EXECUTIVE SUMMARY

Telehealth was not widely used by family planning clinics before the COVID-19 pandemic, but it is likely to stay around post-pandemic as a more significant healthcare strategy.

  • Clinics quickly shifted to phone screening and initial consultations, as well as videoconferences with patients.
  • Some clinics provided contraception renewals and new prescriptions through telemedicine.
  • The Office for Civil Rights said it would not impose penalties for HIPAA noncompliance against covered health providers that used telehealth during the COVID-19 national emergency.

Telehealth was a small part of family planning before the COVID-19 pandemic. The landscape likely will look markedly different for telemedicine strategies after the pandemic.

“If there’s a silver lining to the pandemic, I hope it’s that we have more ability to do telemedicine,” says Amy Paris, MD, MS, director of family planning, Dartmouth-Hitchcock in Lebanon, NH.

Telehealth is a completely different model of healthcare that will be the new normal, said Sophia L. Thomas, DNP, APRN, FNP-BC, president of the American Association of Nurse Practitioners. Thomas spoke at a COVID-19 media videoconference on April 9. “I think going forward this is going to be a new shift in healthcare, the way we provide healthcare in this country,” Thomas predicted. “I think we’re going to be able to do more over telemedicine.”

From a family planning perspective, telehealth visits have been a positive experience that both patients and providers favor, Paris notes. “We get consults from people all over the state of New Hampshire and Vermont, and they might have to drive two to three hours to be here,” she says. “I had a woman in her 70s, who had a new ovarian cyst, referred for consult. She was just so happy to have a phone consult with a gynecologist that did not require her to make a two-hour drive.”

Telehealth offers many benefits to patients, including convenience. (See story on telehealth strategies in this issue.)

“When we first looked into telehealth, it was all for access and convenience,” says Evelyn Kieltyka, senior vice president, program services, with Maine Family Planning in Augusta, ME. “Maine was an early adopter for [telemedicine] reimbursement, so it made it financially feasible, as well. Even five years ago, Maine was one of the few states that allowed you to bill for telehealth visits.”

Maine Family Planning has ramped up its telehealth visits to include a wide range of services because of COVID-19, Kieltyka says. “Every day, there is a rethinking about workflow. We’re making abortion care available through telehealth.”

Telehealth rules were relaxed, both federally and by many states, during the COVID-19 crisis. For examples, rules requiring videoconferencing can be waived in favor of phone calls when patients do not have access to videoconferencing, Kieltyka says.

Lessons Learned from Natural Disaster

An Alaska family planning center was prepared for the telemedicine shift because of its experience during a natural disaster. “In November 2018, we had a really large earthquake in several places near Anchorage. That was enough of a wake-up call that we created a continuation of operations plan,” says Catriona Reynolds, executive director of Kachemak Bay Family Planning Clinic in Homer, AK.

The clinic changed its personnel policy to have employees continue to work during an emergency. If there is a disruption to the clinic’s daily census and practice, then staff can use their available time to catch up on things like completing all needed training and starting projects they had postponed, she says.

Kachemak Bay Family Planning Clinic worked at exploring telehealth options and navigating legal and financial barriers. In the summer of 2019, the clinic implemented a new electronic health record (EHR) that included a robust telehealth feature. The new EHR, along with the temporary government changes in telehealth during the pandemic, made it easier to move services to telehealth once the COVID-19 crisis began, Reynolds explains.

“I think that box is open,” Reynolds adds. “Telehealth is going to be here to stay for remote areas like ours.”

Before the pandemic, all states provided reimbursement for some type of live video in Medicaid fee-for-service. Remote patient monitoring was covered by 22 state Medicaid programs. California and Connecticut Medicaid programs reimbursed for eConsult.1

Since the pandemic resulted in widespread stay-at-home orders, telemedicine rules were temporarily changed. For example, the Office for Civil Rights said it would not impose penalties for noncompliance with HIPAA rules against covered health providers that used telehealth in good faith during the COVID-19 national emergency. Both audio and video communication technology can be provided through popular applications, such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. (For more information on the rule change, visit: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.)

Also, Medicare is allowing practitioners to waive copays and deductibles for all telehealth services, and many prior authorization activities are paused. Some states will reimburse for audio-only phone calls at the same rate as in-person visits, and rural and site limitations were removed. (For more information, visit: https://www.acponline.org/practice-resources/covid-19-practice-management-resources/telehealth-coding-and-billing-during-covid-19.)

