Scenario

Research and Applications

An evaluation of telehealth expansion in U.S. nursing

homes

Gregory L. Alexander 1, Kimberly R. Powell2, and Chelsea B. Deroche3

1School of Nursing, Columbia University, New York, New York, USA, 2Sinclair School of Nursing, University of Missouri, Columbia,

Missouri, USA and 3School of Medicine, University of Missouri, Columbia, Missouri, USA

Corresponding Author: Gregory L Alexander, PhD, RN, FAAN, FACMI, FIAHSI, Columbia University, School of Nursing,

New York, NY, USA ([email protected])

Received 5 May 2020; Editorial Decision 23 September 2020; Accepted 24 September 2020

ABSTRACT

Objective: This research brief contains results from a national survey about telehealth use reported in a random

sample of U.S. nursing homes.

Methods and Materials: The sample includes nursing homes (N¼664) that completed surveys about informa-

tion technology maturity, including telehealth use, beginning January 1, 2019, and ending August 4, 2020. A

pre/post design was employed to examine differences in nursing home telehealth use for nursing homes com-

pleting surveys prior to and after telehealth expansion, on March 6, 2020. We calculated a cumulative telehealth

score using survey data from 6 questions about extent of nursing home telehealth use (score range 0-42). We

calculated proportions of nursing homes using telehealth and used logistic regression to look for differences in

nursing homes based on organizational characteristics and odds ratios.

Results: Significant relationships were found between nursing home characteristics and telehealth use, and

specifically, larger metropolitan homes reported greater telehealth use. Ownership had little effect on telehealth

use. Nursing homes postexpansion used telehealth applications for resident evaluation 11.24 times more (P <

.01) than did nursing homes pre-expansion.

Discussion: Administrators completing our survey reported a wide range of telehealth use, including approxi-

mately 16% having no telehealth use and 5% having the maximum amount of telehealth use. Mean telehealth

use scores reported by the majority of these nursing homes is on the lower end of the range.

Conclusions: One solution for the current pandemic is to encourage the proliferation of telehealth with contin-

ued relaxed regulations, which can reduce isolation and preserve limited resources (eg, personal protective

equipment) while maintaining proper distancing parameters.

Key words: Nursing homes, telehealth, surveys and questionnaires, informatics, long term care

INTRODUCTION

The unprecedented coronavirus disease 2019 (COVID-19) global vi-

rus pandemic has left a wake of uncertainty for nursing home pro-

viders (ie, doctors, nurse practitioners, clinical psychologists, and

licensed clinical social workers), residents, and families of residents

who are isolated to mitigate exposure. This isolation was necessary

to slow the spread of the virus and protect some of the most vulnera-

ble populations. In response to the crisis, Medicare rules and regula-

tions have been relaxed to broaden access to telehealth services in

nursing home settings so that Medicare beneficiaries receive the care

they need virtually without having to risk travel to a healthcare facil-

ity.1 We hypothesize that relaxation of federal regulations with tele-

health expansion will lead to greater nursing home telehealth

VC The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.

All rights reserved. For permissions, please email: [email protected]

342

Journal of the American Medical Informatics Association, 28(2), 2021, 342–348

doi: 10.1093/jamia/ocaa253

Advance Access Publication Date: 9 November 2020

Research and Applications

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adoption nationally, a setting that accounts for over 10 000 (27%)

of COVID-19 deaths in the United States.2

In response to telehealth expansion, the Centers for Medicare

and Medicaid Services published a general provider telehealth tool-

kit to assist healthcare facilities plan for implementation of these

types of services including Medicare telehealth visits, virtual check-

in, and e-visits (electronic visits).1 As of April 20, 2020, every U.S.

