Expansion Of Telehealth Research Articles

Telehealth Expansion During the COVID-19 Pandemic and Beyond.

Information and resources for health care providers.

Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic

BackgroundAt the onset of COVID-19, there was a rapid expansion of telehealth (video/telephone) visits to maintain delivery of primary care (PC) services at the Veterans Health Administration (VA). This study examines patient, provider, and site-level characteristics of any virtual and video-based care in PC.MethodsInterrupted time series (ITS) design was conducted using VA administrative/clinical, electronic healthcare data, 12-months before and 12-months after COVID-19 onset (set at March 2020) at the VA Greater Los Angeles Healthcare System (GLA), between 2019 and 2021. Patients with at least one visit to a VA PC clinic at GLA (n = 547,730 visits) were included in the analysis. The two main outcomes for this study were 1) any telehealth (versus in-person), as well as 2) video-based care (versus telephone). For the ITS analysis, segmented logistic regression on repeated monthly observations of any telehealth and video-based care was used.ResultsPercent telehealth and video use increased from 13.9 to 63.1%, and 0.3 to 11.3%, respectively, before to after COVID-19 onset. According to adjusted percentages, GLA community-based clinics (37.7%, versus 29.8% in hospital-based clinics, p < .001), social workers/pharmacists/dietitians (53.7%, versus 34.0% for PC clinicians, p < .001), and minority groups, non-Hispanic African Americans (36.3%) and Hispanics (34.4%, versus 35.3% for Whites, p < .001) were more likely to use telephone than video. Conversely, mental health providers (43.3%) compared to PC clinicians (15.3%), and women (for all age groups, except 75+) compared to men, were more likely to use video than telephone (all p’s < .001).ConclusionsSince telehealth care provision is likely to continue after COVID-19, additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) versus video-based care (e.g., integrated mental health visits). Additionally, it is important to understand how all clinics can systematically increase access to both telephone- and video-based PC services, while ensuring equitable care for all patient populations.

COVID-19 and the Rapid Expansion of Telehealth in Social and Behavioral Health Services

The spread of COVID-19 changed the landscape of how social service agencies operate. Essential services providers have had to adapt and innovate in order to carry out their mission. As a result, technology has become an integral part of their service model, with an increased emphasis on telehealth services. For many agencies, the abrupt transition to remote services has brought about important conversations around access, use, policy, effectiveness, and efficiency. A qualitative, narrative study was conducted with CEOs or social work directors of 37 social service agencies in the Mid-South region to understand their experience and the impact of the COVID-19 pandemic. Interviews were conducted and data were transcribed and analyzed. Thematic analysis highlighted seven themes: 1) a rapid transition to virtual services, 2) the need to improve infrastructure, 3) new technology and innovation, 4) barriers, 5) benefits, 6) funding, and 7) changes that will be kept. Implications at the client level include continuing to offer telehealth services. At the agency level, implications include managing the logistics of telehealth and the need for insurance and regulator changes. Implications for social work include ethical considerations for providing telehealth services and educating current and future social workers in the use of telehealth services.

Utilization of telemedicine among patients newly diagnosed with cancer.

1595 Background: The use of telemedicine among cancer patients remains limited. Because of the COVID-19 pandemic, CMS expansion of telehealth with 1135 waiver was enacted in March 2020, broadening the opportunities to provide patient care using telemedicine. This study examined the impact of the CMS expansion on the use of telemedicine among cancer patients. Methods: We identified newly diagnosed patients with 5 common cancers (breast, prostate, lung, colorectal, and lymphoma) between 3/2019 and 12/2020 from Optum’s de-identified Clinformatics Data Mart Database. Patients who had 6 months of full enrollment (3 months before and 3 months after the first [index] cancer diagnosis date), had cancer claims on 3 separate dates within 3 months of the index date for the specific cancer diagnosis, and no prior history of cancer were included. We defined telemedicine use as patients who had a telemedicine procedure code within 1 month of their index diagnosis and had the cancer diagnosis on the telemedicine claim. We conducted an interrupted time series analysis to examine the impact of CMS expansion on telemedicine use. A multivariable logistic regression model was used to identify factors associated with telemedicine use during the post-expansion period. Results: Of 96,632 patients included, the average crude rate of telemedicine use was 0.12% before and 14.2% after the expansion in March 2020 (see Table). There was a significant impact of expansion on telemedicine use (21% increase; p&lt;0.001). The peak rate (adjusted) was 28% in April 2020, decreasing and plateauing in July/August 2020, with rates staying in the range of 10-12% between August and December 2020. During the post-expansion period, lymphoma, prostate, and lung cancer patients (adjusted rates: 14.6%, 15.7%, and 15.9%, respectively) were more likely to use telemedicine compared to patients who had breast (12.7%) or colorectal (12.3%) cancer. Patients who were older (adjusted rates: ≥65 years, 13.8%; 50-64, 14.2%; 20-49, 18.6%), Black (12.4% vs 14.4% for White, 15.5% for Hispanic and 16.6% for Asian), resided in East South Central census division (8.4% vs 23.5% in New England) and had Medicare (12.2% vs 20.3% for commercial insurance) were less likely to use telemedicine (all p&lt;.001). Conclusions: After the CMS telehealth expansion, the use of telemedicine among newly diagnosed cancer patients increased significantly. Telemedicine use varied by patient age, geographic location, race/ethnicity, and payer. Further research is needed to understand the pattern of telemedicine use.[Table: see text]

