Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID-19 Public Health Emergency

Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID‑19 Public Health Emergency Jiani Yu, PhD1 , Hyunkyung Yun, MS, MSW1, Mark A. Unruh, PhD1, Eloise M. O’Donnell, MPH1, Paul R. Katz, MD2, Jessica S. Ancker, MPH, PhD3, and Hye‑Young Jung, PhD1 1 Department of Population Health Sciences, Weill Cornell Medical College, New York City, USA; 2Department of Geriatrics, Florida State University College of Medicine, Tallahassee, USA; 3Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, USA ABSTRACT BACKGROUND: Despite expanded access to telehealth services for Medicare beneficiaries in nursing homes (NHs) during the COVID-19 public health emergency, information on physicians’ perspectives on the feasibility and challenges of telehealth provision for NH residents is lacking. OBJECTIVE: To examine physicians’ perspectives on the appropriateness and challenges of providing telehealth in NHs. PARTICIPANTS: Medical directors or attending physicians in NHs. APPROACH: We conducted 35 semistructured interviews with members of the American Medical Directors Association from January 18 through January 29, 2021. Outcomes of the thematic analysis reflected perspectives of physicians experienced in NH care on telehealth use. MAIN MEASURES: The extent to which participants used telehealth in NHs, the perceived value of telehealth for NH residents, and barriers to telehealth provision. KEY RESULTS: Participants included 7 (20.0%) internists, 8 (22.9%) family physicians, and 18 (51.4%) geriatricians. Five common themes emerged: (1) direct care is needed to adequately care for residents in NHs; (2) telehealth may allow physicians to reach NH residents more flexibly during offsite hours and other scenarios when physicians cannot easily reach patients; (3) NH staff and other organizational resources are critical to the success of telehealth, but staff time is a major barrier to telehealth provision; (4) appropriateness of telehealth in NHs may be limited to certain resident populations and/or services; (5) conflicting views about whether telehealth use will be sustained over time in NHs. Subthemes included the role of resident-physician relationships in facilitating telehealth and the appropriateness of telehealth for residents with cognitive impairment. CONCLUSIONS: Participants had mixed views on the effectiveness of telehealth in NHs. Staff resources to facilitate telehealth and the limitations of telehealth for NH residents were the most raised issues. These findings suggest that physicians in NHs may not view telehealth as a suitable substitute for most in-person services. Received October 12, 2022 Accepted February 7, 2023 KEY WORDS: telehealth; long-term care; post-acute care; nursing homes J Gen Intern Med DOI: 10.1007/s11606-023-08087-6 © The Author(s), under exclusive licence to Society of General Internal Medicine 2023 INTRODUCTION Prior to the COVID-19 public health emergency (PHE), restrictions on Medicare payment for telehealth visits posed a major barrier to the provision of telehealth services to postacute and long-term care residents in nursing homes (NHs).1 Increased Medicare coverage of telehealth during the PHE, including interactive audio and video visits, remote patient monitoring, and brief check-ins, along with the inherent benefits of remote care allowing NH residents to be treated in place while reducing the risk of COVID-19 transmission, have provided new opportunities to examine telehealth use in NHs.2 Despite the potential benefits of telehealth allowing for timely consultations,3 potentially reducing avoidable hospitalizations,4,5 and facilitating frequent touch points for residents across multiple parties (e.g., patient, family, physician),1 its use requires NHs to have the technological infrastructure to deliver telehealth visits, and staff and clinician time to be diverted from in-person care.6–8 Increased coverage of telehealth services may also lead to more unnecessary or duplicative services and fragmented care if patients’ care needs cannot be adequately met through telehealth.9,10 Using technology may also be challenging for older patients and for patients with cognitive impairement.11 Furthermore, while telehealth was useful during the early months of the PHE, it is unclear whether telehealth provision will continue to be prioritized in NHs. While studies on the provider perceptions of telehealth use in NHs prior to 2020 focused on interest in telehealth use or on voluntary early adopters,12–14 who tend to be more well-resourced than later adopters,15 the population of NHs utilizing telehealth changed substantially during the PHE. As a much wider array of NHs deployed remote care since 2020, it is important to understand whether Vol.:(0123456789) Yu et al.: Telehealth in Nursing Homes During COVID-19 perceptions of telehealth previously studied in the early adopters apply to a broader sample. We conducted semistructured interviews with physicians experienced in NH care to examine their experiences with telehealth during the PHE, their perceptions on the value of telehealth, and barriers and facilitators to telehealth in NHs. To our knowledge, this is the first paper focused on physicians’ views of telehealth in NHs during the pandemic. METHODS Setting and Study Population We conducted semistructured interviews with physicians experienced in NH care, defined as physicians who currently or previously served as medical directors and/ or attending physicians in NHs. The study sample was recruited from an overall list of 1528 members of the American Medical Directors Association (AMDA) – The Society for Post-Acute and Long-Term Care Medicine, who were surveyed about their primary facility, demographics, and specialty area as participants in a project on NH medical staff organization.16 Among survey participants (566 respondents), 421 physicians provided enough data to be considered for our study sample.16 After initially emailing these 421 physicians, we received 69 responses within a week and stopped enrollment. Among the 69 respondents, we purposively selected 35 physicians in the Northeast, Midwest, West, and South, in order to increase variations in perspectives. The participant characteristics in Table 1, including region of the country they were located in, indicates that broad representation was achieved. Table 1  Characteristics of the 35 Study Participants Physician Characteristics Physician specialty Internal medicine Family medicine Physical medicine and rehabilitation Geriatrics Other Employment type Private practice Government Academic institution Private organization contracting with a nursing home to provide care or care management services Nursing home Female Location Northeast Midwest West South No. (%) 7 (20.0) 8 (22.9) 1 (2.9) 18 (51.4) 1 (2.9) 12 (34.3) 4 (11.4) 4 (11.4) 14 (40.0) 1 (2.9) 17 (48.6) 7 (20.0) 6 (17.1) 11 (31.4) 11 (31.4) JGIM Data Col (...truncated)