Feature

The Role of Telemedicine in the Future of Hospice and Palliative Medicine

by Larry Beresford

The expanded use of telemedicine to connect hospice and palliative care teams virtually with their patients during the COVID-19 pandemic has been well-documented. Many services quickly converted most or all of their patient encounters from home or outpatient clinic visits to telemedicine when the crisis hit the United States in March to prevent virus transmission and support social distancing. But what could this shift mean for hospice and palliative medicine in a post-pandemic world?

In the midst of the pandemic, team members other than nurse case managers may not have been welcomed into hospice patients' homes or the facilities in which they resided, and thus could only connect virtually. Telemedicine's convenience factor, encompassing patients who are homebound or would have difficulty getting to the doctor's office because of long drives or arduous trips on public transportation, was magnified by the pandemic-imposed need to reduce personal contact between patients and professionals.

On March 17, the Centers for Medicare & Medicaid Services (CMS) released a declaration aimed at broadening access to telemedicine on a temporary, emergency basis in response to the pandemic. Measures included paying for telemedicine and even telephonic encounters at parity with in-person visits, removing geographic restrictions on where the patient had to be located, and extending the provider categories that could bill for telemedicine.

Discretion was offered for enforcement of HIPAA regulations to include platforms that might not have been allowed before. Flexibility in physician licensure also was expanded to facilitate provision of telemedicine across state lines.

It is expected that the COVID-19 pandemic eventually will evolve into a new normal, although what that will look like is not known. Relaxation of CMS rules under the emergency likely will be revisited. Experts predict that Medicare will continue to cover telemedicine visits that include audio and video. However, telephonic connection with patients likely will lose its emergency coverage, and HIPAA requirements for platform security likely will return.

Added together, the changes would point to a continued significant role for telemedicine in hospice and palliative care, even if the rules will be somewhat less expansive than during the height of the crisis. What will be tele–palliative medicine's role going forward?

Part of Our Future

"We've been clamoring to be able to do telemedicine visits for years, and the pandemic response opened the doors," said Steven Baumrucker, MD FAAFP FAAHPM, medical director of Palliative Medicine Associates for the Ballad Health System serving Tennessee and Virginia and features editor for this publication. "We have a robust palliative medicine program here at Ballad, which includes rural hospitals. But there's no continuity in those rural hospitals if we're not continuously present. With telemedicine, we can reach out to those communities and their doctors."

But tele–palliative care's emergence has also exposed a dilemma, Baumrucker said. "If health care is a right, as some propose, that means access to telemedicine should be a right, too. And it follows that universal access to the internet also has to be considered a right. If we use it, and people get used to it, it will be harder to take it away."

Advocates have emphasized telemedicine's ability to meet the needs of patients who are homebound, frail, or living far from health resources, added Joe Rotella, MD MBA HMDC FAAHPM, chief medical officer for AAHPM. These groups are ideal targets for increasing telemedicine access, but some have trouble accessing remote health services. "The folks you want to serve the most often lie across the digital divide, where people of color and those historically underserved by health care generally also have less access to the internet. That's an interesting paradox. We want flexibility for telemedicine to increase access to our services at the same time we acknowledge inequities in access to these services," he said.

Providers have seen the value of telemedicine in the pandemic. "Now that we see it works, we need more of it, and to make it permanent. But we need to be sure we use it appropriately. Do we know when an in-person visit is safer, or better, than a virtual visit?" Rotella asked. "We haven't researched it enough, except for studies of some limited telehealth application or concept. There's also a need for new quality measures, since most of the quality improvement measures we generally use in palliative care are specific to face-to-face encounters."

Important issues that will shape the future of tele–palliative care include

• access to service, as a distinct minority of Americans lack access to internet connectivity, particularly in rural areas, and even cell service or the necessary electronic devices and the ability to use them
• health policy, with substantial activity in Congress considering, among other changes, whether and how to make Medicare coverage of telemedicine permanent after the current crisis wanes
• physician licensing and credentialing, which some wish could transfer more easily across state lines to allow for delivery of telemedicine visits regardless of the physician's location
• economic factors, which include the dynamics of fee-for-service versus value-based payment models for palliative care services
• handling of more complicated cases, such as patients who have limitations in seeing or hearing, have dementia, face language barriers, or otherwise find the little screen unhelpful—which may require a patient advocate to go into the patient's space to help set them up.

