Views on Palliative Care via Telehealth: A Virtual Panel Discussion

To say that palliative care teams have been through a lot over the past year and a half is quite an understatement. The COVID-19 pandemic, decision-making in the face of uncertainty, significant increases in demand, and emotional challenges are just the start. Through it all, palliative care teams have been doing their best to deliver high-quality care, virtually. Now that the dust is starting to settle, CAPC spoke with a panel of four palliative care program leaders about their telehealth experiences, to explore what the field has learned so far and what best practices might emerge. (For background, their programs are housed in an academic medical center, a hospice, a regional cancer center, and an independent medical practice.)

The palliative care leaders who were interviewed all used telehealth in some capacity prior to the pandemic. However, when COVID-19 restrictions hit, they all responded with a rapid shift to 100% virtual visits.

As a result, they saw many benefits, including:

• High patient satisfaction
• Greater ability to involve multiple family members in conversation
• Patients showing up for their appointments – no-show rates have fallen to near zero
• New ability to see the home environment
• Greater ability to connect with patients for a quick check-in
• Expanded access to palliative care overall

At the same time, there have been downsides to home-based telehealth, which became more apparent to all. For example, the teams at University of Alabama at Birmingham (UAB) and Virginia Commonwealth University Massey Cancer Center (VCU) had originally provided telehealth to ambulatory patients in geographically dispersed clinics, relying on the clinics’ Wi-Fi, devices, and staff in order to conduct the visits. All advantages of facility-to-facility telehealth disappear when the site of care shifts to the home. Susan McCammon, MD, of UAB adds, “[In the past], it was also easy for the patients – they didn’t have to deal with their lack of broadband or poor technology skills, and it was not difficult for them to get to these regional clinics. Those clinic staff also allowed for ‘medically mediated’ visits, by helping with vitals and physical examinations. Home-based virtual visits can often be difficult for patients and families in comparison.

Danielle Noreika, MD, of VCU underscores the concern about compromised physical examination. First, while some examination can be done virtually, prescribing controlled substances based on physical information collected this way may not meet previously established compliance or regulatory standards. It also complicates medical decision-making. Dr. Noreika notes, “It is difficult to determine the scale of severity – for instance, if a patient living with cancer has a new pain concern, we do not have the ability to do an exam. It can be anything from nothing significant to a true emergency.” To address this concern, Ashwini Bapat, MD, of EpioneMD suggests that the parallels to on-call consults must be applied to home-based telehealth: “The clinician must know how to triage to an in-person provider if there’s a concern.”

Lastly, while everyone on the panel appreciated how telehealth has expanded access to palliative care, Lily Gillmor, MSPC, with Transitions LifeCare, cautioned that too much reliance on telehealth will restrict access for some people in need, particularly those in areas without broadband, those uncomfortable with the technology, or those with sensory impairments. (And while Wi-Fi-enabled loaner devices have improved access elsewhere, Marie Bakitas, DNSc, with UAB, has found that it is labor-intensive for staff to set up patients appropriately, and still roughly half of their patients had difficulty using the devices.)

Most of the programs noted that their home-based telehealth encounters were, on average, shorter than in-person visits, and of course, the elimination of travel time gave much more time for clinical care. For many patients, the frequency of their interactions with the palliative care team also increased – with more frequent, but shorter, encounters through telehealth.

Dr. Noreika (VCU) noted that new workflows and patient management processes can add to this efficiency; for example, team members can make use of the time that a patient is in the virtual waiting room, or can schedule a wide window to reach a patient, since they are waiting for the call in the convenience of their own home. Dr. Bapat (EpioneMD) gains efficiency by deploying additional team members as needed after information is gathered in the initial encounter, and the team at UAB mused that clinical space might be saved, since telehealth can be delivered from the providers’ own homes.

Some program leaders raised cautions about the need to strike a balance between increased efficiencies and workload, to prevent overburdening their teams. More visits per day combined with fewer no-shows can be exhausting. Burnout may also be an issue for those who have diminished professional satisfaction, missing the true human interaction of face-to-face visits. (As Rodney Tucker, MD, of UAB notes, “virtual visits are not nearly as rewarding.”)

While the panelists debated whether, and how much, palliative care practice and patient relationships change when done virtually, most agreed that there was value in conducting the initial visits in-person whenever possible. Lori Gillmor (Transitions LifeCare) shared that for her, in-person initial visits are more comprehensive, allowing her to create a unique ‘human connection’ when meeting with patients in person. She notes, however, that with more training on how to conduct virtual visits, clinicians can improve the emotional connections in virtual interactions to more closely approximate their in-person impact.

Every panelist emphasized how valuable the Medicare flexibilities, which provide full reimbursement for home-based telehealth encounters, are, and how much they hoped this payment parity would continue after the public health emergency ends. However, opinions differed on whether audio-only palliative care encounters should continue to be supported.