Responses to telehealth expansion for older adults with cancer during the COVID-19 pandemic.

1591 Background: Synchronous video visits (“telehealth”) were rapidly adopted to facilitate provision of cancer care during the COVID-19 pandemic, with little time to comprehensively assess patient and provider needs. Attitudes toward telehealth use during active treatment (vs. survivorship care) were largely unknown, as were perceptions of, experiences with, and needed support for telehealth use among older adults with cancer. Older adults in particular may face increased vulnerability to inequities in access to care due to limited digital literacy. Methods: We conducted surveys and semi-structured interviews with providers, staff, and older patients (age ≥60) from a comprehensive cancer center. Data collection occurred between Dec 2020 - Nov 2021. Results: We completed a total of 106 provider/staff surveys, 128 patient surveys, 20 provider/staff interviews, and 15 patient interviews. A majority of surveyed providers/staff felt that telehealth should “definitely be offered” during treatment-phase encounters (55.9% treatment follow-up; 69.1% results communication; 70.2% discussing treatment side effects). Similarly, most patients indicated they would be willing to have video visits with a member of their care team for: discussing treatment side-effects (73.5%), results communication (69.6%), and treatment follow-up (65.7%). Patients reported experiencing challenges with joining video visits (29%) and understanding the telehealth process (28%). Similarly, less than a third (30.8%) of providers/staff agreed or strongly agreed that the institution did a good job of preparing patients for their first telehealth encounter. Patients felt the institution should do more to communicate the advantages of telehealth to older adults in handouts and videos, which included: engaging multiple family members in critical appointments (e.g., treatment decisions, end-of-life), seeing their doctor when they were too sick to travel, and reducing potential exposure to infectious disease at the clinic. Participants suggested several strategies to assist patients with limited digital literacy: offering video tutorials of the connection process, creating “fake appointments” to practice online connections, and hiring a digital navigator to assist with technical difficulties and setup of the online portal. Despite challenges, a majority of surveyed patients (65.7%) and providers/staff (76.9%) intend to continue using telehealth after the COVID-19 pandemic passes. Conclusions: Use of telehealth for cancer care was received positively by older patients and providers/staff. Taking targeted steps to enhance implementation could reduce barriers to care, including among older adults and other populations with limited digital literacy, thereby promoting greater equity of access to telehealth benefits beyond the pandemic.

Addiction and COVID: Issues, Challenges, and New Telehealth Approaches

In recent decades, the United States has seen a substantial increase in the number of people diagnosed with substance use disorder (SUD). Both SUDs and COVID-19 separately have had, and continue to have, a widespread impact on our society. While they are two distinct entities, they are intricately related and have been shown to influence one another. Lockdown mandates intended to enhance public safety produced unintended consequences for people with SUDs by decreasing access to treatment and disrupting their current care. Telehealth could offer a solution to this disruption as its utilization expands the provider’s reach and increases access to treatment in underserved populations, including those with SUDs. The use of telemedicine seems to result in higher rates of patient satisfaction, compliance, and treatment retention rates while maintaining the need for social distancing. Even when pandemic restrictions resolve, telehealth can continue to provide invaluable benefits to individuals with addiction, particularly those in rural America. In summary, ongoing research regarding telehealth delivery and the expansion of telehealth is a byproduct of the pandemic and can advance the American healthcare system beyond the days of COVID-19. This manuscript will review studies regarding the use of telehealth in SUD with the hope that further research within and beyond the COVID-19 pandemic will lead to the increased use of telehealth by those involved in and those receiving care for SUDs.

Association of Telehealth with Short-Interval Follow-Up.

The COVID-19 pandemic led to wide adoption of telehealth in primary care. The impact of telehealth on subsequent follow-up visit volume is mixed. This study examines the association of newly expanded telehealth with short-interval follow-up visits during the COVID-19 pandemic in an academic primary care practice. Scheduling data were used to compare rates of 0 to 60-day follow-up visits after telehealth and in-person visits before and after onset of the COVID-19 pandemic. Compared with in-person visits, telehealth visits were associated with significantly higher rates of total short-interval follow-ups and higher rates of first short-interval follow-ups occurring in 0 to 15 days. Higher rates of short-interval follow-up may be due to inefficiencies created by rapid expansion of telehealth including suboptimal scheduling algorithms, pandemic-related safety considerations, and discomfort with the visit modality. Short-interval follow-ups have potential negative impacts on practice access, patient-centered outcomes, and sustainability of telehealth in primary care. Newly expanded telehealth visits conducted in the year after the onset of the COVID-19 pandemic resulted in higher rates and sooner first occurrence of short-interval follow-up visits. Future research should identify optimal scheduling processes for telehealth visits to minimize short-interval follow-ups.

Differences in access to virtual and in-person primary care by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system

BackgroundResearch exploring telehealth expansion during the COVID-19 pandemic has demonstrated that groups disproportionately impacted by COVID-19 also experience worse access to telehealth. However, this research has been cross-sectional or short in duration; geographically limited; has not accounted for pre-existing access disparities; and has not examined COVID-19 patients. We examined virtual primary care use by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system. We also assessed use of in-person primary care to understand whether disparities in virtual access may have been offset by improved in-person access.MethodsUsing a cohort design, electronic health records, and Centers for Disease Control and Prevention Social Vulnerability Index, we compared changes in virtual and in-person primary care use by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our study population included 11,326 adult patients diagnosed with COVID-19 between March and July 2020. We estimated logistic regression models to examine likelihood of primary care use. In all regression models we computed robust standard errors; in adjusted models we controlled for demographic and health characteristics of patients.ResultsIn a patient population of primarily Hispanic/Latino and non-Hispanic White individuals, and in which over half lived in socially vulnerable areas, likelihood of virtual primary care use increased from the year before to the year after COVID-19 diagnosis (3.6 to 10.3%); while in-person use remained stable (21.0 to 20.7%). In unadjusted and adjusted regression models, compared with White patients, Hispanic/Latino and other race/ethnicity patients were significantly less likely to use virtual care before and after COVID-19 diagnosis; Hispanic/Latino, Native Hawaiian/Pacific Islander, and other race/ethnicity patients, and patients living in socially vulnerable areas were also significantly less likely to use in-person care during these time periods.ConclusionsNewly expanded virtual primary care has not equitably benefited individuals from racialized groups diagnosed with COVID-19, and virtual access disparities have not been offset by improved in-person access. Health systems should employ evidence-based strategies to equitably provide care, including representative provider networks; targeted, empowering outreach; co-developed culturally and linguistically appropriate tools and technologies; and provision of enabling resources and services.

Implementing Virtual Care in Neurology - Challenges and Pitfalls.

Virtual care is here to stay. The explosive expansion of telehealth caused by the SARS-CoV-2 pandemic is more than a necessary measure of protection. The key drivers of this transition in healthcare delivery to a virtual setting are changes in patient behavior and expectations and societal attitudes, and prevailing technologies that are impossible to ignore. The younger population - Generation Z - is increasingly connected and mobile-first. We are heading to a world where we expect to see healthcare in general and neurology, in particular, delivered virtually. The medical community should prepare for this overhaul; proper implementation of virtual care from the ground up is the need of the hour. In an era of virtualization, it is up to the medical community to ensure a well-informed patient population, overcome cultural differences and build digital infrastructure with enhanced access and equity in care delivery, especially for the aging neurological patient population, which is not technologically savvy. Virtual care is a continuum of care that needs deeper integration at systematic levels. The design principles of a patient’s journey need to be incorporated while simultaneously placing physician satisfaction with a better user experience at the center of implementation. In this paper, we discuss common challenges and pitfalls of virtual care implementation in neurology - logistical, technical, medicolegal, and those faced in incorporating health and medical education into virtual care - intending to provide solutions and strategies.

Educating for the Future: a Preliminary Investigation of Doctoral-Level Clinical Psychology Training Program's Implementation of Telehealth Education.

