“Telehealth Allows for Flexibility and More Equity”: Provider Perspectives on Telehealth for Outpatient Palliative Care for Underserved Patients

Abstract

Background:

Telehealth for outpatient palliative care has grown rapidly since the COVID-19 pandemic, yet there remain important questions about the use of telehealth for underserved patient populations in a “postpandemic” society.

Objective:

To examine current perspectives from interdisciplinary providers on the use of telehealth and in-person care for outpatient palliative care among underserved patients.

Methods:

We conducted semi-structured interviews with outpatient palliative care providers and clinic staff (n = 17) from one health system in the United States.

Results:

Providers endorsed tele-palliative care for underserved patients because it enhanced patient-centered care and increased equity. However, providers noted two main challenges to the use of telehealth: technological issues on the part of patients and policies around prescribing controlled substances.

Conclusions:

Future efforts to improve tele-palliative care for underserved patients may focus on technological and institutional infrastructure to support telehealth and consider policies around prescribing controlled substances for palliative care patients.

Key Message

This study highlights current provider perspectives on the use of tele-palliative care for underserved patients in a “postpandemic” society.

Introduction

Patients from underserved communities, or those with low socioeconomic status, rural residents, who belong to a minoritized racial/ethnic group and/or have limited English proficiency (LEP), have historically experienced disparities in palliative care access and quality.^1–6 Telehealth may expand access to palliative care for underserved populations but may also pose challenges for building the trust-based relationship intrinsic to high-quality palliative care,^7–9 particularly for underserved patients who are less likely to receive goal-concordant care for life-limiting illnesses.^4,10,11 As telehealth continues to be widely used in a “postpandemic” world, little is known about the persistent or emerging challenges and benefits of telehealth as a standard modality of care, particularly for underserved patients. The purpose of this study was to examine “postpandemic” perspectives on outpatient tele-palliative care from interdisciplinary providers and clinic staff who provide care to underserved patients.

Methods

We conducted interviews with providers and staff at a large academic health system serving rural, urban, and underserved populations in the southern United States from June to July 2024. The site PI (principal investigator) sent a recruitment email to 19 eligible participants, including attending physicians, nurse practitioners, pharmacists, social workers, chaplains, and administrative support staff. Interviews were conducted using a virtual platform and were facilitated using a semi-structured protocol about providing tele-palliative care (visits conducted by video or phone) to underserved patients. Interviews were conducted by two researchers (J.I.B. and J.T.) trained in qualitative methods and with a background in palliative care and telehealth. The interviews focused on experiences using telehealth to provide palliative care to patients from historically underserved communities, including perceived challenges and benefits of telehealth use, as well as strategies to improve the delivery of care via telehealth. Interviews ranged from 28 to 47 minutes and were audio recorded and transcribed. Interviewees received a $50 e-gift card for participation. The study was approved by the institutional review boards at the authors’ institutions.

Interview transcripts were uploaded to Dedoose to facilitate rigorous thematic coding using an inductive approach.¹² Transcripts were coded by two team members simultaneously during data collection using a codebook that was refined during the process. A codebook was developed, and the first five transcripts were coded to test the codebook. Following further refinement of the codebook, the remaining transcripts were coded. Two team members coded the data, and interrater reliability was established following the achievement of a 0.75 kappa score, indicating strong agreement between coders.¹³ Team members, including coders and members of the larger research team, discussed findings throughout the data collection and analysis processes.

Results

We interviewed 17 providers (response rate 89.5%) (see Table 1 for demographics of interviewees). Providers varied widely in the proportion of visits they conducted via telehealth, from a couple of visits a month to 100% telehealth. This variation was mainly due to institutional reasons (e.g., scheduling) and provider preferences. Below we report on themes around challenges to telehealth and benefits of telehealth (see Table 2 for quotes for these two themes). We also report on communication strategies and goals of care (GOC) conversations (see Table 3 for quotes for this theme) and strategies to improve palliative care via telehealth.

Table 1.

