Planning for a Sustainable Telehealth Program

Telehealth utilizes electronic information and telecommunications technologies to support and promote health care services regardless of distance.¹ The types of care and instruments involved in telehealth can be quite varied, including everything from enabling clinicians at remote locations to check on patients via robots, to videoconferencing, to physicians monitoring patient vital signs in real time via telehealth platforms.

Telehealth has greatly improved access to and utilization of health care, particularly for rural and underserved areas. The Agency for Healthcare Research and Quality (AHRQ) summarized² the rapid expansion of telehealth use during the COVID-19 pandemic, noting that "[t]elehealth has been in its adolescence for decades, but the COVID-19 crisis accelerated its maturation within a matter of weeks." Older adults (OAs) were included in the growth of telehealth; according to one survey³ in August 2020, telehealth use grew by 300% during the pandemic among those aged 64 years and older.

Despite the rapid expansion in telehealth usage, some aging services providers experience barriers to implementation and usage. These can include OAs’ lack of comfort with using technologies that enable telehealth or physical or cognitive limitations to their doing so; in residential care settings, these residents may be dependent on the organization for access to the internet and devices.⁴

This article describes ways in which organizations can best plan new telehealth programs, update their existing programs, and ensure that all laws and regulations regarding telehealth are understood.

For facilities that do not have an established telehealth program and are planning to start one, or for those that are looking to expand an already-existing program, a well-designed plan for implementation is necessary for success.

One of the first steps to developing a successful telehealth program is to assemble a multidisciplinary team to manage the project. The team should comprise staff from the medical director's office, nursing, information technology, risk management, finance, operations, human resources, and quality improvement teams. The team should also include major department heads and any identified individuals who are in positions to capture the attention of senior organizational representatives.^5,6

Even after a telehealth program has been implemented, organizations should periodically reevaluate their communities' needs, as new health care needs may arise (eg, as the population of the community ages, there may be new opportunities that telehealth can address) or advancements in telehealth technology may become more accessible.

Assess Readiness

Next, the team should assess and confirm the organization's readiness for telehealth. See "Telehealth Readiness Checklist"  for an example of an evaluation checklist.

Facilities should review finances to support operations and reimbursement for telehealth services before implementing a telehealth program. Issues to consider include any costs related to the start-up of the program, such as for equipment, associated maintenance, software vendor contracts, necessary software, staff training, and credentialing and licensing.

Telehealth programs are sometimes initially paid for by grants; however, ensuring that there is a continual source of funding for the telehealth program is essential to its success. Another piece of financial information to understand is reimbursement for telehealth by both public and private payers. Evaluating a return-on-investment for the program may be difficult but can include potential reductions in hospital readmissions and increases in preventive and primary care.^5,6

Before implementing a telehealth program, risk managers should work with legal counsel to become well versed in any state laws and regulations that may affect the program. Reimbursement can also prove to be challenging, as some insurers impose limits on which telehealth services are covered.

Risk managers should be aware that regulations and reimbursement policies are rapidly changing, especially due to the public emergency declaration. Risk managers should also establish a program to continually monitor changes and respond to them appropriately.

Despite the benefits of telehealth and the potential to ultimately reduce health care costs, organizations with limited resources may be hesitant to implement telehealth programs due to the costs and resources necessary for an effective program—particularly upfront costs such as purchasing audio or video equipment and ensuring IT support. However, low-cost options for telehealth technology are more widely available than they have been in the past. Health care organizations do not necessarily need to purchase high-cost, sophisticated videoconferencing equipment to effectively implement a telehealth program; organizations with limited resources can often accomplish their goals using a basic computer, mobile device, secure internet connection, and webcam.

Obtain Staff Input
Before purchasing any telehealth equipment, organizations should obtain input from staff who will regularly use the system to ensure they are comfortable using it. They should also verify that the equipment will be compatible with the electronic health record system.

Plan for Implementation
Many start-up IT costs can be offset by available federal grant and funding opportunities; however, facilities should keep in mind that seeking grant funding may impose requirements on the facility for meeting certain timelines, and the facility should have a plan for covering costs once grant funds are exhausted.^5,6

Part of this planning includes evaluating the space in which telehealth encounters will occur, if applicable. For example, some considerations to ensure adequate video consultations include the availability of the following:⁷

• A quality webcam on the computer
• A wired internet connection (wireless systems are generally less reliable)
• Adequate sound quality
• Adequate lighting so that the patient can see the physician clearly
• A simple background, without distracting images or objects

Additionally, provisions should be made in the event that equipment malfunctions; without real-time assistance to fix any issues (eg, loss of audio or video) or an alternative plan, appointments may need to be rescheduled. Equipment testing should also be incorporated into work processes to ensure continued functionality.

Ensure System Security
The organization will need to ensure the use of secure technologies that are not vulnerable to hackers and that visits still meet all HIPAA privacy and security requirements.

Proper training on the use of telehealth technology and on the organization's telehealth policies is essential to ensuring its use. Providers and patients that are comfortable with the technology are more likely to take advantage of it.

Telehealth system developers and software vendors typically offer training on how to use their programs. When planning to implement a system, determine what array of staff training is offered through the system's vendor, including factors such as a timetable for training, system support availability, what form the training will take (eg, webinar, in-person training), and whether any additional resources are available for staff training.⁸ Staff should be encouraged to do practice runs with the system before using it to treat patients.

The organization may also want to develop an frequently asked questions list of common issues encountered in the telehealth system and provide insight on how to address them. Staff should be made aware of the document and where it is stored, and responsibility should be assigned for keeping the list up to date.

Training should continue to be offered on a regular basis to all providers (eg, upon hire, when there are significant changes to the system, and yearly as a refresher), and regular check-ins should be performed to address any issues staff may have with the telehealth platform.⁸

Training strategies may include the following:⁹

• Developing a telehealth educational curriculum for doctors, physician assistants, nurse practitioners, and nurses
• Developing "telehealth encounter preparation" guidelines that outline what a common interaction might look like
• Developing standard call-flow format and triage processes for nurse lines or medical call centers
• Prioritizing patient needs before they reach the doctor or nurse to streamline workflow (eg, who needs to be seen first?)
• Expanding patient education materials to include common complaints

Educate Patients
In addition to physicians and staff, facilities will need to ensure that patients are open to the form of telehealth being offered. A successful telehealth program needs patients who are aware of the program and who are willing to use it. The organization must not only promote its telehealth program, but also educate patients on how to use it.

Organizations that have implemented telehealth programs should reach out to patients to let them know about the program and to educate them on how to use the program, the program's potential benefits, established security measures, and the program's cost to the patient. Strategies for patient education include the following:¹⁰

• Identify individuals who have the interest and capacity to participate in telehealth visits.

• Explain the benefits (eg, cost savings, shorter wait times for appointments). In addition, physicians should define which conditions can be treated virtually and which will necessitate an in-person visit.

• Assure patients that their data is protected, secure, and private.

• Walk patients through a virtual visit and consider doing a trial run with the patient. Use this as an opportunity to answer any questions or address any concerns.

Additional education may also include discussing the limitations of telehealth, including potential technical problems.

Despite the rapid expansion in usage of telehealth, some organizations still experience barriers to implementation and usage. Other organizations that wish to continue using virtual health technologies post pandemic have identified the need for improvement of their current systems. Even organizations with fully implemented programs are dealing with rapidly changing laws and regulations or regulations that will expire at the end of the publicly declared emergency. By securing leadership support and the buy-in of frontline staff, planning for infrastructure and reimbursement, and assessing patients' comfort and providing education to meet their needs, providers can improve their likelihood of improving access to care and improving patients' experiences.