state has amended existing laws or issued new declarations to ex-

pand the use of telehealth or mHealth (mobile health) during the

COVID-19 pandemic.3 These amendments to existing laws provide

opportunities for the use of telehealth, that is, using technology to

assist with procedures, such as medical screenings, consultations,

and second opinions, and to prevent contact with contagious people

during the outbreak, a method thought to protect patients and

healthcare providers.4

The Centers for Medicare and Medicaid Services toolkit specifi-

cally defines telehealth visits as using telecommunication to conduct

visits between a provider and resident. Some examples include a vir-

tual check-in, a short 5- to 10-minute visit or remote evaluation

with a provider via a telephone or other telecommunication device

(ie, Skype, Facetime, or Zoom) to determine what services are re-

quired for the resident and e-visits, and any communication occur-

ring between a provider and resident using an online portal. In this

study, we conceptualize these tools as forms of telehealth used by

nursing homes to protect people living and working in these facili-

ties. To remove potential delays in implementation, the Health and

Human Services Office of Civil Rights also exercised enforcement

discretion and waived Health Insurance Portability and Account-

ability Act violations for providers using telehealth tools in the care

of these vulnerable populations, which could also result in greater

levels of telehealth expansion.1

The purpose of this article is to examine the use of telehealth

services being reported in a random sample of U.S. nursing homes.

Telehealth is a valuable resource identified in the nursing home liter-

ature, as it has been associated with reducing polypharmacy, explor-

ing treatable causes of weight gain, and reducing frailty.5 Telehealth

applications can now be viewed in a broader sense to help reduce or

eliminate infections caused by known contagious organisms spread

through various means of contact. Hence, demonstrating greater sig-

nificance of this research to understand pre- and postexpansion rates

of telehealth usage following the public health emergency declara-

tion in nursing homes nationally. Furthermore, not all nursing

homes are alike. Accounting for organizational characteristics that

are used frequently in nursing home research involving technology6

will help to describe potential disparities in telehealth implementa-

tion. Our research questions are the following:

1. Did telehealth expansion, beginning March 6, 2020, increase tele-

health uptake in U.S. nursing homes?

2. What are nursing homes using telehealth for?

3. Are there differences in nursing home telehealth uptake pre– and

post–telehealth expansion based on facility characteristics (bed

size [<60, 60-120, >120], location [metropolitan, micropolitan,

small town, rural], and ownership [for profit, not for profit])?

MATERIALS AND METHODS

Sample Facilities were randomly selected from Nursing Home Compare7 af-

ter removing facilities from Guam, Puerto Rico, and Virgin Islands.

Facilities that were designated as special focus facilities and that

identified as having poor quality outcomes or safety issues requiring

focused interventions to fix problems were also removed. Included

in this analysis are survey results from a random sample of nursing

homes that completed surveys beginning January 1, 2019, and end-

ing August 4, 2020, which provides an estimate of pre– and post–tel-

ehealth expansion telehealth use, based on the March 6, 2020,

expansion date.

Survey items A national survey began January 1, 2019, in U.S. nursing homes to

examine trends in information technology (IT) maturity over 3

years. As part of this evaluation, researchers are using a nursing

home survey that measures the extent of telehealth use in resident

care and clinical support domains (eg, laboratory, radiology, phar-

macy).8 A detailed description of the survey has been previously

published.9 The survey has been tested and determined to have good

reliability and validity measures.10,11

To answer our research questions, we focused on 6 telehealth

questions in the survey (see Table 1). These 6 questions measure ex-

tent of use of telehealth applications, including those used to facili-

tate medical screenings, conduct follow-up visits and consultations,

and perform medication management activities virtually, thus reduc-

ing unnecessary exposure to threatening environmental agents, in

resident care and clinical support areas (eg, laboratory, radiology,

pharmacy). In this context, we consider all these applications as tele-

health activities.

Participants were asked to rate these survey items according to

their telehealth extent of use using an 8-point scale ranging from 0

(not available) to 7 (extensively used). We calculated a cumulative

telehealth score using data from questions 1-6 for each home, with a

minimum score of 0 and maximum of 42. We created binary out-

come measures for these variables by assigning “0” if the respondent

indicated 0 and “1” if the respondent indicated between 1 and 7.