Demographics of Interview Participants

Interview participants (N = 17)
Role
Physician (MD)	9 (52.9%)
Nurse practitioner (NP)	3 (17.6%)
Chaplain/spiritual care counselor	2 (11.8%)
Pharmacist (PharmD)	1 (5.9%)
Social worker (SW)	1 (5.9%)
Administrator	1 (5.9%)
Race
White	13 (76.5%)
Black/African American	2 (11.8)
Asian	1 (5.9%)
Multiple races	1 (5.9%)
Ethnicity
Hispanic	1 (5.9%)
Non-Hispanic	16 (94.1%)
Gender
Female	15 (88.2%)
Male	2 (11.8%)
Mean number of years since completing clinical training^a	13.6 years

This question did not apply to the clinic administrator.

Table 2.

Challenges and Benefits to Telehealth: Additional Quotes

Themes	Quotes
Challenges to telehealth
Technological challenges	“The high likelihood of having no working number. People will elect for it. They’ll say like, ‘yeah, call me.’ And then their number has been disconnected. It’s exclusively a busy signal. Actually, they don’t have a phone. You call their landlord, and their landlord has to be home and has to walk them a phone. That kind of thing happens all the time.” (Participant 19, MD) “I think [it] definitely is frequent for patients to have challenges logging on to the video platform… And so, it’s just like not even sort of being able to find that email or click on the link or something’s happening. And then we have issues with folks being able to do that, but then for whatever reason, like not having audio that’s working.” (Participant 09, MD)
Prescribing of controlled substances	“In Atlanta, the law before and now today says that if we’re prescribing controlled substances, we need to see patients in-person every three months, every 90 days. Now, there’s a carve out. There’s an exception, at least now, that says if the person has a I can’t I think it’s his terminal diagnosis, then they don’t have to come in. So then we have this question. What is a terminal diagnosis? Because it’s not defined.” (Participant 03, MD) “If they’re really far and they’re on opiates though, I still have to see them every 90 days. So I can think of one lady who lives a two-hour drive, but because she takes the [health system] transportation, one day I waited for her, and it took her four hours to get to the hospital.” (Participant 19, MD)
Benefits of telehealth
Promotes patient-centered care for underserved patients	“Patients have to pay for parking when they come to our campuses and those parking fees stack up. I know that that’s another thing that many people struggle with. And of course, gas and transportation are a huge consideration because many of our patients can’t drive themselves. So, I think we lose that patient-centered convenience factor, and I don’t want to just minimize it with convenience. I think for many people, it was a game changer for them to be able to still have access to care.” (Participant 01, MD) “I’ve heard time and time again, it’s a long drive to come here. Many of my rural patients hate Atlanta. They hate being in a city. They hate being in a place that has more than three traffic lights or intersections. The valet parking, paying for valet parking, walking around this labyrinthine hospital, it’s too much for a lot of them, even if they weren’t sick. So to push that upon them for no clear medical reason, I think is quite absurd.” (Participant 07, MD) “I would venture to say like 70% of our patients would prefer to do telehealth appointments.... I think patients really enjoy being able to sit in their home and have their loved one next to them and be on the couch and talk about distressing things that are sort of going on.” (Participant 13, MD)
Increase equity and access for underserved patients	“Our patients who are working sometimes will do their visits in between work and it allows them to do that versus stopping a day. And some of our patients, if you’re concerned about those communities, Georgia is a right to work state—our minimum wage is terrible. And if you don’t go, you don’t work. I mean, you don’t get paid. And patients we’re saying are non-compiant may not be non-compliant, they just actually have to make these very, very tough choices. So we make it really hard. This allows for flexibility and I think allows for more equity. The only problem is that we have to have the infrastructure built. To accommodate that as well.” (Participant 04) “So either they were admitted to the hospital or just didn’t feel well or like so either being sick, or not having transport, not having transportation. Basically, once we instituted telehealth, the no show rate dropped way down.” (Participant13, MD) “Many of these patients have a lot of financial needs, being very, very sick. Sometimes they can’t work. Sometimes they’re not getting a paycheck. Gas is very expensive. They have to ask family members to take off work to bring them to the clinic. So, it’s less burdensome financially for them.” (Participant 18, NP)
Provides a holistic view into patients’ lives	“I think that it can be helpful to see people’s surroundings. You get only a snapshot, but a snapshot of their home, you know, where are they sitting what’s around them, who’s around them animals, things on the wall, you know, those are, that’s a window into a person’s life that we don’t have or a different one anyway than when we see them in-person.” (Participant 09, MD) “I can tell when people are living in conditions that are less than ideal. I have patients who have a third-story bedroom, and getting up and down the stairs for anything is extremely difficult. And so, it allows me to assess their living situation. It allows me to make referrals for things that I think they might need. You know whether it be equipment or home health or things to make their lives a little bit easier. There’s really more that works well than I would have ever imagined.” (Participant18, NP) “They can retain some power because they’re surrounded by their stuff. And in the office, they’re very much on my territory. So even no matter how you try to level the hierarchy or make them comfortable, that power dynamic is still there.” (Participant 04, MD)

