Telehealth Use and the Quality of End-of-Life Care for Nursing Home Residents with Alzheimer's Disease and Alzheimer's Disease-Related Dementias

PROJECT SUMMARY/ABSTRACT Expanded Medicare coverage for telehealth services during the COVID-19 public health emergency (PHE) has removed many of the barriers to telehealth provision in nursing homes (NHs). For NH residents with Alzheimer's disease and Alzheimer's disease-related dementias (ADRD), who make up over 60 per cent of NH

residents, increased telehealth provision may allow more timely access to specialty care at the end of life (EOL) and provide clinicians and caregivers with an important layer of audiovisual information to make informed patient-centered decisions. However, EOL care is highly variable across NHs and there are

substantial disparities in the quality of EOL care associated with race/ethnicity and socioeconomic disadvantage. For example, residents who are racial and ethnic minorities are less likely to complete advance care planning and are more likely to die in a hospital. It is not clear how telehealth may impact these

disparities. Additionally, there may be unintended consequences and challenges of telehealth provision for residents with ADRD. Over three years after the start of the PHE, the expansion and phase out of telehealth flexibilities requires a careful evaluation of its capacity to impact the quality, utilization, and cost of care for NH

residents. The overall objectives of this study are to leverage the natural experiments surrounding changes in Medicare telehealth benefits to examine changes in access to telehealth for NH residents with ADRD and in the last 90 days of life. We will focus on the following specific aims to achieve these objectives: (1) To

characterize patterns of telehealth provision at the EOL for NH residents with ADRD, including the overall and relative rates of telehealth to in-person services; (2) To evaluate the extent to which access to telehealth mediates the relationship between resident race/ethnicity, dual-eligibility, and rurality of the NH, and the use of

specialized medical care at the EOL; and (3) To measure the relationship between telehealth provision and the quality and cost of care at the EOL for NH residents with ADRD, overall and by race/ethnicity, dual-eligibility, and rurality. This application is innovative because it leverages a quasi-experimental approach to estimate the

effect of telehealth use, with a focus on the extent to which telehealth may impact disparities in EOL care for residents with ADRD. This project it will be the first to measure telehealth use in NHs for both Medicare FFS beneficiaries and residents enrolled in MA, who constitute over 25% of long-stay NH residents. The proposed

research is significant because as coverage for many telehealth services are set to expire December 2024, this study will shed light on the potential impacts of reducing access to telehealth for NH residents and individuals with ADRD. This project will also importantly inform NIH goals for expanded research on the use and efficacy

of telehealth to improve the delivery of care for people living with ADRD.