Telehealth in home care



Home health agencies have the green light from CMS for face-to-face, initial assessment and more


In an attempt to reduce the risk of COVID-19 to homebound patients made particularly vulnerable by age, illness and underlying medical conditions, the Centers for Medicare and Medicare Services (CMS) has relaxed its rules for telehealth in home health and hospice.


The changes authorizes agencies to use Facetime on Apple’s iPhone, a Skype or Zoom program on a patient’s laptop computer and other platforms to secure the required face-to-face encounter between patient and physician, make the initial assessment and more.


CMS changed telehealth rules as part of numerous regulatory waivers it has put in place temporarily to help agencies deal with the coronavirus public health emergency.


“These are important and much-needed changes designed to mitigate some of the risk to our patients,” said J’non Griffin, president and owner of Home Health Solutions, a nationwide consulting and outsourcing firm serving home health, hospice and long-term care.


“But telehealth will not be replacing actual in-home visits,” she cautioned. “These changes just make it possible for agencies to incorporate the use of telehealth along with in-person visits they will still be making to the home. “


In many cases, the relaxed telehealth rules may make it easier and faster to provide treatment and services to patients who need home care -- without requiring a doctor’s office visit which might expose those patients and others to possible infection, J'non said.


The Face-to-Face Encounter


Both home health and hospice agencies will now be able to use telehealth to secure the face-to-face encounter with a physician. In home health, the face-to-face is required so that the patient can be certified eligible for home care services. In hospice, it is required for re-certification of the patient at a specific timepoint.


Using telehealth for the face-to-face is expected to be advantageous because it will allow agencies to initiate care and services in a timely manner, without requiring a doctor’s visit which could expose patients and others to possible infection.


As the COVID-19 crisis ramped up throughout March, with the numbers of reported cases growing across the country, some agencies found their patients unwilling to keep doctor’s appointments because of fear of infection, J’non said. Many patients also canceled visits from home health workers out of concern over the risk.


CMS responded with more lenient rules which grant permission for the face-to-face encounter to occur on certain approved devices and platforms where communication can occur between patient and physician.


“A telephone call will not work,” J’non said. “The telehealth encounter must take place on a device allowing live video with audio."


Specific platforms have been approved. CMS has said agencies must use a "non-public facing remote communications device" – and we explain at the end of this blog post where you can find out more about platforms which meet the requirements.

Face-to-face documentation requirements for a telehealth encounter have not been established by CMS at this time, but Home Health Solutions is recommending providers meet previous documentation standards.


This means the physician or other provider who certifies the patient for home health should note in the record when and how the telehealth encounter occurred, the name of the provider who conducted it via telehealth, and that it is recognized as the official encounter.



Not just physicians

This recommendation to incorporate the telehealth encounter into the record also applies for non-physician providers who may certify home health patients for home care during the COVID-19 crisis.


CMS has granted permission to nurse practitioners, clinical nurse specialists and physician assistants to certify patients, saying that it will not review documentation for episodes of care during the coronavirus crisis to determine whether a physician issued the orders and signed the plan of care. Those three provider types were already allowed to conduct the face-to-face encounter but did not have permission in most states to certify eligibility and create the plan of care. The Community Health Accreditation Partner (CHAP) is recommending that agencies check with their states to make certain state licensure law does not prohibit accepting orders from these provider types.



The Initial Assessment


Another way in which CMS is attempting to expedite the timely initiation of home health services during the COVID-19 crisis is by temporarily waiving 42 CFR § 484.55(a) so that telehealth may be used for the initial assessment.


Home health agencies will be able to determine the patient’s homebound status remotely or by record review. As with the face-to-face, a telephone will not meet the telehealth definition, but a platform such as Apple’s Facetime, which offers live video with audio so that patient and nurse can see and talk to each other via iPhone, would suffice.


The initial assessment will still need to be conducted by an RN within 48 hours of referral and should verify the patient’s homebound status.


Homebound eligibility requirements are broader now than before the pandemic. CMS has said a patient may be eligible for home care during the public health emergency if he or she has a diagnosis of COVID-19 or is suspected to have a diagnosis of COVID-19, and the physician has recommended that the patient not leave his or her home. Qualifying criteria for homebound eligibility may also be an underlying medical condition which places the patient at an increased risk of COVID-19.


If a patient has been referred to home health for rehabilitation therapy only, the initial assessment may be conducted via telehealth by the appropriate skilled professional: speech language pathologist, physical therapist or occupational therapist.



Telehealth Visits


Although CMS has said that it encourages agencies to use telehealth during the COVID-19 crisis, it has also reiterated several times that telehealth visits may not be used in place of regular in-home visits, and must be used in a manner addressed by the plan of care.

“For example, your plan of care might call for 4 nursing visits each week, two in person and two via telehealth,” J’non said.


No reimbursement has been discussed by CMS for telehealth visits.


Supervisory visits


Another way in which CMS is attempting to use telehealth to reduce the number of people in the homes of patients is by waiving onsite visits for supervision of aides and recommending telehealth instead.


Normally, a supervisory visit by a registered nurse or other skilled professional who is familiar with the patient must occur in the patient’s home every two weeks in order to evaluate whether aides are providing care consistent with the care plan.


CMS wants agencies to rely on telehealth for these supervisory check-ups during the coronavirus crisis.


Approved telehealth platforms


Are you wondering exactly what a "non-public facing remote communications" device is?


The Department of Health and Human Services Office of Civil Rights explains in a series of FAQs on telehealth and HIPAA exactly what may and may not be used for telehealth during the COVID-19 crisis.


Click here to read the FAQs.



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