Table 3.

Communication and Goals of Care Additional Quotes

Engaging in difficult or GOC conversations

“I definitely think it is helpful with counseling. I feel like it’s just as good, just as effective as being in-person because I’m able to, you know, make eye contact with the patient, see how the patient is behaving.” (Participant 16, SW)

“I have been, frankly, surprised that it is not as hard to connect with people on a screen as I might would have thought it was. Many of the patients actually do very well with the goals of care conversation on screen... I suspect it’s because the patient is in their own home. You know, they’re in a setting that’s very comfortable for them.” (Participant 18, NP)

“I think the things that are more sort of discussion heavy, so like having a goal of care, making sure that somebody understands what their disease trajectory is and talking to them about what’s important to them and who’s making decisions. Those are hands down a hundred percent better done this way via video because the patients don’t have to travel anywhere. We can see them in their natural sort of habitat and sort of have a better understanding of like where, how they might be making decisions, how they’re like, what things are, are important to them.” (Participant 13, MD)

“I think the words we use, building rapport, empathy—all of those, like all of our good palliative care skills. I think they translate pretty well on telehealth.” (Participant 09, MD)

Communication strategies

“My general strategy in all of the encounters, whether they’re in-person or telemedicine is like, I’m actively listening to you. I’m not on my phone. I’m not answering texts and pages. I’m not in my email. When you’re talking about something that I need to listen to, I’m not typing at the same time as you’re doing it. I’m here in this encounter with you.” (Participant 05, NP)

“My attunement is hyper focused on things like cadence or when are they pausing? Can I ascertain if I feel like their voice is sort of shaking and, you know, they’re becoming a little bit more emotional? Are they sniffling? Are they crying? What are the background sounds? Are they in the middle of the grocery store while we’re having this call? Oh, a caregiver just came in and now they’re changing their tone of voice and how revealing they’re being with me, so I’m attuning to all those, auditory cues, which is what I have to rely on outside of what they’re describing and how they’re responding to questions.” (Participant 15, Spiritual Care)

“So one strategy I have is just like spending an extra minute or two once I feel that awkward kind of pang to leave. I’m like, I’ll stay for another minute or two, see what else is going on before running away.” (Participant 07, MD)

“I honestly feel that I can build pretty good rapport via telehealth as in-person....I think that as long as you are showing that you are actively engaged in a conversation and doing the things as palliative care providers, we’re trained in communication to do just via video, just like in-person, using the same words that we’re trained to use and these kinds of things to align with patients, show empathy and compassion. I think that communication is still very effective over telehealth, just like in-person.” (Participant 01, MD)

GOC, goals of care.

Challenges to telehealth

Technological challenges

Providers felt that access to a device was not typically an issue for underserved patients but described challenges if the patient did not have a working phone number. For example, one physician described having to call the patient’s landlord to reach the patient if their video platform did not work. Patients often had difficulties navigating the virtual platform or lacked access to quality internet service.

