Telehealth utilization has skyrocketed amid the coronavirus pandemic, with hospice and palliative care providers increasingly exploring new avenues of care. Prior to the pandemic, staff burnout was among the factors that helped to drive telehealth forward as it slowly emerged from a few early adopters to become virtually essential during COVID-19.
In March of this year the U.S. Centers for Medicare & Medicaid Services (CMS) temporarily expanded the use of telehealth during the federally declared COVID-19 emergency to help patients, families and clinicians practice social distancing. As CMS allowed health care providers to bill for telehealth services, the flexibilities propelled virtual care to the forefront, with many hospices ramping up their telehealth platforms to ensure continuity of care while limiting spread of the virus.
The coronavirus has continued its grip across the nation, with the U.S. Centers for Disease Control and Prevention (CDC) reporting 3.66 million new COVID-19 cases and more than 241,000 related deaths. With patients and staff alike falling ill to the virus, the pandemic has weighed heavily on the sustainability of a shrinking workforce.
Hospice and palliative care providers have been developing new virtual avenues of care as they work to keep their workforce and high-risk patients healthy. Telepalliative care is among the emerging digital models.
Resolution Care launched in 2015 as a palliative care service provider in northern California. In addition to hands-on care, Resolution developed a community-based telehealth model aimed at supporting the hospice and palliative care workforce, caregivers and the patients and families they serve.
“There is a new and different way to structure a sustainable palliative care one that actually includes the entire 360-degree interdisciplinary team,” said Michael Fratkin, M.D., the company’s founder and CEO, during a Hospice News Elevate podcast. “We’ve been able to actually grow our caseloads and the size of our organization within the renewed sustainability. Staff are actually working in concert with their other parts of their lives. They have figured out how to drop into the functioning working from their homes and working to manage their own sort of bandwidth on a going-forward basis.”
Resolution Care’s telehealth program is a technology-enabled, home-based community palliative intervention that functions as an extra layer of support in addition to the specialty care that patients receive. In addition to enabling communication with patients and families, the model also allows for greater work-life balance among clinicians, a key consideration in an industry in which close to 62% of clinical staff have indicated they have experienced burn out.
The hospice and palliative care space has been plagued with staff shortages.across all disciplines that are expected to worsen during the next two decades. Recruitment, retention and work environment issues will become major priorities for providers as time goes on.
“Burnout was the biggest motivator for me [in building a telepalliative care program]. In order to provide service to people who desperately need it, I thought it would be possible to build out something that really was sustainable for both the people we care for, but also the people providing the care,” Fratkin told Hospice News in the podcast. “It turns out that the equation started with telemedicine, plus value-based economics, plus an inspired organizational culture with a distributed workforce. That equation lands as sustainability. It’s important that we make it clear to our field that telemedicine technologies can be very, very useful.”
As telehealth has expanded during the pandemic, the issue of reimbursement for those services has been murky for hospices, as well as for home health organizations. More avenues for payment may open up for hospice and palliative care providers. Traditionally billed under fee-for-service models, reimbursement for telehealth hospice and palliative services could be reshaped by the value-based payment model demonstrations rolling out in 2021.
Beginning in January, CMS will add a hospice component to the Medicare Advantage Value-Based Insurance Design (VBID) Model. Commonly called the hospice carve-in, the new payment demonstration project could have long-term impacts on the further growth of telepalliative and telehospice care. Slated to start small with only 53 participating plans, the impact of a hospice carve-in remains to be seen as a fee-for-service model continues to hold weight.
“Telephone has been billable for palliative care interventions, but that has been murky ground and just a grey space because we don’t know how long these relaxed regulatory guidelines will last,” Fratkin said. “Fee-for-service is a huge brick wall between the enormous demand and need for this service. We don’t know the aftermath after the public health emergency is lifted or what the circumstances will be. Will they try to put video conferencing back into the genie’s bottle? What we’ve discovered since March has been video conferencing and telemedicine can really make a big difference in lots of areas of medicine. Ours is just one of them, guided carefully downstream, that we can use this work exclusively and provide high-quality palliative care to people in their homes. It remains murky, but in the gray and unpredictable. Video conferencing will persist and be considered to be equivalent to in-patient work with the standard of care determining that quality as equal. I think that will remain free to use video conferencing, even in the fee-for-service structures.”
The landscape of telehealth in hospice care remains uncertain, despite CMS expressing plans in August to make permanent a number of the temporary flexibilities. The agency is evaluating which flexibilities could be made permanent, but the number of rules that will affect hospices remains unknown. Some of these flexibility have included virtual patient visits, as well as the ability to conduct face-to-face encounters for hospice recertification via telehealth.
The use of telehealth for grief counseling and bereavement care has also expanded greatly, often replacing in-person support groups or even children’s summer camps during the pandemic. Providers are increasingly looking ahead toward new possibilities for the next evolution of telehealth. This could involve real-time data-sharing among interdisciplinary care teams, along with expanded opportunities to monitor patients remotely and increased collaborations.
“A payment model should look at local life, focusing on the needs of people,” Fratkin told Hospice News. “Within the palliative care and hospice space, it shouldn’t matter what tool I pull out of the toolbox as long as I’m meeting or exceeding a standard of care. Whether I’m doing it by telephone, video conferencing or in person, if it delivers on the outcome that all stakeholders can agree upon: a better quality of life, better satisfaction, greater support, sustainability for their workforce. If it meets those criteria, then it shouldn’t matter what mechanism I use. The economic structures that support that kind of program development we call value-based payment are what we call outcome-based payment, and they are really built on a kind of agnosticism for this channel of communication or the setting of care. It’s not the setting that matters, it’s the outcome that matters.”