across state lines (H.R. 4900), and improve telehealth for underserved communities (H.R. 6792), amongst others. Reports from Politico (Ravindranath, 2020) have also detailed the calling of hearings specific to telehealth and the formation of a cross-industry lobbying group. Although there is clear momentum, the passage of any of these bills is far from assured.
Recommendations During Policy Change Discussions
As nurses and other professionals advocate for the expansion of telehealth, it is important to consider how to make the greatest gains toward achieving telehealth interdisciplinary PCC. We argue that several provisions are key. First and foremost, communicating the priority of ensuring adequate access to telehealth services for underserved populations so as to increase equity and not perpetuate a dual-class system. Second, not tying reimbursement to physicians or health systems. Evidence abounds that nurse-managed programs tend to be innovative, of high quality, and reach underserved populations (Barkauskas et al., 2011; Esperat et al., 2012). Restricting reimbursement to systems through bundled payments and physicians restricts trade unnecessarily, limits innovation, and further disadvantages underserved populations. Beyond nursing, other disciplines, such as social work and rehabilitation therapy, should have the opportunity to lead teams. Interdisciplinary leadership is especially important when targeting different patient populations where disciplinary expertise plays a lead role. Third, these models should be implemented with requirements around non-burdensome but rigorous quality reporting standards that are adjusted for the patient population to reward effective practices and disincentivize ineffective ones. Fourth, existing structures, such as home health and hospice agencies, should be reimbursed for performing telehealth, including remote monitoring, as these practices may be more efficient and effective in managing care in these settings. Fifth, Congress should fund through research and demonstration projects rigorous, conceptually sound telehealth programs, and evaluate them effectively through prospective means so that the true benefit (or null effects) of the programs can be determined and adjustments to regulation and law made to ensure the best use of taxpayer funds to address PCC for older adults. Sixth, we need to better understand through policy, research, and practice who to target with different types of telehealth interventions as results, even of singular interventions such as ENABLE (Educate, Nurture, Advise, Before Life Ends), have worked variably in different populations (Bakitas et al., 2020; Bakitas et al., 2009). Finally, the way the law is written should encourage interdisciplinary care, ensuring reimbursement across disciplines, and an integrated rather than captain-of-the-ship approach to care.
Telehealth is a promising intervention whose time has finally come, with a window opened by the unfortunate circumstances of the COVID-19 pandemic. Now is the time to advance PCC for older adults through interdisciplinary telehealth, using the many policies and regulatory levers necessary to meet these needs. Simultaneously, it is imperative to develop models further, and advance research and innovation to grow the evidence base for effective and optimal interdisciplinary telehealth PCC.
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