Telehealth Boosts Psychiatric Visits Within Skilled Nursing Facilities

August 23, 2023 - Skilled nursing facilities (SNFs) in the United States rapidly adopted telehealth during the COVID-19 pandemic, which was linked to improved access to psychiatry visits, according to new research.

The use of telehealth in SNFs grew as demand for skilled nursing services spiked. In March 2020, the Centers for Medicare and Medicaid Services implemented a regulatory waiver that removed the requirement that SNF stays be preceded by a three-day hospitalization for fee-for-service Medicare plans to receive reimbursement.

As a result, the share of SNF episodes without a preceding three-day hospitalization increased from 6 percent before the COVID-19 public health emergency (PHE) to 32 percent during the PHE, according to a study published in April. Researchers also found that the share of SNF episodes provided for long-term care residents increased from 12 percent to 25 percent.  

But, as demand for SNF services rose, COVID-19 ravaged the facilities, CMS data shows. This was a key driving factor in the rapid adoption of telehealth at SNFs.

The study, published in JAMA Network Open, assessed telehealth use in SNFs before and during the pandemic. Researchers identified short- and long-term care SNF residents using 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records. They grouped clinician visits into routine visits for primary care within the SNF and outpatient visits with non-SNF affiliated primary and specialty care clinicians).

The research team also examined whether there were changes in various metrics, including off-hours weekend visits, new specialist visits, and psychiatrist visits, between 2018-2019 and 2020-2021 for SNFs with high versus low telehealth use in 2020.

The study included data from 15,434 SNFs and 4.4 million residents from January 2019 through June 2022.

Between January 2019 and February 2020, telehealth visits constituted 0.15 percent of all visits for SNF residents. By May 2020, 15 percent of all routine SNF visits and 37 percent of outpatient visits were performed using telehealth. But telehealth usage dropped to 2 percent of SNF visits and 8 percent of outpatient visits by 2022.

Across all SNFs, 5 percent used telemedicine at least once in 2019, 91 percent in 2020, 81 percent in 2021, and 61 percent in the first half of 2022.

The study also shows that facilities with high telehealth use were more likely to be situated in the Midwest or West and more likely to be in rural areas. These SNFs were also smaller and served fewer Black residents.

In addition, residents younger than 65 and with a COVID-19 diagnosis during their stay were more likely to receive telehealth visits. On the other hand, residents in long-term care, as well as those who were older, non-White, and dual-eligible for Medicare and Medicaid, were less likely to receive telehealth services.

Compared with 2018-2019, SNFs with high telehealth use in 2020-2021 provided about 20.2 percent more psychiatry visits per resident year than low-use SNFs. High-telehealth use SNFs also provided approximately 7.2 percent more outpatient visits for residents with limited mobility.

Further, SNFs with high telehealth use had fewer routine visits on weekends and no difference in new outpatient visits with specialist physicians compared with low-telehealth use SNFs.

"Likely, telemedicine helped maintain established patient-clinician connections and expanded access to potential new clinicians, especially amid the long-standing decline in psychiatrist numbers," the study authors wrote.

But researchers cautioned that telehealth use was concentrated among a small group of clinicians, which suggests "staff and clinician preferences were likely an important driver in the magnitude of telemedicine implementation."