Telehealth is increasingly becoming an integral part of post-acute care in various settings such as skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care hospitals, and in the home health and hospice care settings. As healthcare moves more towards value-based models that focus on quality outcomes and keeping patients healthy at home whenever possible, telehealth provides opportunities to enhance care coordination, improve access to specialty providers, and reduce readmissions from post-acute care settings back to hospitals. Some of the key ways telehealth is being used in post-acute care include:
Remote Patient Monitoring: Many post-acute care patients, especially those with chronic conditions, can benefit from ongoing remote monitoring of vital signs and symptoms at home. Conditions like congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes and wound care are well-suited for remote monitoring. Devices can track things like blood pressure, heart rate, oxygen saturation, weight, and glucose levels and transmit the data via Bluetooth or Wi-Fi to the patient’s clinicians for review. This allows earlier detection of potential issues before they worsen and require a readmission. It also empowers patients to better self-manage their conditions at home with oversight from their care team.
Video Conferencing Visits: Secure video conferencing provides a way for clinicians to remotely “visit” with their post-acute patients to assess their conditions, answer questions and ensure treatment plans are on track for recovery and health maintenance. This is useful for providers to conduct virtual follow-up visits for things like wound care, medication management and therapy progress without requiring an in-person trip back to the facility or specialists’ offices. Therapy telehealth visits allow physical, occupational and speech therapists to remotely guide patients through exercises and provide training.
Specialty Consultations: Accessing specialty provider expertise can sometimes be challenging for post-acute facilities located in rural areas. Telehealth enables on-demand access to cardiologists, dermatologists, neurologists and others to evaluate patients as needed. Specialists can remotely examine patients, diagnose issues, adjust treatment plans and recommend additional testing or interventions to the bedside clinicians. This reduces transfers to hospitals or delays in advanced care. Tele-stroke programs similarly allow rapid neurology evaluations for acute stroke patients in remote facilities.
Discharge Planning & Care Transitions: Care coordinators use video visits to remotely prepare patients and families for discharge to lower levels of care or home. This could involve medication teaching, home safety evaluations, therapy scheduling and answering questions. Post-discharge remote follow ups via telehealth then allow earlier identification of any difficulties and opportunities for intervention to prevent readmissions. Virtual hospital rounding programs also utilize telehealth to better coordinate care as patients transition between acute and post-acute levels of care.
Staff Support & Education: Telehealth provides opportunities for off-site specialists, supervisors and educators to remotely support staff in post-acute facilities. Examples include consultations on complex patients, supervision and feedback on therapy techniques or wound care practices, teaching sessions on new policies/procedures and virtual observation of patient interactions to ensure quality and regulatory compliance. This enhances skills and knowledge while reducing travel time away from patient care duties.
Facility Usage Examples: Some real world examples of telehealth integration in post-acute care include:
A 200-bed skilled nursing facility in New York developed a comprehensive remote patient monitoring program utilizing Bluetooth-enabled devices. It reduced 30-day readmissions by 23% and led to earlier interventions for potential issues.
An inpatient rehabilitation hospital in Texas conducted over 7,500 video therapy and specialty telehealth visits in 2020, allowing continued treatment during the pandemic’s visiting restrictions while avoiding unnecessary transfers.
A home health agency partnered with a major hospital system to launch virtual hospital-at-home programs using remote patient monitoring. Initial data showed readmissions were 57% lower than similar in-patients.
A long-term acute care hospital collaborated with neurologists at a large medical center to run a tele-stroke program. Over 90% of patients received a same-day remote neurology evaluation and management plan compared to average 2 day wait previously.
As policymakers and payers increasingly recognize telehealth’s benefits, its role in post-acute care coordination and disease management will likely expand further in the coming years. Outcomes data thus far indicates telehealth technology can reduce costs while maintaining or improving quality of care and patient/family satisfaction during recovery and transition periods. With clinicians facing workforce shortages as well, telehealth ensures geography is not a barrier to accessing specialists and continued recovery support.