Telemedicine is not new and has been used in parts of the healthcare system for a decade, said Phillip Rodgers, MD FAAHPM, director of the Adult Palliative Care Clinical Programs at the University of Michigan. "At first, it was a way to reach isolated areas, but the patient needed to be in an 'originating site,' which meant leaving their home and going to a doctor's office or hospital for the televisit. This can place an incredible burden on many patients with serious illness and their caregivers," he said.

"What might the post-COVID world look like? I think we'll see different portfolios of services that palliative care teams can provide, with different members establishing contacts with patients virtually and sending other team members into the home in person," he added. Screens can allow multiple parties to participate in family conversations or have group visits with different physician specialties. Tele–palliative care also includes smart phone applications, remote symptom monitoring, and other peripherals to enhance physical exams conducted at distance.

Teaching Telemedicine

Brook Calton, MD, is an outpatient palliative care doctor at the University of California, San Francisco (UCSF) and also directs its home-based palliative care service. "We were already using telemedicine a lot over the past 4 years, but now we're almost entirely virtual, with very few home visits, which are mostly required for people who can't use the technology," she said.

Although UCSF's palliative care service cares for a lot of older and medically underserved patients, it has found that it usually can connect them to a telemedicine platform, in contrast with affiliated programs at the San Francisco VA Medical Center and Zuckerberg San Francisco General Hospital and Trauma Center, which more often encounter hurdles including language barriers or patients who don't have a home, smart phone, or data plan. Also contributing to UCSF's success has been administrative support staff, who not only believe in the power of telemedicine but also have the time to spend with patients and families, walking them through technology set-up and troubleshooting when needed.

Calton recently received grant funding from the Cambia Foundation to develop education for medical trainees on how to most effectively host virtual serious illness conversations with patients and families. The curriculum will include synchronous and asynchronous didactic material followed by simulated training experiences with a standardized patient, played by an actor, on a virtual visit.

Calton noted that prior to COVID-19, very few medical trainees or practicing clinicians had received formal training on how to provide clinical care by telemedicine. "A lot of things we do when we see the patient in person carry over to telemedicine," she said. "However, there are certain practices—like letting the patient know where you're sitting, asking where they're sitting or who else is in the room, or ensuring a private space for sensitive conversations—that are unique to telemedicine and must be taught."

More data on telemedicine and national consensus on best practices are needed to support telemedicine curriculum development, she added. Questions include: What is the difference between in-person and virtual telemedicine visits? Is the communication different? Are we engaging in different clinical activities during in-person versus telemedicine visits?

Ashwini Bapat, MD, who previously served as a palliative care physician at Massachusetts General Hospital in Boston, is the lead author of an abstract presenting five models of tele–palliative care to bridge the access gap submitted for the 2020 Annual Assembly of Hospice and Palliative Care. The Assembly was cancelled because of the pandemic, but her presentation is slated for the next Assembly in 2021. Bapat now lives in Portugal, where she recently relocated with her family.

Telemedicine, in theory, does not require the provider to be in the same country as the patient, but the provider needs to be licensed in the state where the patient lives, she said. "Although there are certain realities regarding reimbursement and licensure—for instance, providers outside the United States can't bill Medicare and Medicaid—some telemedicine companies are more open to working with physicians outside of the US."

Currently, Bapat wears two hats. "I'm cofounder of Hippocratic Adventures, an online community that educates US-trained physicians in how to practice abroad. And I'm starting a new tele–palliative care company to target areas where access to the palliative care workforce is not universal—particularly now, when more patients have used it. It's the perfect time to start a company to link patients in need with doctors, wherever they are based."

Ashwin Kotwal, MD MS, assistant professor in the division of geriatrics at UCSF, has been building a tele–palliative program for the San Francisco VA Medical Center, serving patients who are homebound or in rural locations across Northern California. He helped the organization go from zero to nearly all tele–palliative consults.

"There's so much conversation happening right now about telemedicine," Kotwal said. "We have to make sure telemedicine is not just a substitute for in-person visits, but that it adheres to standards. Not enough has been done to build consensus on what those standards should be."