The Federal Communications Commission (FCC) published a final rule on April 9 to establish the COVID-19 Telehealth Program. The program helps healthcare providers offer connected care services to patients at their homes or mobile locations during the pandemic. The order provides $200 million in emergency funding, under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The federal money will help providers purchase necessary telecommunications services and devices to provide telehealth. (The FCC rule is available at: https://www.federalregister.gov/documents/2020/04/09/2020-07587/promoting-telehealth-for-low-income-consumers-covid-19-telehealth-program.)

Maine Family Planning uses a HIPAA-compliant vendor for telehealth. The center also can accept electronic signatures.

“We’re fortunate that patients can sign forms online and look at consent forms for treatment, and it’s made it very useful to us to streamline a lot of those things,” Kieltyka says. “There are other workarounds that you can do.”

Maine does not require pre-abortion ultrasounds. “And there is emerging new evidence and protocols, showing that if women have a good [health] history and are under 10 weeks pregnant, it is very safe to provide them with medication abortion, using misoprostol,” Kieltyka says. “We’re part of a research study and can mail the [abortion] medication to those patients. Patients also can pick up the medication.”

Telehealth Streamlines Care, Increases Access

As family planning centers continue to provide telehealth visits during the pandemic, they are discovering its benefits.

“I was talking to our medical director a few weeks ago, and she said, ‘We’re going to realize there are a lot of unnecessary things we do in healthcare, in providing good care, and we’ll realize we can streamline with telehealth,’” Kieltyka recalls. “With telehealth, we’ll find out retrospectively that some of the things we made people come into the office for were not necessary for good care, and patients will accept this.”

If flexible telemedicine changes are maintained, family planning centers might decide to continue telehealth for most of their screening and consultation services, as well as other visits that previously were performed in the clinic.

“I hope we continue to keep some of the good parts of telemedicine even after it’s over,” Paris says.

In some larger, rural states, telehealth has been used to make contraceptive services more accessible to families in remote areas and to use limited medical resources more efficiently. For example, some North Dakota Title X family planning sites have limited access to advanced practice nurses, says Jean Smith, RN, BSN, PHN, family planning director at Richland County Health Department in Wahpeton, ND.

“We’re very rural and have very few full-time advanced practice nurses on staff, so that pushed us into telemedicine,” she says.

Clinics needed a full-time advanced practice practitioner on site for regulatory reasons, so the solution appeared to be telemedicine, Smith adds. “We couldn’t afford to have a practitioner on site, full time, so we had to think more remotely,” Smith explains. “We had to have a change to state legislation to allow Title X family planning nurses to dispense without having an advanced practice nurse on site.”

This process took three years, from 2016 to 2019. The change also opened the path for more telemedicine because an advanced practice nurse can be involved, remotely, while a family planning nurse handles onsite visits.

The way the process works now is that advanced practice nurses connect through telemedicine. “We had a contract with another family planning center that their advanced practice nurse would provide services to us,” Smith says. “We added to our contract that they would do telemedicine visits on demand, when their schedule allowed, and it was a win-win.”

Since the pandemic resulted in North Dakota issuing a stay-at-home order, the Richland office has operated remotely. “A lot of nurses are working from home,” Smith says. “We have advertised on Facebook that we’re still here. Family planning is an essential service.”

Telemedicine has helped women maintain access to birth control during the pandemic.

“I think that it’s more important now than ever to make sure our patients have the tools they need to plan their pregnancies or to avoid becoming pregnant, if that’s their desire,” Paris says. “Pregnancy right now is a very fraught time as our pregnant patients are very worried about the health of their pregnancy during the pandemic.”

Dartmouth-Hitchcock has used telemedicine in an innovative way to ensure women have access to any form of contraception they choose. Contraceptive counseling, starting new contraception, and shared decision-making sessions are performed via telemedicine, Paris says. “We still bring patients into the office to start LARC [long-acting reversible contraception] methods — IUDs [intrauterine devices], implants, and injectable methods — which need to be done in person,” she adds.

Their offices have postponed many gynecological visits, but not contraceptive visits, Paris adds.

“We’re trying to provide the same access to contraception that they would have had without the pandemic through a telemedicine visit or inpatient when necessary,” Paris says.

REFERENCE

  1. Center for Connected Health Policy. State Telehealth Laws & Reimbursement Policies: A comprehensive scan of the 50 states & the District of Columbia. Fall 2019. https://www.cchpca.org/sites/default/files/2019-10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf