Providing therapy to patients in a skilled nursing setting is the definition of a hands-on task. The nature of that task did not change over the course of the COVID-19 crisis, which forced a slew of occupations to pivot to virtual formats.
While the Centers for Medicare & Medicaid Services (CMS) issued widespread waivers for telehealth coverage in the early days of the pandemic, it took longer for the agency to give physical, occupational, and speech therapy practitioners the ability to provide Medicare-covered telehealth services.
The resulting flexibilities allowed therapists to continue to provide care while navigating some of the COVID-19-induced challenges, such as therapists needing to quarantine after an exposure. And they made some aspects of care, such as conducting patient evaluations, much easier.
In turn, therapists are strongly advocating for the telehealth provisions that allowed them to offer care to be retained even when the COVID-19 emergency comes to a close.
This would include adding the therapy codes used by therapists to bill for services to the permanent list of codes that CMS deems eligible for delivery through telehealth, Mark Besch, the chief clinical officer at the Frisco, Texas-based Aegis Therapies, told Skilled Nursing News.
While this is a step therapy providers are lobbying for and would welcome, some adjustments are needed to provide services with telehealth in the most optimal way.
“I think first and foremost, we need some well-established guidelines and protocols as an industry,” Tammy Tuminaro, the CEO of Baton Rouge, La.-based Century Rehabilitation who has more than two decades of therapy experience, told SNN. “I know that some of the professional organizations have been very, very helpful when it comes to telehealth, and very involved in the lobbying and being proactive in trying to get their members access to this, as well as keeping them informed. But there really are no established guidelines just yet.”
Integrating telehealth into therapy services
Tuminaro and other therapists were united in the opinion that telehealth is a critical tool for therapists to have at their disposal, even outside the constraints of the COVID-19 pandemic that necessitated its use.
When SNFs had to implement near total-lockdowns in the start of March last year, some therapists were told that the therapy services were off-limits, though therapy care plans still needed to be followed even in lockdown. CMS did allow therapists to provide virtual check-ins and so-called “e-visits,” but those were not reimbursed at the same rate as true telehealth visits.
Some states issued waivers that said supervisory visits of a therapy assistant by a therapist, for example, could be allowed through telecommunications, Besch explained. But “telecommunications” is a broader term than telehealth, with different regulations, he noted.
Telecommunications could also be used to set up a session with a therapist when therapists were either not allowed to enter a unit or were strictly capped for infection control purposes, he said.
“An occupational therapy assistant, for example, on the unit could facilitate – in other words, be with the patient and help them connect via a device and have a speech therapist who’s in the facility but in a different room actually conduct the treatment session,” Besch explained. “That’s not considered by CMS to be truly telehealth, … but it allowed therapists to reach more patients.”
The waivers allowing therapists to provide Medicare-covered telehealth visits, when they came, allowed therapy providers some critical avenues for offering care safely in the pandemic. Functional Pathways, a therapy provider based in Knoxville, Tenn., with a presence in 20 states, would use telehealth to conduct evaluations and work around staff being restricted to particular areas of facilities.
“We would utilize it in some cases to initiate care, perhaps, to conduct the evaluation,” Derhonda Thomas, vice president of operations at Functional Pathways, told SNN.
A therapist conducting either an evaluation session or treatment session through what Besch called “pure telehealth,” where the therapist is truly off-site and connecting with the patient through either a device or a platform, was the most common use of telehealth for Aegis, he told SNN.
Century also found telehealth useful in providing evaluations and treatment as needed, particularly in situations where resources were limited by either the pandemic or facility locations. Like both Functional Pathways and Aegis, Century’s therapists were often limited in their scope of movement to either one facility or a unit within the facility.
But even with evaluations and treatment possible when a therapist was offsite, Century found that it was usually necessary to have someone in the room with the patient, whether that was a rehabilitation technician or a nursing assistant, Tuminaro said. And that cuts into the efficiencies that telehealth might be able to offer, at least when it comes to the provision of therapy.
“I think when the thought of telehealth first came out, really early in the pandemic, I think the first thought process for some providers was: This is going to be a great tool, because it’ll actually be less costly. We will be able to provide services more efficiently from a financial standpoint, because we don’t have to ship therapists all over these little rural communities,” Tuminaro said. “However, we’ve now found that in many cases, it’s more costly.”
For this reason, she would like to see some kind of reimbursement or compensation for the person who is at the other end of the device with a patient in the SNF setting, because with two people needed to provide the care, the costs are still significant.
This need for a second person present is often due to SNF residents or patients having trouble with the technology required for telehealth visits. It is a need that Aegis, Functional Pathways and Century all viewed as a challenge over the course of the pandemic.
It became a focal point for Aegis in terms of the procedure of connecting with patients for a visit, Besch said.
“We have a requirement that our therapist has to receive verbal confirmation from the [patient] for every visit to consent to conduct this visit via telehealth,” he told SNN. “If there’s anybody else in the room, meaning the second person, the helper, or if a family member were there, we ensure that we say, ‘I’m aware that so-and-so is in the room with you, are you okay with proceeding with the session and communicating with me in this manner with that person present? It’s just really important that we do that every single visit, and that we document that.”
Developing those protocols early was critical for all the providers SNN interviewed. One of the very first steps for Functional Pathways was pulling in the clinical team to come up with policies and protocols for the utilization of telehealth, Thomas said. It also wanted to ensure HIPAA compliance for the technology, which necessitated sorting out the logistics of the best platform for providing treatment.
“We initiated training with our team, made sure that each of the therapists who were utilizing that method [of treatment] had gone through our training and been checked off, if you will, as being competent,” she said. “So we wanted to take that part very seriously, to make sure that we felt comfortable with the caliber of the care we were giving.”
While telehealth was useful for offering services, the predominant mode of therapy delivery remained face-to-face, she said. While Thomas did not have specific numbers, she told SNN that while Functional Pathways used telehealth “quite a bit” at the peak of the pandemic, most care was face-to-face.
Aegis Therapies peaked at 2,300 telehealth visits in December 2020, with just over 10,000 total, Besch said.
All of the providers agreed that telehealth was a necessary part of the therapist toolbox, particularly during the pandemic. But in Tuminaro’s estimation, the regulatory hurdles to telehealth in therapy were the biggest challenge.
Besch noted that clearing some of the regulatory hurdles took multiple steps from CMS: the first hurdle being to get the codes used by therapists added to the list of codes CMS deems eligible for telehealth, then the second being the list of clinicians considered eligible for telehealth. At the start of the pandemic, that list did not include physical and occupational therapists.
The codes that made telehealth possible for therapists will remain eligible through the end of 2021, but the ability of therapists to provide services through telehealth will end when the COVID-19 public health emergency ends, unless some action occurs, Besch said.
“We’d like to see both of those,” he said. “In other words, the codes added permanently, as well as the therapists designated permanently as eligible providers of telehealth services.”
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Telehealth for Therapists Could Change Care for the Better, But Refinements Are Needed - Skilled Nursing News
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