Subsequently, we calculated proportions of telehealth use in nursing

homes completing the survey.

Analysis We used descriptive statistics to compare our study sample with the

national sample relative to ownership, bed size, and location. These

Table 1. Telehealth survey questions with proportions of telehealth

use (N¼ 664)

Survey question Yes No

1. Telehealth for evaluation of residents and

pretransfer arrangements

250 (37.65) 414 (62.35)

2. Telehealth for transmission of diagnostic

images and/or consultations and second

opinions

257 (38.70) 407 (61.30)

3. Electronic reporting of laboratory test

results to nursing home

442 (66.57) 222 (33.43)

4. Electronic transmission and reception of

laboratory results for interpretation (eg,

pathology)

393 (59.19) 271 (40.81)

5. Telehealth for results capturing and inter-

pretation by radiologists

184 (27.71) 480 (72.29)

6. Remote order entry for medications from

locations outside of the nursing home (eg,

MD access from home, office or clinic)

355 (53.46) 309 (46.54)

Questions scored on an 8-point scale ranging from 0 (Not Available) to 7

(Extensively Used).9

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specific organizational variables were selected because they were

available in a public dataset that all nursing homes receiving Medi-

care are required to report.12 In addition, these variables were se-

lected because they were found to have significance in previous

analyses conducted to evaluate relationships between IT maturity

and quality measures, also found in Nursing Home Compare.10,13

Next, we incorporated poststratification weighting procedures to

reweight the nursing homes to national proportions regarding these

variables. Using poststratified weights, the team looked at differen-

ces in total telehealth use scores among each of the 6 survey ques-

tions contributing to the total telehealth use score.

Next, we used logistic regression for survey data to examine the

relationship between each type of telehealth use, based on the 6 sur-

vey questions, and nursing home characteristics including location

(rural, small town, micropolitan, metropolitan), bed size (<60, 60-

120, >120), and type of ownership (for profit, not for profit). Loca-

tion was determined using rural-urban commuting area codes estab-

lished from census data population statistics (rural ¼ <2500, small

town¼2500-9999, micropolitan¼10 000-49 999, metropolitan ¼ >50 000).14 Finally, with poststratified data, we assessed relation-

ships between telehealth use in nursing homes completing surveys

prior to and after telehealth expansion on March 6, 2020, by incor-

porating an additional variable into the logistic regression models to

calculate odds ratios (OR) and 95% confidence intervals while

adjusting for nursing home characteristics.

RESULTS

The nursing home sample (n¼664) was reflective of the population

(N¼13 958) according to location but not according to bed size or

ownership. This sample had a greater proportion of smaller (<60

beds) and medium-sized (60-120 beds) nursing homes but had fewer

large nursing homes (>120 beds) compared with the national sam-

ple. The sample also had a larger proportion of nonprofit facilities.

Nursing home administrators in our study reported a full range

of telehealth use scores ranging from 0 to 42. Among this sample

(n¼664), 105 (16%) nursing homes had a telehealth use score of 0

and 32 (5%) nursing homes had the maximum telehealth use score

(42). Partial telehealth implementations were reported in 527 (79%)

nursing homes, the majority being on the lower end of the distribu-

tion. See Figure 1 for distribution of telehealth use scores.

Table 2 shows mean telehealth use scores according to nursing

home characteristics of bed size, ownership, and location. In this

sample, mean telehealth use scores increased as bed size increased

from small (<60) to large (>120). Mean telehealth use scores were

lower in nursing homes in rural locations compared with in nursing

homes located where populations sizes were much larger. Although

our sample included many more for-profit nursing homes, mean tel-

ehealth use scores and confidence intervals were not much different

based on ownership status. The mean telehealth use score reported

by facility administrators during the pre-expansion period were

lower than during the post-expansion period, indicating greater tele-

Figure 1. Distribution of total telehealth use score (N¼ 664).

