Kurt MelkelzTelehealth utilization soared during the COVID-19 pandemic. The Centers for Medicare & Medicaid Services (CMS) released waivers for home health, palliative care and hospice organizations to use more telehealth during the public health emergency—protecting patients and staff from exposure.

But there’s still work to do.

Dr. Kurt Merkelz, chief medical officer of Compassus, sat down with us to share why telehealth matters for hospice patients. Compassus provides a continuum of home-based services, including hospice, home health, home infusion and palliative care. The company has 200 locations in 30 states.

HOMECARE: I think of hospice as being high-touch, hands-on care. Why is telehealth important for hospice patients?
Kurt Merkelz: There’s no question that hospice is a high-touch, personal care service. We deal with individuals during one of the most intimate periods of their life. Hospice is a home-based service, and leveraging telehealth can be a cost-effective means of supporting the health care system. Providing a structured telehealth visit can also meet the needs of the patient—delivering care focused on comfort, safety and quality of life.

The real possibility with telehealth is having a structured methodology to provide chronic care management designed around in-person visits. It’s not about just showing up, but what you do when you enter a patient’s home. This really gets to the fundamental aspect of providing telehealth care. Individuals are struggling in their homes. We’re not talking about replacing in-person visits but using telehealth as additive to the care plan. Utilizing a certain level of in-person care, a certain level of video conference and perhaps mobile health applications—where an individual patient can key in on how they’re feeling and send that communication to the provider—the care experience can be enhanced. I think there’s so much potential that we’re going to be seeing with asynchronous communication—non-live, in-person activity where, for example, we can take pictures of wounds, do wound management and have it reviewed by the physician at a later point in time.

I think implementing mobile health reporting is a very exciting aspect of telehealth. It really allows patients and families to have more opportunity for monitoring and responding to their personal needs. Home-based care of any sort is empowering for patients, especially individuals dealing with terminal illness who have lost so much autonomy. By bringing forth various aspects of telehealth, time savings can be secured both for the individual patient and for the provider, and it allows for the potential for a more structured and outcome-focused interaction.

HC: How did telehealth in hospice and home health evolve during the pandemic?
KM: We had a high priority shift to improve our capacity for communication, both within and outside our organization. Infection control practices had to be done in accordance with recommendations from the CDC regarding COVID. We couldn’t all be in a room together to discuss the patient. In long-term care, we found ourselves locked out of many facilities; we couldn’t even get in to see patients whose care we manage—we had to put practices into place to make sure the interactions we were having, certainly those that were only filling a regulatory responsibility, were done remotely. So, we implemented policies, procedures and guidelines that would facilitate interaction and facilitate discussions by each of the members of the care team, from the social worker to the chaplain and the nurse, to uncover the patient’s issues.

The CMS waivers came out shortly after we put our telehealth practices in place. But we didn’t have a choice [in implementing telehealth]. First, as I mentioned, we literally could not get into some buildings. Second, we had staff that said, “Look, this isn’t safe, I’m worried about my health risk.” So we put in place policies and procedures, then the CMS waivers came along. Now the whole genie’s out of the bottle. That’s what the pandemic helped accelerate. The real opportunity lies in how we leverage technology to benefit the patient and the payer. There are a lot of regulatory requirements that go into care delivery, and telehealth can support that.

By putting together a platform utilizing telehealth we can support patients in what they need. Now the nurse can support what’s most important—if somebody is in pain, I want that nurse there to see that patient in person. But if I just need to educate the patient on using their inhaler, let’s do that by a telehealth visit. Telehealth care is a powerful tool in our care delivery toolkit and can be utilized more effectively to deliver outcomes; and this should be recognized by auditors and payers as an important tool. 

HC: How does telehealth increase access to hospice services?
KM: By supporting the services that need to take place more efficiently and effectively. The interdisciplinary team members can connect in a more efficient time setting; extended families can all come together for the same meeting and bring up their issues; training sessions can take place using virtual technology. It allows for more opportunity to access the whole wealth of services that we provide—the chaplain services, the social worker services. Hospice and home health provide a 24/7 type of benefit, but by using telehealth, providers can better meet the needs of families at the most important time.

Bereavement is an excellent example. After someone passes, it’s still our responsibility to continue to counsel and support families. When does the grieving person need that support? They may not need it at 2:30 in the afternoon. Maybe it hits them hard late in the evening. I may not need an in-person visit, and by leveraging telehealth, I can potentially support, listen, and validate emotions. COVID has allowed us to explore and develop additional means to reach out and have different ways to connect available to individuals and to get those services that they need. 

HC: In what ways were agencies reimbursed for telehealth visits? How could that change after the end of the PHE?
KM: Hospice is paid on a per diem basis. The services that are provided are not separately billable. Palliative care visits by nurse practitioners or physicians are predominantly fee-for-service, and again were difficult due to lack of access. It has been a challenge to drive innovation under difficult circumstances. There’s a lot of a need we recognized early on; with goals of care conversations, advanced care planning—trying to make sure that patients receive care where they want it when they want it. In addition, uncovering socioeconomic determinants of health, and connecting individuals to needed services is complex. Telehealth can greatly support all of these efforts. Prior to the waiver, Medicare would only pay for telehealth for palliative care on a limited basis, generally just for individuals who were designated in rural service areas. 

The waivers opened up access. Palliative care providers were reimbursed the same visit rate on the telehealth visit as they were for a live visit. After this waiver goes away, we’re certainly going to see that change. But, even outside of the waiver removal, we’re already seen a significant change in utilization—it’s decreasing. Telehealth utilization has fallen nationally. I saw 15% to 20% just in the first two months of the year. And there was a common thread. I was asking, “Why are palliative care nurse practitioners not making telehealth visits?” And it came back to individual preference. Providers said they just preferred the home visit.

And I think it comes back to the lack of understanding of how to drive an effective virtual encounter. We thrust clinicians into using telehealth platforms across [the continuum of care]. But nobody was trained in how to set up the meeting, what questions to ask, how to set up the other end so the patient is ready and responsive. So clinicians are wanting to go back to the live visit because they don’t know how to do a quality virtual visit. We’re just getting started; so much more can be done because we haven’t trained people on how to effectively conduct telehealth visits.

HE: What’s next in the evolution of telehealth?
KM: So where does it go? I’m passionate about health care and medicine, so I can make the argument that it’s probably a little too much too soon. And I think right now we’re at risk of decreasing patient care. What we have now is medical billing opportunities with uncertain value of what it means for the patient, but there’s real opportunity. 

There are opportunities for us to develop effective platforms to solve difficult care needs for patients, and one important problem is access—health equity for all members of our communities, trying to get the right resources to them across the board. We need new policies, new procedures. We need to make sure we’re HIPAA compliant in how we conduct virtual meetings; our clinicians need training in how to prepare for a meeting, how to document the meeting, how to code for the meeting, how to bill the actual interaction. [We need] checklists for connectivity and checklists for interaction. 

There are so many opportunities for telehealth beyond just this two-way, audio/visual connection. But one thing that absolutely has to be next is CMS support. The government has to recognize the importance of our use of technology and what we’re trying to do. Hospitals received billions to upgrade and integrate their technology, and right now every single home health and hospice organization is trying to do it at their own expense. There has to be interoperability. How else can we leverage all this opportunity to result in Medicare cost savings, reduced waste, increased efficiency? We can’t do it unless we can properly scale technology. And others, like hospitals, have received support to do this. CMS has to recognize home health and hospice needs to receive this support. So, what happens now after the pandemic? We’re just getting started.