Senior citizen woman in wheelchair in a nursing home.

Telehealth and the Future of Long-Term Care

Join us on Wednesday, April 7 for further discussion of these issues during our virtual event, “Triumphs & Tensions of the Telehealth Boom.

By Tara Sklar

The COVID-19 pandemic accelerated the trend away from providing health care and long-term care in institutional settings in ways not previously imagined; the result of a reckoning with the massacre that disproportionately killed hundreds of thousands of older adults living in nursing homes or similar congregate facilities, along with the staff who cared for them.

Beyond the immediate staffing and infection control issues at hand, this juncture leads to a larger question, in the U.S. and abroad: how can we best care for an older population in the decades — and not just years — ahead?

The major advances and shortfalls that have surfaced during the pandemic around telehealth and its related technologies in digital home health care are essential to this discussion.

Among Medicare beneficiaries (Americans aged 65 and older), nearly half of all primary care visits were provided by telehealth in April 2020, compared to less than one percent before the public health emergency in February 2020. The use of telehealth services among older adults skyrocketed, largely due to relaxing legal and regulatory measures and expanding the existing Medicare telehealth benefit, including:

  • Increasing eligible services, types of providers, and communication technology (e.g., reimbursement for audio-only visits);
  • Removing geographic and site of service requirements to wherever a Medicare beneficiary is located; and
  • Suspending enforcement of Health Insurance Portability Accountability Act (HIPAA) compliant technology requirements.

The Centers for Medicare and Medicaid Services (CMS) and Medicare beneficiaries have expressed a high level of satisfaction with telehealth, which is reflected in its increase in use by 300 percent from seniors during the COVID-19 pandemic. Yet, the legal and regulatory measures highlighted above are temporary and will end with the public health emergency.

We are at a critical point with whether to make these temporary changes permanent and, if so, then how to optimally implement them when the declared public health emergency ends.

Making Telehealth Age-Friendly in a Long-Term Care Setting

The Department of Health and Human Services estimates that 70 percent of adults aged 65 and older are going to need some form of long-term care. Further, the rise in Americans with Alzheimer’s Disease or another form of dementia is expected to triple by 2050. Also, by 2050, the ratio of working age people to older adults will decrease from 7:1 to 3:1.

These statistics are increasingly making the headlines, as news stories highlight the tragedy surrounding America’s nursing homes during the pandemic and the importance of including long-term services in our continuum of care.

The U.S. does not have a secure financing infrastructure for long-term care; on average, we pay less for long-term care, per capita, than for costs associated with health care administration, at $516 compared to $937, respectively. This results in a fragmented system, with families struggling to pay out-of-pocket, spending down savings to qualify for Medicaid, or joining the ranks of the 50 million unpaid caregivers.

Widespread adoption of telehealth and digital home health care devices may be the missing key needed to finally shift the pendulum to providing sustainable, affordable, high-quality, and safe long-term care in the home.

Long-term care provided in an institutional setting is double to triple the cost of care provided in the home, which is a primary driver behind the rise in state Medicaid waivers. These waivers enable states to pay for Home and Community-Based Services (HCBS), rather than nursing home care, to support older and disabled individuals’ ability to remain living in the home.

To date, there is pent-up demand for HCBS, as the majority of states have waitlists that limit enrollment. While there have been wide variations in staffing and quality among states in how they implement these waivers, telehealth holds promise to expand access to these programs as well as to improve quality. As patients and providers navigate a virtual care space, approaches such as the 4Ms Framework for Age-Friendly Care can support a patient-centered telehealth visit by personalizing the care, obtaining meaningful consent, and protecting privacy.

Another advantage of the recent telehealth expansion is that providers can see their patients, in this case Medicare beneficiaries, in their home setting, and access their continuous biometric data (e.g., resting heart rate, activity, and sleep) via remote patient monitoring. Given high concern around the rise of elder abuse and neglect, this is an especially important development. This additional information can potentially help to shed light on a patient’s overall wellbeing and environment — more so, even, than an in-person visit.

Relatedly, relying on unpaid caregivers to take family members to in-person visits poses a burden and presents coordination challenges, which can result in missed appointments. A telehealth option literally meets Medicare beneficiaries where they are, and when they are best prepared for a visit — i.e., at the time of day when they are most coherent. The now-widespread adoption of telehealth offers an opportunity to study the potential benefits of this modality to improve quality of life for older adults and their caregivers, which may in turn inform a stronger long-term care infrastructure.

Telehealth Access and Equity Among Older Adults: Beyond the Digital Divide  

According to a recent, national study approximately one quarter (26.3 percent) of Medicare beneficiaries lacked digital access in the home, making video visits not feasible. The proportion of beneficiaries who lacked digital access was higher among those with low socioeconomic status, those 85 years or older, and those in communities of color. Although an audio-only visit is reimbursed at the same rate as video or in-person visits under Medicare, it may be associated with increased disparities in care, and limit safeguards against elder abuse for some of the reasons aforementioned.

Disparities in access to care existed prior to the COVID-19 pandemic and the expansion of telehealth. However, telehealth is in a unique position to bridge, rather than exacerbate these disparities, through policy approaches that recognize underlying barriers. As an example, the Federal Communications Commission has a program called Lifeline, which provides reduced-cost phone or internet services to families who meet income eligibility requirements. There are also ongoing efforts to provide devices to seniors through groups, such as Telehealth for Seniors, and related organizations, such as the Telehealth Equity Coalition.

Given the projected need for long-term care and the costs of providing it in an institutional setting, it is critical to explore how laws and regulations around telehealth can be optimally structured to support older adults, their caregivers, and providers.

The current expansion of telehealth that occurred as a result of relaxing laws and regulations during the pandemic should not be rolled back, but rather examined for areas where access to quality care still falls short, and optimized to better address those gaps going forward.

Tara Sklar

Tara Sklar, JD, MPH is a professor of health law and director of the Health Law & Policy Program at the University of Arizona James E. Rogers College of Law.

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