Literature has reinforced the importance of telehealth-focused education to foster provider competence and optimal patient care. As clinical psychology evolves to meet field needs, many have suggested graduate school as an optimal time to offer comprehensive telehealth education. Despite the rapid expansion of telehealth post-COVID-19, the extent of telehealth-specific doctoral-level programming, as well as the foci of available trainings, has remained unclear. To address this gap and inform future work, the current study evaluated doctoral-level clinical psychology training programs throughout the USA. Fourteen doctoral-level training programs completed author-created REDCap-hosted demographic and telehealth training surveys. Pre-COVID-19, three of fourteen programs reported implementing some form of telehealth-focused education, with a majority of the information being viewed as optional targets for instructors. Contrastingly, thirteen programs indicated implementing telehealth-focused education post-COVID-19, with a majority of the information being indicated as mandatory educational targets. Despite increases in educational activities, a large number of programs endorsed a desire for additional telehealth-focused education for students as they transition into future roles. Educational foci, methods of training, and instructor preparation are discussed. While participation was limited, the current study demonstrated positive trends in the development of telehealth-focused education. Nevertheless, there remains an ongoing need for both specialized coursework and a wider range of educational topics. Ultimately, the current study is believed to have provided a preliminary evaluation of the types and foci of telehealth-focused education among doctoral-level clinical psychology training programs.

Closing Disparities in Pediatric Diabetes Telehealth Care: Lessons From Telehealth Necessity During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that prioritizing inclusive telehealth workflows can reduce disparities in access to care.

Transitioning Behavioral Healthcare in Louisiana Through the COVID-19 Pandemic: Policy and Practice Innovations to Sustain Telehealth Expansion.

A statewide COVID-19 quarantine order forced an abrupt shift for Louisiana’s behavioral health providers who provide mental health and substance abuse treatment services. The Center for Evidence to Practice conducted a study of this unprecedented shift to better understand the disruption and continuation of care during early statewide adoption of telemental health. The Center performed a mixed-method assessment including a series of focus groups and key informant interviews followed by a survey of over 300 responding providers. Over 85% of providers reported sustaining behavioral health services using a variety of telemental health strategies. While traditional referral networks and client volume were significantly disrupted, temporary relaxation of Medicaid regulatory and reimbursement policies appeared to be a key facilitator of telemental health adoption and continued services. Shifting to telemental health relied on provider’s quick adaptations, engaging clients with a hybrid of teleconferencing platforms, calls/texts, and socially-distanced in-person visits. Larger multi-clinician providers and evidence-based practice (EBP) providers were better equipped to support the adoption of telemental health. Rural and EBPs providers disproportionately discontinued services. Although many practitioners viewed the original COVID-19 pandemic as a short-lived condition, the recent emergence of Delta and other variants has shown the impact on the BH care system may be lasting. Flexibility across policies and a variety of telemental health platforms are keys to telehealth adaptation. However, the contraction of the client base raises concerns of increasing disparities among vulnerable and hard-to-reach populations if telemental health becomes a sustained approach in response to future COVID-19 variants.

Ensuring Healthcare Resilience &amp; Transformation Through Policy

Are we headed for a capitated risk based model? How will this impact telehealth expansion through policy? How is policy supporting the use of new technology in health care and how important are these changes? What is the impact of policy on privacy, interoperability and access to health data to support health care transformation? If the federal government is focused on advancing racial equity and support for underserved communities how is policy and practice changing to meet these goals? Join panelists to learn more.

Congressional Momentum Builds for Telehealth Expansion

Congressional Momentum Builds for Telehealth Expansion

Congressional Momentum Builds for Telehealth Expansion

Congressional Momentum Builds for Telehealth Expansion

Effects of a nursing home telehealth program on spending and utilization for Medicare residents.

To assess the effects of eLongTermCare (eLTC), a telehealth program implemented by an integrated health system in 45 nursing homes across the Midwest, on the use of acute hospital services and total expenditures for Medicare residents. Minimum Data Set, Medicare fee-for-service claims, and enrollment data from 2013 to 2018. We used a longitudinal difference-in-differences design to estimate the changes in outcomes for treatment beneficiaries before and after participating in the eLTC program, relative to changes for the matched comparison beneficiaries over the same period. We measured outcomes over a 24-month follow-up period, including total Medicare spending, emergency department (ED) visits, hospitalizations, and the likelihood of readmission. Using administrative data, we identified treatment beneficiaries who stayed at participating nursing facilities during the program period and matched comparison beneficiaries with similar baseline characteristics from non-participating facilities in the same geographic locations. For long-term care residents, the eLTC program led to an estimated reduction of 73 ED visits per 1000 beneficiaries (p < 0.01, 8.6% effect) over the two-year follow-up period. The estimated effects for this group were concentrated among beneficiaries who entered the nursing home after program startup, with sizable reductions in hospitalizations, ED visits, and spending. For skilled care residents, the program was associated with an estimated reduction of 85 ED visits per 1000 beneficiaries (p=0.03, 9.7% effect), but had no discernible effect on their hospitalizations or total Medicare spending. Telehealth can be a valuable tool for nursing homes to enhance care coordination and provide timely access to care, leading to lower spending for nursing home residents. Future research needs to explore payment methods that encourage telehealth expansion in nursing homes.

