Best Practices for Using Telehealth in Hospice and Palliative Care

Michelle Webb, DNP, RN, BC-CHPCA; Susan Lysaght Hurley, PhD, GNP-BC; Jennifer Gentry, DNP, ANP-BC, GNP, ACHPN; Melanie Brown, LCSW; Cynthia Ayoub, BSN, RN, BC-CHPCA

Disclosures

Journal of Hospice and Palliative Nursing. 2021;23(3):277-285. 

In This Article

Background

The evidence supporting the use of telehealth in hospice and palliative care has been slowly expanding over the past 20 years.[5,10–13] Both qualitative and quantitative research studies have been conducted; however, most are of mixed scientific rigor.[14,15] The majority of studies are descriptive in nature and focus on provider experience and satisfaction, barriers to telehealth adoption and delivery, and patient and informal caregiver attitudes toward telehealth.[16] Despite broad acceptance of telehealth among hospice and palliative care providers, patients, and family caregivers, there is a scarcity of knowledge regarding clinical outcomes.

Adoption of Telehealth: Barriers and Facilitators

Barriers to and facilitators of the adoption of telehealth in hospice and palliative care have been a frequent focus of research, and several have been identified that have relevance to developing best practices. Organizational and contextual variables serve as either barriers to or facilitators of the adoption and use of telehealth. Variables associated with the use or disuse of telehealth in hospice and palliative care include clinician acceptance and readiness to use technology, satisfaction with available technology, executive leadership characteristics, perceived cost-benefit value, and the presence of organizational infrastructure that supports adoption (ie, education and training, information technology, financial, and administrative support) and provider support.[8,13,14,16–18]

Reimbursement Barriers and Facilitators. One of the most frequently identified issues affecting the adoption of telehealth for hospice and palliative care providers is lack of funding to start and sustain telehealth, specifically the lack of adequate reimbursement for these services by primary payers of hospice and palliative care. In response to the growing demand for telehealth during the COVID-19 pandemic, temporary and permanent changes at the federal and state level have been made to telehealth policy, coverage, and implementation, promoting its wider use during this PHE.[19,20] Documentation and billing guidance have been provided throughout the pandemic consistent with the evolving reimbursement guidelines by those specializing in billing systems and practices, as well as payers and professional organizations.[21] This has been a significant facilitating factor for providers adopting telehealth—many for the first time—during the PHE.

Clinician, Patient, and Caregiver Barriers and Facilitators. A growing body of evidence suggests that while overall telehealth is well accepted by patients and families and has been positively experienced by members of interdisciplinary hospice and palliative care teams, all of these groups can serve as barriers to or facilitators of telehealth adoption.[5,8,14,16,17] Pivotal studies of acceptance of telehealth use for hospice and palliative care patients showed mixed provider attitudes.[5,18,22] Perceived lack of leadership support for successful implementation of telehealth dissuades providers from using the available telehealth technology. At issue specifically have been the lack of adequate training and education and the unavailability of equipment for patients who do not have access to the technology needed to receive telehealth services.[5] Clinicians also expressed concern that telehealth would be used as a replacement for in-person visits, fear of the technology replacing people, and worry that technology would be a barrier to effective communication and patient-provider relationships.[22] Because of the highly personal and often emotional nature of communications with patients receiving this specialized care, issues of privacy and usability were also raised.[22]

Patients and their family and caregivers also identify access to technology, privacy, and mistrust in the security of the internet as barriers to telehealth feasibility and usability.[9] Access to equipment, high-speed internet, and in-person support from clinicians to effectively, safely, and securely participate in telehealth activities make acceptance of telehealth by patient, family, and caregivers more likely.[11,14,16]

Technology Barriers and Facilitators. Access to the technology needed to support the delivery of telehealth remains at issue today as 24% of rural Americans report that access to high-speed internet is a major problem,[23] and disparities in digital access (ie, access to home technology that enables video visits) have been identified among Medicare beneficiaries.[24] Improvements in technology and successful telehealth experiences in other specialties where the care is highly interpersonal have led more hospice and palliative care providers in rural communities to adopt telehealth and to report positive provider experiences.[10]

Clinical Outcomes

Only a few studies address specific clinical outcomes for people receiving hospice and palliative care who receive telehealth services (ie, improved symptom management, quality of life, family experience of care).[8,25,26] Videophone technology, when used to allow for caregiver participation in the care planning process, demonstrated potential to change caregiver perceptions of pain medication and to improve pain management for hospice patients.[26] A pilot study using videophones found (1) that family caregiver anxiety was significantly decreased for participants over time, (2) communication between hospice team members and family caregivers was enhanced, but (3) there were no observed significant differences in quality-of-life scores.[26] A statistically significant improvement in mean scores for anxiety and appetite was noted at the first follow-up in-person visit after a videoconference virtual visit was conducted to provide pain and symptom control.[26]

A 2018 study explored the impact of telehealth and remote patient monitoring for persons receiving palliative care and concluded that remote patient monitoring activities improved symptom management and increased timely transition to hospice care.[8] More evidence is needed to evaluate the comparative effectiveness of telehealth versus usual care for palliative care patients and those at the end of life.

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