Innovations in Telehealth for Care Teams


The COVID-19 pandemic led to great growth in virtual collaborative care teams with telehealth tools. In one study, the use of telehealth tools in February 2021 was found to be 38 times higher than pre-pandemic levels and a catalyst to home care (reference 1). About 40% of surveyed patients indicated they would continue to use telehealth in the future. Additional research on telehealth indicated positive feedback from both clinicians and family members, along with quantifiable benefits. Telerounding reduced the risk of 30-day readmissions compared to non-telerounding facilities, resulting in fewer missed appointments. Telehealth tools assisted in timely and personalized discharge planning and improved adherence to post-hospitalization plans of care.

Telehealth offers new opportunities to address longstanding challenges in the healthcare system. The majority of our national healthcare spending pays for a small percentage of “high utilizers.” Studies show that 5% of patients, who have two or more chronic conditions, account for almost half of healthcare spending per year (reference 2). Common factors that increase utilization of healthcare MBA include multiple or complex medical conditions, disabilities and untreated mental health concerns such as anxiety and substance abuse. Another contributor to high utilization can be the aggregate effects of social determinants of health (SDOH), which include intergenerational patterns of poverty and systemic racial inequity. Interventions that provide effective home-based solutions and services with telehealth tools and targeted to the needs of high utilizers can generate a cost savings of $45 billion per year (reference 3).

The effectiveness of telehealth interventions stems from their ability to embrace the whole person in the context of the home environment, offering fresh insights that would be missed by more traditional care modalities ((reference 4). Virtual visits also have the potential to decrease healthcare utilization and expenditures by creating a more lasting and personalized support system. An integrated care management program (iCMP) patient virtual visits survey, sent in February 2022 to a selection of 500 randomized patients, explored barriers and challenges associated with virtual visits, as well as patient preferences for communication with their case managers. Seventy-nine percent of those who were surveyed recalled working with a health-related social need (HRSN) community health worker (CHW), and 82% accessed at least one of the resources provided.


Telehealth can support patients in their desire to stay at home and avoid the long-term care facility. Through patient-centered collaborations, the patient and their caregivers are equipped with the resources to fully engage in their primary care. Telehealth tools can encourage medication compliance, offer appointment reminders and alerts and improve access to preventive care opportunities. They can also create opportunities to collect a more accurate patient history. While visiting nurses may have a limited number of visits to the patient’s home, family members may notice behavioral changes they can report to a provider.

Additionally, family members often have questions and need guidance in supporting their loved one to remain safely in the home. Virtual visits and instructional support can teach and guide family and friends to manage their loved one’s care from the home. Caregivers who might feel separated from the care team can also be better integrated with providers through new avenues of digital communication. Caregivers can be provided with supportive educational reinforcement of documented care paths through a telehealth tool and easy access to a supportive care team to provide alerts, concerns or ask questions.


RAND Health, in partnership with a large structured family caregiving (SFC) provider and others, published a white paper outlining barriers that limit family caregiver integration and identify key policy opportunities that can help to facilitate change (reference 5). Some states offer the SFC program as adult foster care (AFC) or adult family living (AFL) provider programs. The report indicated that successful integration of caregivers is key in improving health outcomes in older adults.

In the traditional approach, caregivers are unpaid and often decrease their work hours in order to assist their loved one. Through telehealth interventions provided by the cost-free SFC program, an SFC program can implement a payment system for caregivers in the form of a tax-free stipend. Caregivers in their program also obtain paid respite care, a downloadable, free and secure telehealth app care collaboration platform to connect to providers and receive clinical oversight by an assigned care team member. The caregiver is empowered to be a team member supporting their loved one’s continuum of care. The program results in better integration of family caregivers, who are responsible for 80% of the total estimated economic value of community-based long-term services and supports for older adults (reference 6).

The innovative model connects caregivers to real-time alerts, informing them of changing consumer health and incidents. They can access educational content based on the specific care needs of the consumer or caregiver, and can send and receive text messages and images to share information and facilitate convenient communication. Caregivers also receive coaching and companionship from caregiving experts, and access to a shared calendar to easily schedule and view appointments, events and tasks.


There can be a more sustainable longitudinality and continuity of care generated through a telehealth model. A case study illustrates the impact of telehealth during care transitions. For one senior patient during the day after discharge, friends and family of the patient were not available to prepare the house or assist the patient at home. With the support of telehealth tools, the RN case manager created solutions for the patient and visiting nurse RN to avoid rehospitalization.