Table 2. Table 2. Telehealth use score by nursing home characteris-

tics and survey period

Nursing home characteristics Total facilities Telehealth use score

Bed size

<60 139 11.45 (9.51-13.40)

60-120 388 15.70 (14.47-16.94)

>120 137 16.39 (14.57-18.22)

Ownership

For profit 480 15.27 (14.14-16.39)

Not for profit 184 14.63 (13.05-16.21)

Location (population)

Metro (50 000) 428 15.82 (14.66-16.98)

Micro (10 000-49 999) 99 15.23 (12.70-17.77)

Small town (2500-9999) 82 13.54 (11.06-16.02)

Rural (<2500) 55 10.82 (8.64-13.01)

Survey period

Pre–telehealth expansiona 491 13.51 (12.49-14.52)

Post–telehealth expansion 173 19.08 (17.03-21.12)

Values are mean (95% confidence interval). aSurvey period prior to March 6, 2020.

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health adoption overall during the postexpansion period when tele-

health regulations were relaxed.

Table 3 illustrates the relationships between telehealth use score,

organizational characteristics, and survey period, including change

over time between pre–telehealth expansion (prior to March 6, 2020)

and post–telehealth expansion. Using poststratification to correct for

sample differences, there were significant associations found among

the dependent variables and organizational characteristics in our lo-

gistic regression analysis (Table 3). For instance, medium-sized (60-

120 beds) and larger nursing homes (>120 beds) were 1.85 (P ¼ .01)

and 2.89 (P < .01) times more likely to have electronic reporting of

lab results to the nursing home compared with smaller facilities (<60

beds), respectively. In addition, nursing homes located in micropoli-

tan and metropolitan areas, with larger populations, were 2.30 (P ¼ .04) and 3.44 (P < .01) times more likely to have electronic reporting

of laboratory results compared with nursing homes in rural locations,

respectively. Similar results were found for electronic transmission

and reception of laboratory results with larger (>120 beds) and

medium-sized (60-120 beds) nursing homes having 2.10 (P < .01)

and 1.83 (P < .01) times the odds of having this telehealth capability

compared with small homes (<60 beds), respectively. Also, metro-

politan nursing homes were 3.19 times more likely to have transmis-

sion and reception of laboratory results capability compared with

rural nursing homes (P < .01). Telehealth used for results capturing

and interpretation by radiologists were more likely to be used in

nursing homes in larger metropolitan areas (OR, 2.86; P < .01) and

small towns (OR, 2.95; P ¼ .03) compared with rural nursing homes.

Finally, the odds of a nursing home having remote order entry capa-

bilities for medications was greater in medium-sized (OR; 2.16; P <

.01) and larger (OR, 2.02; P ¼ .01) facilities.

Adjusting for bed size, location, and ownership, Table 3 illus-

trates the comparisons of telehealth use pre– and post–telehealth ex-

pansion based on surveys completed before and after March 6,

2020. The regression table shows statistically significant differences

in mean telehealth use scores among 3 areas, including telehealth

used for evaluation of residents and pretransfer arrangements, trans-

mission of diagnostic images or consultations and second opinions,

and results capturing and interpretation by radiologists. In particu-

lar, nursing homes in the postexpansion period were 11.24 times

more likely (P < .01) to use telehealth for resident evaluation and

pretransfer arrangements compared with facilities in the pre-

expansion period. Nursing homes in the postexpansion period had

4.30 times the odds of using telehealth for consultations and second

opinions vs facilities in pre-expansion period. Finally, in this sample,

radiologists were 2.89 times more likely to use telehealth for results

capturing and interpretation after the telehealth expansion (P <

.01). Nursing home administrators did not report significant

changes in other telehealth opportunities after expansion occurred

on March 6, 2020.

DISCUSSION

Administrators completing our survey reported a wide range of tele-

health use including approximately 16% having no telehealth use,

5% having the maximum amount of telehealth use, and 79% report-

ing partial telehealth implementations. Our finding that facilities

have partial technology implementations especially in clinical sup-

port areas, such as laboratory systems and pharmacy systems, are

consistent with other research in this area.15 Findings from this

study suggest that there are gaps and opportunities in the use of tele-

health, such as opportunities for building greater interoperability

among telehealth systems supporting providers decision-making

abilities and enhanced provider order entry, which could improve

timeliness and safety of care delivery in nursing homes.

The overall mean telehealth use scores reported by the majority

of these nursing homes is on the lower end of the range, which indi-

cates that there is much room for improvement. These findings are

supported because adoption of newer forms of technology have

struggled to achieve a maximum adoption level. Some reasons nurs-

ing home administrators struggle include a need for systematic im-

plementation processes and evidenced based protocols, lack of

technology support and infrastructure, low levels of interoperability

among disparate systems, and poor investments in staff training.16

However, there are bright spots, with several homes, who likely

have strong leadership advocating for technology, having adopted

high levels of telehealth use.17 The relaxation of current regulations

and the formation of telehealth toolkits due to the COVID 19 pan-

demic maybe useful, but it remains to be seen if loosening regula-

tions can help nursing home administrators overcome some of the

monumental struggles that they have experienced trying to keep

pace with other health sectors (eg, acute care) who have tradition-

ally been provided greater financial resources for technology imple-

mentation.18

This analysis illustrates telehealth use has some significant rela-

tionships with nursing home location and size but less significant

relationships with type of ownership. Telehealth that is associated

with the exchange of laboratory results, results capturing and

reporting by radiologists, and remote order entry by pharmacists for

medications were significant in our study. In prior studies, research

has shown that smaller and more rural nursing homes are often

found to have greater disparities in technology use compared with

facilities in larger, urban areas.19 One concern about these findings

is whether access to telehealth in larger, urbanized nursing homes

will lead to greater disparities among vulnerable populations in rural

locations. This is especially important during pandemic times, when

isolation precautions and social distancing are required to protect

vulnerable residents and staff who work in these facilities. Only time

and ongoing research on this topic will tell.

LIMITATIONS

Recruitment for this study was grouped according to state. Because

we had only begun recruiting nursing homes in some states for our

national survey, some states had fewer strata represented, especially

for larger, nonprofit nursing homes. As we complete our national as-

sessment, scheduled to be completed in September 2, 2020, we an-

ticipate that our randomization process will correct for this lack of

representation.

CONCLUSION

Telehealth technology is thought to be a critical access point to

health care for vulnerable populations, chronically ill nursing home

residents, and people living in rural settings.20 The current situation

for most nursing home residents, staff, and administrators world-

wide, as a result of the COVID-19 pandemic, includes greater isola-

tion and separation to prevent spread of the virus. Without a

vaccine and electronic connections to the outside world, nursing

home residents could spend weeks, months, or even years in a facil-

ity without visitors other than regular staff. This could have a pro-

found effect on resident outcomes including depression rates,

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Table 3. Relationships of telehealth use score, organizational characteristics (bed size, location, ownership), and survey period

Dependent variable Independent variable Parameter estimate Odds ratio (95% CI) P value

Telehealth for evaluation of residents

and pretransfer arrangements

Bed size

<60 Ref Ref Ref

60-120 �0.02 0.98 (0.60-1.62) .95

>120 �0.51 0.60 (0.31-1.17) .14

Location

Metro 0.12 1.13 (0.50-2.58) .77

Micro 0.52 1.69 (0.65-4.40) .29

Small town 0.12 1.13 (0.42-3.01) .81

Rural Ref Ref Ref

Ownership

For profit 0.35 1.42 (0.90-2.25) .13

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 2.42 11.24 (7.21-17.53) <.01

