In response to the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services (CMS) recently published guidance for states on how to expand the use of telehealth services in Medicaid. For people with disabilities, who may receive health care through Medicaid, this expansion of telehealth has both benefits and limitations.
Telehealth makes access easier
Getting to facility-based health care appointments can be challenging for people with disabilities with or without their own accessible transportation. Problems accessing in-person medical appointments include:
- Public transportation runs on a set schedule, is not available everywhere, and is only suitable if a person can safely get to a pick-up point and it is available where the person lives.
- Paratransit services typically need to be scheduled a day in advance, are not available everywhere, and are often expensive.
- Rideshare options like Uber and Lyft are often not accessible to wheelchair users or users of mobility aids like walkers or scooters and are expensive.
- Accessible parking at hospitals and clinics is typically in high demand and may be limited.
- Many people with disabilities routinely require a caregiver’s assistance to leave home which can be problematic if a caregiver is unavailable, is sick, or has other work/ obligations.
- People with social anxiety, agoraphobia, or similar diagnoses may need to avoid busy public spaces like hospitals.
All of the previous challenges are magnified if a person must travel long distances, or experiences any number of other environmental factors that make getting out of the house difficult.
Telehealth video conferences or audio-only appointments potentially alleviate many of these barriers. Being able to simply call a provider helps increase people’s access to health care. This is especially true for people who live in remote and underserved areas, or have difficulty leaving their home or getting to a doctor’s office. Other benefits of telehealth include improved access to specialists, increased patient satisfaction with care, improved clinical outcomes, reduction in emergency room utilization, and cost savings.
Limitations of telehealth
Phone and video appointments are a good alternative for patient screening and aftercare follow-up appointments when a visit to the provider’s office may not be absolutely necessary. Telehealth is not a substitute when a thorough physical exam is needed, which people with physical disabilities routinely have trouble accessing.
A provider may be inclined to visually examine patients with a videoconference, but the movements and positioning often necessary for a physical exam may be hard for people with mobility and sensory disabilities to perform. This problem increases when a person’s disability causes them to be unaware of symptoms indicating they have developing health issues.
Similarly, people with intellectual or developmental disabilities may not be able to effectively describe their medical problems over the phone or video chat that a physician could otherwise assess during an in-person exam.
Physical therapy (PT) and occupational therapy (OT) appointments are approved for telehealth through private pay and by Medicaid in certain states. Medicare, however, does not cover telehealth PT. Similar to physical exams, PT and OT appointments that require a hands-on approach assisting patients with exercises are often not possible over the phone.
Rehabilitation telehealth should comprise multiple techniques: phone check-ins, video conferencing, and other remote monitoring applications. Therapists need to be able to provide demonstrations, assess how well patients are performing exercises, and track progress.
For people with cognitive or intellectual disabilities, telehealth poses potential challenges if they have trouble using internet-based training or computer technology due to the complexity of the systems or a lack of digital literacy. Some telehealth interventions targeted at people with developmental disabilities require a nurse, health aide, or parent caregiver to assist with the interaction with the health provider.
Even with these limitations, research indicates that telehealth improves adherence to self-care practices for individuals with severe functional disabilities by allowing providers to demonstrate techniques to patients with many opportunities for follow up and educating family caregivers. Additionally, telehealth allows children with developmental disabilities to receive care in a less stressful, less threatening environment.
The numerous problems experienced by deaf patients with video interpretation services illustrate the potential limitations of telehealth video conferencing. Some of the limitations include whether the quality of the video connection or translation services will meet the individual’s needs, whether the telehealth service itself will be accessible, if the people involved will have the necessary training to operate the telehealth equipment, and whether the technology available will support the service for providers and all people with disabilities equally.
Opportunities for health care improvement
Despite the technological and logistical challenges of remotely connecting patients to their health care providers, studies indicate that for people with disabilities – particularly those in rural areas – telehealth provides many benefits for people with disabilities. However, the technology needs to be accessible and appropriately matched to the needs of the patient. This relevant both during the COVID-19 pandemic and for care delivery in the future.
It is important that states and health systems continue to work with people with disabilities and their advocates to identify potential accessibility problem areas when implementing telehealth. The goal should be to make telehealth accessible and functional for everyone.