As Dr. Bapat (EpioneMD) points out, “As a clinician, you get so much more information when patients have their cameras turned on – even seeing how much effort they put into preparing themselves for the visit gives you important clues.” Dr. Noreika (VCU) adds, “Audio-only doesn’t give you any feedback on the conversation, such as those important body language cues.” However, Dr. Bakitas (UAB) has found—particularly with family caregivers—that the anonymity of audio-only can lead to more disclosures. Regardless of the pros and cons, all panelists agreed that audio-only was necessary to ensure access for those without broadband, video-enabled devices, or tech-savviness.

One of the strongest benefits in the rise of telehealth is the ability to reach more people, especially those previously not served by palliative care teams—such as those living in long-term care (LTC) facilities. Virtual visits make consultations more accessible because resident travel arrangements do not need to be made, and it is no longer cost-prohibitive to see only one or two residents at a time. In a survey CAPC conducted in February 2021, 13 percent of respondents reported expanding their services to these facilities during the pandemic. In fact, Dr. Bapat founded EpioneMD with the goal of reaching those who do not currently have access to specialty palliative care, and has moved quickly to fill this need.

Transitions LifeCare also expanded their services in LTC facilities, finding that they provided tremendous value by speaking with family members, and supporting complex decision-making. Lori Gillmor (Transitions LifeCare) notes, “This practice lends itself well to telehealth – a quick visual on the patient is helpful to start, and then you can hold a discussion across multiple family members”. Others on the panel are looking into expansion into long-term care, bolstered by tele-palliative care programs in facilities reporting tremendous impact.

Based on the varying experiences and opinions of this virtual panel, the advantages and disadvantages of delivering palliative care solely through telehealth will continue to be explored and debated. That said, it is clear from these interviews that telehealth as a palliative care tool has proven its value during the pandemic. “In the end, what’s really needed is a menu of palliative care delivery options, deployed based on the purpose of the encounter, the patient and caregiver circumstances, and the variability in clinician preferences,” concludes Dr. Tucker (UAB). Dr. Noreika (VCU) adds that a preliminary screening to include video communications capabilities and comfort levels can help make the right choices from this menu.

Currently, this menu operates primarily within temporary payment policy, specifically, the Medicare flexibilities that are slated to end on December 31, 2021. As Jennifer Hicks, MSHA, with UAB points out, these flexibilities are what allows so many of their patients to receive palliative care, with 56% of all encounters via home-based telehealth. While all the participating programs hope to preserve home-based telehealth visits in the future, the extent of this will be limited if payment parity is not preserved.

The drive for continued payment parity is strong, with bills in Congress, a growing advocacy base, and the field of palliative care adding to the effort. “Palliative care is one of the ideal fields to use telehealth, as you can provide really good care and our economics can really use the added efficiency,” notes Dr. Bapat (EpioneMD). When hearing policymaker concerns over expanding health care costs, she reminds us, “don’t forget that there are costs to traditional office visits, and those are borne by patients and families. You can’t say that in-person visits are really cheaper.”

The Center to Advance Palliative Care (CAPC) provides guidance to help programs optimize palliative care delivery via telehealth. Resources exist to help with a wide variety of issues, ranging from preparing patients and families for the virtual visit, to conducting physical examinations virtually, to enhancing the human connection. Please review the following for more information:

• Telehealth and Palliative Care Toolkit, covering setting up the program, preparing patients, performing remote physical examinations, and billing Medicare appropriately
• Telehealth Best Practices for Palliative Care, a conversation with Drs. Michael Fratkin and Dana Lustbader, early adopters of telehealth who have perfected their approaches over the years
• Expanding Access to Palliative Care Through Technology, a presentation by Dr. Marie Bakitas from UAB from CAPC 2X4

For more information on telehealth payment parity policy, see the Center for Connected Health Policy.

CAPC wishes to thank the following individuals for sharing their experiences and opinions:

• Marie Bakitas DNSc, CRNP, Professor and Associate Director at the Center for Palliative Care and Supportive Care at the University of Alabama at Birmingham
• Susan McCammon, MD, Professor and Assistant Director at the Center for Palliative Care and Supportive Care at the University of Alabama at Birmingham
• Jennifer Hicks, MSHA, MBA, Administrator of Hospital Serious Illness Services at the University of Alabama at Birmingham
• Rodney Tucker, MD, MMM, FAAHPM, Professor and Director at the Center for Palliative Care and Supportive Care at the University of Alabama at Birmingham
• Lily Gillmor, MSPC, BSN, RN, CHPPN Associate Vice President of Palliative Care at Transitions LifeCare, Durham North Carolina
• Ashwini Bapat, MD, Founder, EpioneMD
• Danielle Noreika, MD, FACP, FAAHPM, Associate Professor and Medical Director of Palliative Care at Virginia Commonwealth University, Massey Cancer Center
• J. Brian Cassel, PhD, Associate Professor of Medicine at Virginia Commonwealth University, Massey Cancer Center