Covid-19 Opened the Telehealth Floodgates, But Barriers Remain in Senior Living

Over the past three months, senior living providers have embraced telehealth during shelter-in-place orders. At the same time, the way providers and residents use telehealth, along with the forces propelling it forward, continue to evolve.

Changes in federal policy and new flexibilities from insurers — some of them from before the pandemic — have made it easier to implement and pay for telehealth in the Covid-19 era. Still, telehealth places operational demands on senior living providers, and providers are not necessarily being reimbursed through insurance for their role in the process. It’s also not clear that the new flexibilities will carry over into the post-pandemic landscape, although momentum to do so is building.

One source of that momentum is the sheer number of people who have come to use telehealth out of necessity in recent months. At NYU Langone, a medical center in the Covid-19 hotspot of New York City, telehealth visits totaled about 7,000 per day at the peak of the outbreak, versus 300 per day previously.

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Another tailwind came from the Centers for Medicare & Medicaid Services (CMS).

In April, the agency implemented new flexibilities allowing physicians to be reimbursed for a telehealth appointment wherever their patient is located. CMS also increased the number of telehealth services that could be reimbursed by Medicare, including ER visits, nursing facility visits, discharges and therapy services. And the agency granted doctors more flexibility to conduct appointments using video apps such as Apple’s FaceTime or Skype.

Some insurers, including Blue Cross Blue Shield, have followed the government’s lead by temporarily expanding telehealth coverage for beneficiaries during the Covid-19 pandemic.

Although there are questions regarding how long these flexibilities and waivers might last, many in the telehealth industry are optimistic that they will stick in the long-term, according to Alissa Meade, president and CEO of Curavi Health. Curavi offers telemedicine solutions specifically designed for post-acute and senior living settings.

“There were a number of the waivers that lifted the restrictions on when providers could bill for telemedicine, and it has basically opened the floodgates,” Meade told Senior Housing News.

Telehealth takes off

Before Covid-19, most of Maplewood Senior Living’s telehealth use was on an individual basis, and it was often driven by what residents’ health care providers offered. The Westport, Connecticut-based operator coordinated doctor visits for residents and families, but the volume of remote visits was not high.

All that changed the moment Covid-19 arrived, according to Brian Geyser, Maplewood’s chief clinical officer. Maplewood saw a real need to keep residents on lockdown connected with health care providers. And doctors began encouraging telehealth use as a way to care for their patients without seeing them in person.

“What we had to do was quickly adapt and ramp up what was a very spotty, scattered telehealth program to become more sophisticated and more voluminous in terms of the number of telehealth visits,” Geyser old SHN.

To handle all of the new demand for telehealth services, Maplewood bought between 10 and 15 iPads for each of the 16 communities it manages in Connecticut, Massachusetts, New Jersey, New York and Ohio. Maplewood in April also began working with senior living technology company Connected Living to deploy a Temi companion robot set up for telehealth in each of its communities. That includes Inspir Carnegie Hill in New York City, which will deploy a Temi robot on each floor when it opens this year.

While Geyser didn’t share an exact dollar amount for Maplewood’s investment in telehealth, he acknowledged it was a significant expense, and one aimed at preparing the operator for a more digital world.

“It’s proven to be an efficient and effective way of delivering care in many circumstances,” Geyser said.

Indeed, telehealth is being leveraged for various types of services, according to a recent SHN Pulse survey of 22 senior living providers. Routine primary care is by far the most common, however, with more than 75% of respondents utilizing telehealth for this purpose.

The surge in telehealth is not a trend unique to Maplewood. Anecdotally, many other senior living providers have reported increased telehealth use. One of those providers is Health Dimensions Group (HDG), a Minneapolis, Minnesota-based provider which manages 35 senior housing and care communities, among other services the firm provides.

“It has given us a way to access care,” HDG Executive Vice President of Operations Sharon Thole told SHN. “It has also helped to … mitigate the chances of somebody being transferred to the hospital and being exposed to Covid-19.”

That was also the case for Bloom Senior Living, a Birmingham, Michigan-based senior living provider with nine communities in five states. Bloom’s residents didn’t frequently use telehealth services before April. But as physicians and other medical professionals began restricting routine in-person appointments due to the pandemic, telehealth use really began to “take off,” according to Melissa Campbell, the company’s director of education and development.

Bloom has its own laptops equipped with Skype for residents to use for telehealth if they so choose. But the visits and methods differ from resident to resident, usually depending on their level of acuity. Bloom’s independent living residents, for instance, often communicate with their doctors on their own through their own devices, while those residing in assisted living or memory care generally need more assistance in doing so.

“Typically, the wellness director is going with the resident and helping to get them logged in … or anything else that they may need,” Campbell said. “[For example], they might be providing a resident’s most recent vitals.”

Bloom also struck an agreement with a physician to handle some of its telehealth services. This has been useful in cases dealing with Bloom associates, or in cases where residents are unable to get a visit with their doctor, remotely or otherwise. The provider has found this service helpful when screening new residents prior to their move-in date — particularly, among older adults who live at home and have limited access to their doctor because of the pandemic.

“What we can do for new move-ins is a telehealth appointment, either with their private physician or with [our] physician,” Campbell said. “If they don’t have one that we’ve made arrangements with, we can also pre-test them for Covid-19 to make it as safe as possible.”

Offering telehealth services has given Bloom wider clinical flexibility during a tough operational time. And, outside of the cost of the laptop computers, it hasn’t come as much of an added expense, as visits are billed through residents’ own insurance plans.