Telehealth for transmission of diag-

nostic images and/or consultations

and second opinions

Bed size

<60 Ref Ref Ref

60-120 0.18 1.20 (0.75-1.92) .44

>120 �0.15 0.86 (0.48-1.55) .61

Location

Metro �0.30 0.43 (0.36-1.53) .42

Micro 0.07 1.07 (0.45-2.58) .87

Small town �0.44 0.64 (0.28-1.50) .31

Rural Ref Ref Ref

Ownership

For profit 0.23 1.25 (0.82-1.92) .30

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 1.46 4.30 (2.85-6.51) <.01

Electronic reporting of laboratory

test results to nursing home

Bed size

<60 Ref Ref Ref

60-120 0.62 1.85 (1.15-2.97) .01

>120 1.06 2.89 (1.55-5.38) <.01

Location

Metro 1.24 3.44 (1.71-6.91) <.01

Micro 0.83 2.30 (1.04-5.11) .04

Small town 0.57 1.76 (0.77-4.00) .18

Rural Ref Ref Ref

Ownership

For profit �0.27 0.77 (0.48-1.21) .25

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 0.17 1.19 (0.77, 1.83) .44

Electronic transmission and recep-

tion of laboratory results for inter-

pretation (eg, pathology)

Bed size

<60 Ref Ref Ref

60-120 0.61 1.83 (1.21-2.78) <.01

>120 0.74 2.10 (1.26-3.52) <.01

Location

Metro 1.16 3.19 (1.72-5.92) <.01

Micro 0.52 1.69 (0.84-3.40) .14

Small town 0.33 1.39 (0.67-2.86) .38

Rural Ref Ref Ref

Ownership

For profit �0.38 0.68 (0.47-0.99) .05

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 0.23 1.26 (0.87, 1.82) .22

Bed size

(continued)

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mobility, etc. One solution is to encourage the proliferation of tele-

health with continued relaxed regulations that can reduce isolation

and preserve limited resources (eg, personal protective equipment)

while maintaining proper distancing parameters and allowing for

timely care delivery and social connectedness everywhere.

FUNDING

This project was supported by grant number R01HS022497 from the Agency

for Healthcare Research and Quality. The content is solely the responsibility

of the authors and does not necessarily represent the official views of the

Agency for Healthcare Research and Quality.

AUTHOR CONTRIBUTIONS

GLA, CBD, and KRP all provided substantial contributions to the over de-

sign, acquisition, analysis, and interpretation of the data for this manuscript.

GLA, CBD, and KRP assisted in original drafts and revisions of the manu-

script. All authors gave final approval of the last version submitted for publi-

cation. All authors agree to be accountable for all aspects of the work,

including but not limited to accuracy and integrity of statements in this publi-

cation.

CONFLICT OF INTEREST STATEMENT

GLA is owner and cofounder of TechNHOlytics LLC. GLA is also a member

of the Agency for Healthcare Research and Quality National Advisory Com-

mittee.

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Table 3. continued

Dependent variable Independent variable Parameter estimate Odds ratio (95% CI) P value

Telehealth for results capturing and

interpretation by radiologists

<60 Ref Ref Ref

60-120 0.22 1.25 (0.75-2.07) .40

>120 0.19 1.21 (0.65-2.25) .56

Location

Metro 1.05 2.86 (1.25-6.50) .01

Micro 0.89 2.45 (0.93-6.40) .07

Small town 1.08 2.95 (1.14-7.66) .03

Rural Ref Ref Ref

Ownership

For profit 0.11 1.12 (0.73-1.72) .60

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 1.06 2.89 (1.89-4.42) <.01

Remote order entry for medications

from locations outside of nursing

home (eg, MD access from home,

office, or clinic)

Bed size

<60 Ref Ref Ref

60-120 0.77 2.16 (1.36-3.42) <.01

>120 0.70 2.02 (1.15-3.54) .01

Location

Metro 0.45 1.56 (0.82-2.98) .17

Micro 0.21 1.23 (0.58-2.62) .59

Small town 0.01 1.01 (0.45-2.24) .98

Rural Ref Ref Ref

Ownership

For profit �0.05 0.95 (0.63-1.43) .81

Nonprofit Ref Ref Ref

Survey period

Pre–telehealth expansion Ref Ref Ref

Post–telehealth expansion 0.34 1.41 (0.95-2.10) .09

CI, confidence interval; Ref, Reference Variable.

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