In this complex situation, the iCMP RN case manager contacted elder services and obtained a same-day visit. The case manager performed the intake for at-home care and homemaker services. The result was a more patient-centered, personalized and comprehensive form of care that went beyond immediate medical needs. The case manager initiated Meals on Wheels and later completed a frail elder waiver (FEW) to qualify the patient for comprehensive Medicaid services. These steps enabled access to other essential services such as transportation, durable medical equipment (DME) coverage, ensured supplementation, daily nurse visits for medication administration and general oversight and increased care hours. The iCMP RN case manager also discussed medication discrepancies identified by the visiting nurse with the iCMP pharmacy. Due to this conversation, they were able to correct the medication list in the EMR system and have these medications delivered to the patient within two business days.


SFC or AFC or AFL are Medicaid programs for those caring for a family member or friend in the same home, providing structured family caregiving and addressing many of the inequities that lead to high utilization of healthcare. To participate, the patient receiving care needs to qualify for Medicaid, live in the same home as the caregiver and have at least one activity of daily living that needs support. Each state may have age-eligibility requirements for the patient and the caregiver residing together. Often, the eligible person is in need of nursing care, the cost of which would be covered by Medicaid. Through SFC, a family member provides the care in place of the nursing home. The family member receives a tax-free stipend for care and also receives coaching by an assigned care team through the SFC program as well as a free care collaboration platform known as a telehealth tool.

Personal coaches assigned to the caregiver through SFC programs will include an RN and care manager, daily check ins, and helping the family caregiver answer questions, finding resources and providing emotional support. Health outcomes through the SFC program can surpass care in a nursing home for several reasons. First, the coaches engage in daily check-ins. Additionally, the caregiver shares the same home, providing continuum of care and the ability to send secure messages to the assigned care team to provide any alerts, concerns or ask questions. Finally, the patient may be most comfortable emotionally in their home environment.


Research on SFC from a provider program across 10 states demonstrates a reduction in readmissions and provides reduced-cost managed care, suggesting that care transitions can be significantly improved through the platform of telehealth. The impact of this approach is a substantial reduction in unnecessary hospitalizations, ED visits and fall-related injuries. Due to the focus on underserved populations, the program can also contribute to a reduction in health disparities. Lastly, the program offers cost savings for the state, reducing the overall burden of care.

SFC utilizing a secure telehealth care collaboration platform demonstrates supporting people to thrive outside of the hospital and adhere to their continuum of care. Without these supports, the emergency department can become a frequent and inevitable destination. Furthermore, as ambulatory patients return home, providers can be uncertain as to whether the patient is compliant with discharge instructions A provider may find it difficult to assess whether someone is safe at home. The elderly, disabled or frail population who have recently left the hospital may also feel anxious or uncertain about the transition. Care transition can be our patients’ most vulnerable time. Someone who was recently discharged may not understand what next steps are needed, or may feel distrust in their doctor or the health system as a whole or feel intimidated in the use of medical terminology. As a result, any intervention to support the caregiver during these critical junctures creates a strong positive impact. A more connected, telehealth-enhanced approach has the potential to address countless challenges that may be otherwise invisible to the provider.

This article was written as an outcome from Collaborative Care Teams & Telehealth Tools: The Future is Now! Presented at the CMSA Annual Conference 2022 by Amelia Wiffin, RN, BSN, CCM, and Barbara Robbins, RN, BSN, MBA.


1. Bestsennyy, O., Chmielewski, M., Koffel, A., Shah, A. (2022). From Facility to Home: How Healthcare Could Shift by 2025. McKinsey & Company. February 2.
2. Zulman, D. M., Chee, C. P., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Richie, C., & Asch, S. M. (2015). Multimorbidity and healthcare utilization among high-cost patients in the US Veterans Affairs Health Care System. BMJ open, 5(4), e007771.
3. Aldridge, M. D., & Kelley, A. S. (2015). The myth regarding the high cost of end-of-life care. American journal of public health, 105(12), 2411-2415.
4. Groom LL, McCarthy MM, Stimpfel AW, Brody AA. Telemedicine and Telehealth in Nursing Homes: An Integrative Review. J Am Med Dir Assoc. 2021;22(9):1784-1801.e7. doi:10.1016/j.jamda.2021.02.037.
5. Friedman, E.M., Tong, P.K., (2020). A Framework for Integrating Family Caregivers Into the Health Care Team. RAND Corporation.
6. New England Journal of Medicine. (NEJM). Supporting Family Caregivers of Older Americans. December 29, 2016.
barbara robbins

Barbara Robbins, RN, BSN, MBAis the director of community partnerships at Seniorlink & Caregiver HomesBarbara works with all members of the interdisciplinary team – nurses, social workers, case managers, discharge planners, practice managers – to support clients eligible for Medicaid long-term services and supports (LTSS) home and community-based services (HCBS). Seniorlink & Caregiver Homes focuses on medically and physically complex clients requiring assistance with activities of daily living by promoting safe, supportive at-home care. The client’s caregiver receives tax-free pay, respite care, a free telehealth care collaboration platform and clinical oversight provided by an assigned care team through Seniorlink & Caregiver



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