Since the beginning of this ongoing public health emergency, we’ve learned and experienced an astonishing amount.
One important detail we now know from recent studies and data collection is that COVID-19 most aggressively transmits with extended contact in enclosed spaces.1 Those who are at higher risk are adults aged 65 and older (229.7 per 100,000 per CDC)2 and people of any age who have serious underlying medical conditions.3 Given the typical resident population of most skilled nursing facilities, their congregate nature, and the challenges with obtaining personal protective equipment, it is of no surprise that at least one-third of the of COVID-19 deaths in United States are in long term care facilities.4
Given these concerns, providers have incorporated isolation into resident care to minimize infection transmission. Many residents have been restricted to their rooms for over two to three months with limited physical activity and social connection. While isolation may be essential to resident safety, these restrictions have other concerning consequences, such as increased risk for falls, development of wounds, and changes in cognition and mental health to name a few.
Equally concerning is that, per the World Health Organization, “Rehabilitation services have been disrupted in almost two-thirds (63 percent) of countries,” even though rehabilitation providers such as physical therapists, occupational therapists, and speech-language pathologists play such a vital role not only in recovery from illness but also in overall health and wellness.5
Incorporating telehealth into physical therapy, occupational therapy, and speech and language pathology practice offers one solution for patients to continue receiving critical ongoing treatment, even when isolation restrictions may limit the type of services available to them. Initially, the primary limitation preventing skilled nursing providers from providing care in this way was coverage. Now payers are recognizing the importance of telehealth coverage for their beneficiaries in skilled nursing facilities, and at the end of last month, CMS addressed Medicare coverage.
Let’s examine what needs to be considered for successful telehealth implementation in skilled nursing facilities.
Step 1: Know the Rules and Regulations
The telehealth landscape has been changing rapidly. State, federal, and payers have been loosening telehealth restrictions on a day-to-day basis, yet we must still keep in mind that these may only be on a temporary basis. Before you begin implementing telehealth into practice, know the following:
- While most states have moved toward allowing telehealth, it is each professional’s responsibility to be aware of whether their state practice act allows for telehealth. Even if your state is silent, consider contacting your board administrator to seek further guidance.
- Determine whether your state practice allows for telehealth services to be utilized to meet supervision requirements for PTAs, OTAs, and SLPAs as well as face-to-face requirements.
- Ensure compliance with any state-specific consent or documentation requirements.
- Be aware of whether telehealth is allowed by the payer, and if so, be informed of payer requirements such as:
- CPT allowances or restrictions
- Place of Services codes, and originating and distant site requirements
- Billing modifier requirements, which vary per payer (please note: rules for private practice are different than for skilled nursing providers)
- Stay up to date on any changes including any expiration dates or reversal to state/government executive orders surrounding telehealth allowances.
Step 2: Update Company Policies
Policies are an important step in the process when implementing telehealth into your practice. Considerations should include adding or updating policies for:
- Emergency preparedness and response when using telehealth
- Clinical services and care delivery policies for using telehealth in practice and documentation
- Human resources policies for hourly work and liability coverages
- Resident rights policies, especially those related to informed consent and disclosures related to use of electronic communication systems
- Infection control and cleaning of electronic equipment
- Billing and claim management
Step 3: Do You Have the Technology?
Telehealth services are typically furnished using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between you and your patient.
Maintaining the patient/therapist professional relationship and duties when using technology include:
- Preparing ahead of time by checking your hardware such as tablet, computer or phone; internet connection capabilities; video and audio; and HIPAA-compliant platforms
- Enhancing the human connection by using non-verbal communication more and by practicing active, empathetic listening
- Limiting distractions, both self-induced and environmental
- Practicing responsible use of technology, including HIPAA compliance
- Staying aware of your patient’s digital literacy
- Keeping informed of technology troubleshooting strategies
- Making any necessary updates to EMR systems, including modifier codes as well as other state/payer requirement documentation
Step 4: Educate Your Staff
When providing telehealth services, you must balance the benefits of providing treatment in this alternative way against the risk and costs. During our current public health emergency, many therapists have been restricted to certain units within a facility or from the centers as a whole due to isolation restriction. In these circumstances, telehealth services may be better than no services.
