Delivering Telehealth to Home and Community-Based Services

The Medicaid home and community-based services (HCBS) delivery system has experienced extraordinary disruption to individual recipients, their families, and providers as a result of the COVID-19 pandemic. Executive orders that prohibited traditional service delivery models, combined with shelter-in-place orders, forced the closure of most places where people congregated. This resulted in reliance on telehealth to reduce participants’ risk of infection while continuing access to care to promote health and wellness of those in HCBS programs. Looking forward, HCBS providers and state agencies overseeing HCBS must work to improve and optimize the delivery of telehealth services for HCBS, acknowledging the potential duration of social distancing requirements, its impacts on traditional HCBS, and the reality that telehealth and remote delivery is here to stay.

Under the current public health emergency (PHE), many states have rapidly expanded telehealth in HCBS delivery via Social Security Act §1915(c) Appendix K emergency waivers. These same states and their provider networks are learning as they go. Now that telehealth is approved for a wide array of HCBS, leaders need to review and refine their approach to promote the basic tenets of HCBS, including individual autonomy, person-centeredness, community integration, and positive outcomes and value. States can prepare now for how they want telehealth to operate under HCBS and start to formulate changes to policies and procedures.

Focus on Core Intent of HCBS When Using Telehealth

States should consider the core intent of HCBS when evaluating the use of telehealth, promoting maximum independence of those receiving services, as well as autonomous and meaningful community participation. The progress achieved by HCBS networks in advancing participant’s personal choice, community integration, and personal autonomy must be sustained and improved upon even with increased use of telehealth. The Centers for Medicare & Medicaid Services (CMS) is clear in their expectations that people who access Medicaid-funded HCBS have the same opportunities for access, choice, and integration as any member of their community.

Telehealth can help states to overcome service delivery issues that often arise within HCBS, such as workforce shortages and access to services in rural areas. Services like adult day health, habilitative services, and supports to facilitate community participation afford individuals the opportunity to engage in their community and develop skills that drive positive interpersonal relationships. States should continually reflect and confirm that the core intent of HCBS is a pillar of their approach and decision-making when it comes to telehealth delivery methods.

Considerations to uphold the intent of HCBS when using telehealth include:

• Consider how community integration and inclusion are impacted by an individual’s telehealth choices. For example, implement safeguards to assure that individual plans of care are monitoring the balance of service delivery with goals for integration and inclusion in the community.
• Remember that while socialization can be accomplished remotely, it may take creativity and focus on assuring that participants actively participate, can use technology platforms to communicate, and are genuinely stimulated by activities.
• States may need to revise service definitions to clarify fundamental changes to reimbursable services. For instance, allowable service periods for group services may need to be revised — whereas an eight-hour day was customary, a participant may not want to sit in front of video conferencing equipment for more than one to two- hours.
• Clarify documentation requirements with providers, including progress notes and other standard clinical components of service delivery when using telehealth delivery.

Safeguarding Informed Individual Choice

An integral component of person-centered planning is the notion of informed choice by the individual, and this must persist in the use of telehealth. State agencies must consider individual choice in the development of future telehealth service requirements. These choices will evolve as shelter-in-place and social distancing requirements change and can also be influenced by service providers eager to maintain services and reimbursement during a time of disruption. Presently, telehealth may be the primary option to receive certain services as staff and individuals may be hesitant to interact face-to-face.

Telehealth should be an option for individuals to consider, but the delivery method should be offered in a way that respects freedom of choice and the potential that a participant does not want to receive their services in this way. Examples of methods to properly inform and engage individuals about their choices in the use of telehealth include:

• Educate and prepare case managers and providers in advance of policy changes and public notice as individuals look to case managers and providers as reliable sources of information.
• Update participant-focused materials, such as program pamphlets and informational packets, to include information about options for telehealth and the types of equipment required.
• Create a telehealth checklist, to be completed by individuals and case managers, that provides information on expectations, service guidelines, equipment, and privacy considerations.
• Establish enrollment materials that directly address the differences between telehealth and traditional service delivery, transparently conveying potential pros and cons.
• Provide training on risk identification and planning for those participants who wish to suspend services long term due to lack of interest in the telehealth modalities.

While internet and computer use are common in many people’s daily lives, not every individual who receives HCBS may have access to internet service and devices, or live in a region where they have broadband or high-speed internet. In addition, individuals may share their home with household members who also need access to shared devices for school or work. These practicalities can make or break the ability to deploy HCBS via telehealth and are integral when considering telehealth services. State agencies must identify clear methods for supporting individuals who elect to use telehealth services.

During the PHE, most states are allowing audio-only telephonic technologies as an additional eligible modality for providing services. State agencies must make clear when traditional means for communication, such as telephone calls from a case manager to check in, are considered delivery of a reimbursable service. States may decide they want to continue with expanded telehealth after the COVID-19 pandemic subsides, as such clear definition of telehealth policies will be required.

States should consider the following:

• Train case managers on assessing the practicalities of telehealth and where to obtain low-cost internet resources (which are currently being expanded by many internet providers due to the pandemic) when the cost of internet is a deterrent to telehealth.
• Develop and release training on privacy considerations pertaining to telehealth and how to identify and address the risk of privacy intrusions when incorporating telehealth services into an individual’s person-centered plan.
• Work with providers to gauge access to technology within provider-controlled residences, possibly establishing telehealth spaces where an individual can access a service with some degree of privacy.
  • Determine the support, if any, state agencies will provide to individuals in the selection and/or procurement of equipment and internet access necessary to receive telehealth services:
    o Do the eligibility/access rules for the use of telehealth disproportionately exclude any class/group?
  • How could the excluded individuals access the telehealth services differently?
  • Consider the appropriateness of purchasing computer equipment within goods and services or a participant’s service budget when a participant seeks telehealth but does not have personal computing equipment.

Looking Forward: Navigating Uncertainty and Shifts in Pandemic Intensity

Changing state and federal guidance, widespread public health orders, and variance in guidance for high-risk populations will directly influence the need for and use of telehealth HCBS. Shelter-in-place orders may continue for some states while other states move to re-open.

Moreover, public health officials have suggested there may be future waves of COVID-19 infection that will force HCBS networks to nimbly respond to renewed shelter-in-place orders. Individuals who are high-risk, including older adults and those with chronic health conditions or immune-compromised health, will likely need to limit community outings for extended periods. States will need to examine their approach to service delivery with a critical eye on policy revisions.

Expectations at CMS are that “the genie is out of the bottle on telehealth” and there’s no going back. States should expect that their waivers and policies related to telehealth within HCBS will need to evolve in a way that reinforces best-in-class HCBS that continue to advance a participant’s person-centered goals and acknowledge personal choice and preference.

The good news is that states now have increasing access to claims and other data from their Appendix K implementation to gather information about provider and individual experiences to inform change. States are strongly encouraged to study early patterns in utilization and reimbursement, and conduct sampled reviews of person-centered planning and service delivery documentation to review the early effectiveness and outcomes of Appendix K changes. This will help identify what long-term changes are needed to optimize HCBS during this time of disruption.

Lastly, freedom of choice and dignity of risk (self-determination and the right to take reasonable risks) remain essential for dignity and self-esteem for the individual. These are at the heart of HCBS and are in the balance as states reopen. Individuals, their families, and advocates will expect the ability to make informed choices about how they receive HCBS during and after the PHE. Any policy changes should uphold the core intent of HCBS.