The standards should address best communication practices, such as how to convey information, support people emotionally, and involve other stakeholders, he said. "When I'm communicating in person, I'm listening, processing the overall mood in the room, seeing if the patient is not responding or is crying. In a virtual visit, I have to be really intentional to try to normalize the experience. I can't put my arm on their shoulder. I also have to be careful about delivering bad news, especially when the video lags. Many communication skills don't translate to the virtual encounter, but the principles still stand.

"What I see moving forward, I hope, is a combination approach, both tele-visits and seeing people in person, coordinating with other medical services, establishing rapport, and thinking through technology integration," Kotwal added. "There are practical ways to integrate these two models, and to think about tele–palliative care, what it contributes in itself—we can't just think one-dimensionally about it. Palliative care is critically important to overall health care and needs to be integrated sooner."

Some of the hurdles to accepting tele–palliative care are specific to the technology, but others are about palliative care in general, public understanding of the role of palliative care in serious illness, and even about the term "palliative care," Kotwal said. "We've shown that palliative care improves quality and healthcare outcomes. Now we need to see if we can translate those gains to tele–palliative care. And if physicians are noting that patients are unable to access telemedicine, that can be a window to other unmet needs." There are adaptive technologies for limitations in hearing, vision, or cognition, he said. But sometimes you just need to have someone there in the room with the patient.

An Inevitable Trend

For Michael Fratkin, MD FAAHPM, founder, CEO, and physician for Resolution Care Network, a community-based palliative care service based in Eureka on California's largely rural North Coast, technology and economics favoring the wider adoption of telemedicine have become so well aligned in the past 12 months, especially during the height of the pandemic, that the evolution has felt inevitable.

Fratkin is a true believer in the benefits and opportunities for telemedicine in palliative care and was among those who pioneered its application for palliative care patients. His service converted from 40% tele-visits to 100% when the pandemic hit the US in March. "There's no way to expect that all the experience we've gained will be bottled back up. The lessons can't be unlearned," he said.

The Resolution Care team, which employs four physicians—Fratkin and another in California, one in Oregon, and one in Louisville, KY—has mostly overcome the challenge of uneven connectivity with the help of community workers who coach the patients and families.

For Fratkin, a bigger hurdle is the inadequacy of fee-for-service reimbursement for palliative care services because the system has only gradually evolved toward value-based and population health–based models. Fee-for-service coverage of palliative care customarily only covers physician or advanced practitioner visits, which then may be used to subsidize the expense of the whole palliative care team, including nurses, social workers, chaplains, psychologists, pharmacists, and others, he said.

"As we buy into palliative care as a team-based, person-centered intervention, the idea that we need to generate sufficient physician billing to cover the whole team can cause great stress for the team. Depending on physician billing leaves programs generally underfunded to provide a comprehensive integrated approach, whereas value-based approaches allow for negotiation to cover the full team," he said. "Telemedicine is part of the solution going forward. Our value-based contracts are agnostic as to the mechanism by which we connect with families, whether it's in the office, the home, or virtually."

Fratkin said 94% of the team's visits are covered by value-based contracts, based on per-member-per-month or case-based payment. Most of these patients are covered by California's MediCal (the state's Medicaid program) managed care plans, stimulated by SB1004—a 2016 state law directing Medi-Cal managed care plans to provide access to palliative care.

"We are thriving and growing, and our health plan partners are over the moon," he said. "They want to reward us for managing the needs of the plan's seriously ill patients outside of the hospital. We have focused on educating our referral sources to know the eligibility of the various health plans. Other organizations may be more nimble in fee-for-service billing, but we're more interested in Medicare Advantage and accountable care organizations and others with whom we can make a deal.

"My vision for telemedicine after the pandemic is that palliative care will be better understood, better integrated, and something that people with serious illness will come to expect. This is what our service has been working toward for the past 5 years. Our vision is to provide this kind of compassionate care for everyone who needs it, regardless of where they live, efficiently and safely."

Larry Beresford is a medical journalist in Oakland, CA,with a strong interest in hospice and palliative care.

Insights From The Field

Learn more about how technology is affecting hospice and palliative care clinicians. Visit aahpmblog.org to read AAHPM member Mei-Ean Yeow's firsthand account of conducting guided imagery practices on virtual platforms and the results among four patients with COVID-19.

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