COVID-19 effects on practice: Perspectives of Tennessee APRNs.

BackgroundIn response to the COVID‐19 pandemic, Tennessee's Governor issued executive orders temporarily suspending certain practice restrictions on advanced practice registered nurses (APRN), which expired after 2 months as the pandemic worsened.PurposeThis purpose of this qualitative study was to analyze APRN interview data to evaluate how prepandemic APRN practice barriers, executive orders, and the pandemic affected APRN practice in Tennessee.MethodsFifteen Tennessee APRNs who completed the National APRN Practice and Pandemic study also completed follow‐up interviews via a HIPAA‐compliant Zoom platform. Given the unprecedented circumstances associated with the COVID‐19 pandemic, we conducted a qualitative descriptive study seeking descriptions and unique perspectives of Tennessee APRNs. Consistent with qualitative study design, we conducted an atheoretical study that featured interviews, purposeful sampling with maximum variation sampling, and content analysis.ResultsThe major themes were practice changes, impact of executive orders, and ongoing care barriers. The data revealed that patients, APRNs, and other health care providers were strained in new and profound ways during the pandemic. An underlying theme was Tennessee APRNs' frustration with continued regulatory and other practice barriers despite their state's health and health care disparities and under resourced health care system.ConclusionThese findings indicate the need to improve care access and health outcomes, advocate for full practice authority for APRNs, support telehealth expansion, address transportation deficiencies, and respond to the pandemic‐precipitated mental health crisis.

The role of telehealth in oncology care: A qualitative exploration of patient and clinician perspectives.

The COVID-19 pandemic has accelerated the rapid expansion of telehealth, affording opportunities to study its impact on oncology care. Our qualitative study explored physician and patient perspectives of telehealth in cancer care. Semistructured interviews were conducted with seven physicians and eleven patients, recruited from an Australian hospital oncology department. Two authors independently coded the transcripts with emerging themes identified and refined iteratively in a thematic analysis. Telehealth offered broadened possibilities by allowing continuity of care in the pandemic and revealing advantages of convenience in consultations. It also highlighted core elements of in-person care that were unavailable. These included the information communicated through formal and informal physical examination, the collaboration between patient and physician in shaping outcomes and building rapport and the confidence in decisions made and physician performance. While patients and physicians envisioned the continuation of telehealth postpandemic, logistical steps are necessary to address these challenges. This study highlights the unprecedented opportunities that telehealth presents in widening access to oncology care and simultaneously reveals that it cannot always reach equivalence in quality of care. Further research is required to identify when and for whom telehealth is most acceptable as future care models are considered.

Remote Patient Monitoring in Diabetes: How to Acquire, Manage, and Use All of the Data.

The ability of patients and health care providers to use various forms of technology for general health has significantly increased in the past several years with the expansion of telehealth, digital applications, personal digital devices, smartphones, and other internet-connected platforms and devices. For individuals with diabetes, this also includes connected blood glucose meters, continuous glucose monitoring devices, and insulin delivery systems. In this article, the authors outline several steps to facilitate the acquisition, management, and meaningful use of digital diabetes data that can enable successful implementation of both diabetes technology and telehealth services in primary care clinics.

Age and Racial Disparities in Telehealth Use Among People with HIV During the COVID-19 Pandemic.

The COVID-19 pandemic resulted in widespread telehealth expansion. To determine telehealth uptake and potential sociodemographic differences in utilization among people with HIV (PwH), we examined HIV care appointments at the University of Chicago Medicine, an urban tertiary hospital. Visits between March 15th and September 9th for 2019 and 2020 were categorized as in-person, telehealth, and within telehealth, video, and phone. Differences in visit types were modeled using logistic regression to examine associations with demographics, insurance type, and HIV risk transmission category. Telehealth appointments were more likely for those aged 46–60 versus those 31–45 [46–60; AOR 1.89 95% CI (1.14, 3.15)]. Black race and participants of other races were less likely to use telehealth compared to whites [Black: AOR 0.33 95% CI (0.16, 0.64), other: AOR 0.10 95% CI (0.02, 0.34)]. Future studies should continue to examine potential disparities in telehealth use among PwH, including age and racial differences.