“If we can manage somebody’s clinical care internally so that they don’t require an emergency room visit or a hospitalization, doing a telehealth visit, overall, is a very nice option,” Campbell said. “So, I think there is a future in telehealth long after we move beyond Covid-19.”

Even as providers embraced telehealth as a way to keep residents connected during Covid-19, they have also expanded the definition of the word to include less-formal medical visits and other communications that can be easily facilitated, according to Amy Kaszak, president of special needs plans for Glen Allen, Virginia-based AllyAlign Health. AllyAlign helps senior living providers launch and run Medicare Advantage plans, which also have increasingly been covering telehealth more broadly.

“We are seeing the definition of ‘telehealth’ really being expanded more into ‘telecommunications,’” Kaszak told SHN. “Partners are using iPads, FaceTime, cell phones, and other video conferencing tools … to provide video and voice connection for residents and family members or caregivers that often includes some general health updates from a staff nurse or CNA along with social updates, updates on member activities, and an overall status of life on campus.”

AllyAlign is building a “teleconnection eco-system” of devices supported by a platform it calls GracieCare. The platform allows AllyAlign’s members to stay connected with medical professionals, family members and during new member enrollment. AllyAlign has developed two teleconnection devices: Gracie, a cart-based model with two touchscreens; and GracieGo, a portable, single-touchscreen device for multi-site or emergency use.

AllyAlign Health

Many of AllyAlign’s partners are looking to make telehealth a more regular part of on-campus care, with assisted living, memory care and continuing care retirement communities (CCRCs) seeking to offer residents more on-campus health care services. Medicare Advantage plans can serve as a funding source for these services.

Questions about the future

Although it’s clear telehealth has become a more popular choice during Covid-19, what isn’t as clear is whether that will carry over into the post-pandemic era. Much of that hinges on the flexibilities and waivers, which have opened up new avenues for telehealth use and payment.

While telehealth has always been relatively popular with end users and providers, that popularity actually served somewhat as a deterrent to CMS adopting more flexibilities, according to Curavi’s Meade.

“Any time they’ve done longitudinal studies on the impact of telehealth on costs and outcomes, it generally found that it would drive costs up, because it would drive a number of consults that otherwise might not have happened, due to the convenience,” Meade said.

Other barriers include the complexity of using telehealth given that residents usually have different physicians and insurance payers. One problem is that many telehealth offerings are dependent on accessing a specific device or platform designed to work with a particular electronic medical record or system.

“Insurance payers contract with physicians/clinicians providing telehealth just like they do with traditional practices,” Kaszak said. “Senior housing communities often find themselves being asked to support, work with, or facilitate telehealth visits on a variety of devices, platforms, and websites and helping residents navigate to their ‘in-network’ or preferred telehealth provider.”

And, despite the clinical advantages of offering telehealth services on-campus, doing so often means added time and cost for providers facilitating those visits — but the reimbursement goes to physicians or clinicians, and not the senior living provider, Kaszak said.

“You need someone to bring up the website, wheel in the mobile unit, position the camera, help with patient communications, provide vital signs, and even take notes in order for a physician or other clinician to provide assessment and treatment via video and voice,” Kaszak explained. “While our partners all are eager for their residents to get care, they are already facing severe staffing challenges and the extra time needed to facilitate individual visits puts further pressure on the community.”

Still, Meade believes there is now more optimism in the air regarding the future of telehealth than before the Covid-19 pandemic.

“A couple months ago, I would have said that they’re going to roll back the waivers [after Covid-19] and we’re going to be back where we are,” Meade told Senior Housing News. “But given the groundswell that’s happened, I am optimistic that we’ll make changes before the waivers go away.”

Some of the new flexibilities are set to expire in late July, but CMS Administrator Seema Verma has hinted that telehealth’s new flexibilities might be here to stay in the long run.

“I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back,” CMS Administrator Seema Verma said in April.

Policymakers have also voiced support for some of those flexibilities. Sen. Lamar Alexander (R-Tenn.), who chairs the Senate Committee on Health, Education Labor & Pensions, has called for a permanent extension to many of the temporary allowances and flexibilities regarding reimbursement and services.

“Because of this 10 years of telehealth experience crammed into 3 months, patients, doctors, nurses, therapists, and caregivers can write some new rules of the road, and we should do so while the experiences still are fresh on our minds,” he said in a June 17 statement.

Which flexibilities or allowances the federal government might ultimately extend, and how such rules are written in the post-Covid world, remains to be seen. Specifically, reimbursement is one barrier that will need to be overcome for wider adoption.

“We have always been capable of doing telehealth and would have done a lot more of it if it was reimbursable,” Geyser said. “But it hadn’t been, and for that reason, physicians didn’t offer it and we couldn’t organize it.”

Although Maplewood itself could absorb the cost of its telehealth program, that is not something the company is interested in doing. But Geyser theorized that a new model for telehealth could emerge after the pandemic where reimbursement rates are adjusted for in-person and remote visits.

“If it’s a medically necessary situation and you have to be seen in person … the rate for that encounter is going to be higher versus the telehealth visit, which might be paid at a lower rate,” Geyser said.

And despite all the current uncertainty, Geyser is certain that the future will include more ways to make telehealth work in senior living.

“Covid has forced the system to move into the future,” he said. “And I just can’t imagine we’re going to go back.”

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