Sound critical thinking and clinical judgment remain at the core of determining if telehealth is the best mode for patient care, and you must be able to identify when this mode of service may not be an option. Foundational education prior to delivering this service may add to overall patient safety and compliance with care.
Consider the following topics when educating your teams:
- Emphasize that ethical and professional responsibilities continue to apply.
- Remember that patients in skilled nursing facilities typically require more assistance with care, and consider who can be with the patient during the treatment.
- Identify opportunities to provide telehealth services with non-billable support from PTAs, OTAs, or SLPAs to meet supervision requirements.
- Review what parts of evaluation and treatment may be provided via telehealth services and what requires face-to-face in-person interaction.
- Share professional resources related to telehealth services (see the list at the bottom of this article).
Step 5: Don’t Forget About HIPAA
During this public health emergency, the HHS Office for Civil Rights is relaxing enforcement and waiving penalties for HIPAA violations against clinicians who practice in good faith. However, the Office of the Inspector General and the Department of Justice are continuing to monitor for health care fraud and abuse; therefore, you must adhere to any state laws governing privacy and patient data security.
Considerations for privacy and security of telehealth technology include:
- Using software vendors who offer a HIPAA business associate agreement.
- Using encryption and data monitoring technology. Protected Health Information includes web URLs, IP addresses, device identifiers, and serial numbers.
- Disclosing to your patients the risk of potential breach of confidential information while using electronic communication.
- Documenting that patients have been educated on the risks and benefits of telehealth and electronic communications.
- Obtaining and documenting patients’ consent to participation in telehealth.
- Maintaining HIPAA-secure areas at both the originating site and distant site of service.
Step 6: Celebrate Your Successes
Studies have shown that meaningful recognition fosters an environment of positivity and team building.6 Certainly healthcare providers, more vital now than ever, require resilience during this unprecedented time.
By setting up a system to celebrate your successes, you can also:
- Demonstrate positive outcomes
- Recognize employees
- Improve employee morale and foster engagement and loyalty to the healthcare organization
- Empower patients and residents (and their families)
- Raise customer awareness
- Support advocacy efforts
Telehealth practice is a safe way to ensure that patients, including those in SNFs and other long-term care facilities, continue to receive excellent care, both during the current pandemic and beyond. In addition to those listed below, the MedBridge blog has multiple resources to help you successfully incorporate telehealth into your practice.
Additional Resources for Providers:
- Cascella, M., Rajnik, M., Cuomo, A., Dulebohn, S. C., & Di Napoli, R. (2020). Feature, evaluation, and treatment coronavirus (COVID-19). StatPearls. Retrieved 6/18/20 from https://www.ncbi.nlm.nih.gov/books/NBK554776/
- Centers for Disease Control and Prevention. (2020). COVIDView Summary ending on May 23, 2020. Retrieved 6/18/20 from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/past-reports/06012020.html
- Centers for Disease Control and Prevention. (2020). Groups at higher risk for severe illness. Retrieved 6/18/20 from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
- Romo, V. (May 9, 2020). For most states, at least a third of COVID-19 deaths are in long-term care facilities. NPR. Retrieved 6/18/20 from https://www.npr.org/sections/coronavirus-live-updates/2020/05/09/853182496/for-most-states-at-least-a-third-of-covid-19-deaths-are-in-long-term-care-facili
- World Health Organization. (2020). Rolling updates on coronavirus disease (COVID-19). Retrieved 6/18/20 from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen
- Sherwood, G., Cherian, U. K., Horton-Deutsch, S., Kitzmiller, R., & Smith-Miller, C. (2018). Reflective practices: meaningful recognition for healthy work environments. Nursing Management, 24(10), 30–34.