Prescribing controlled substances

Providers reported that state policies for prescribing controlled substances have continued to evolve since the COVID-19 pandemic, and these policies present a barrier to conducting visits via telehealth for many of their patients who are prescribed opioids for pain management. Providers noted the current policy in their state requires an in-person visit every 90 days for patients receiving controlled substances; the policy makes an exception for patients with a “terminal diagnosis” but does not define terminal diagnosis. Providers expressed that these policies are not well-defined and not patient-centered, especially for underserved patients with advanced illnesses who face greater barriers coming to the clinic.

Benefits of telehealth

Telehealth promotes patient-centered care for underserved patients

Providers described how telehealth promotes patient-centered care for underserved patients by offering a virtual option for palliative care, which they noted was preferred by most patients. Providers articulated reasons that patients preferred telehealth, namely transportation challenges and the “hassle” of getting to the clinic while managing a serious illness. While a few providers expressed a preference for in-person visits, they also recognized that patient preference for telehealth carries important value for underserved patients.

Telehealth increases access for underserved patients

Providers expressed that telehealth increases equity and access to palliative care by allowing patients and their caregivers to have a visit without having to miss work or arrange transportation. Providers also noted that “no show” visits or cancelations have decreased following the introduction of telehealth, which may be related to socioeconomic factors such as limited transportation and resources, particularly for underserved patients.

Telehealth provides a holistic view into patients’ lives

Providers described how telehealth offers a holistic view of patients’ lives, in terms of their home surroundings and other aspects of their life beyond their illness. Providers were able to assess if patients’ living situations were “less than ideal” (e.g., bedroom on a third floor only accessible by stairs) and make appropriate referrals if needed (e.g., home health referrals). Telehealth also enables providers to “break the ice” by engaging in short conversations about their surroundings to start the visit. In addition, providers noted that telehealth can level the power dynamic by allowing patients to be comfortable in their own environment.

Communication strategies and GOC conversations

Providers described the pros and cons of communicating via telehealth, particularly for GOC conversations (see Table 3). Some providers preferred to have GOC conversations in-person because they found it easier to establish rapport and be attuned to nonverbal cues. Others felt GOC conversations may be better done by telehealth where the patient is comfortable in their home, surrounded by family members who may not otherwise be able to attend. Some providers perceived no difference in how they communicated between in-person and telehealth visits.

Providers discussed communication strategies for engaging with patients and their family members via telehealth. Many providers noted the importance of maintaining eye contact and proactive communication when they need to look away from the camera (e.g., to view the patient’s medical record or take notes).

Strategies to improve palliative care delivery via telehealth

Providers recommended proactive strategies to address technology issues during telehealth visits. Several providers recommended that clinic staff reach out to new patients in advance to ensure they are ready to use the virtual platform. Other suggestions included having medical assistants virtually “room” the patient or having support staff in a breakout room to troubleshoot patient technology issues. Several providers recommended that clinic staff who schedule visits help triage patients into telehealth or in-person visits based on the reason for a visit.

Providers noted that some of their patients face communication barriers that can make virtual visits challenging, but there are opportunities for telehealth platforms to improve accessibility. For example, patients who cannot vocalize can use the chat feature, and closed captioning can be useful for patients with hearing impairment or LEP. Several providers suggested the need to improve the functionality of the telehealth platform to address communication barriers, such as improving the chat feature, improving closed captioning, and making it easier to include a medical interpreter in virtual visits.

Several providers suggested that for patients living in rural or remote areas, health systems should ideally partner with local providers who could see patients in-person more regularly. Suggestions included dispatching a local nurse to assess patient vitals prior to telehealth visits and having patients’ local providers teleconference with the palliative care team. Providers also suggested alternative delivery models to better meet the needs of patients with serious illnesses who live far from the health system, such as offering a hybrid of home-based visits and telehealth.

Discussion

Providers emphasized the importance of tele-palliative care to enhance patient-centered care and increase equity and access to care in a “postpandemic” society. In Table 4, we outline key findings from interviews with providers and actionable recommendations for improving tele-palliative care.

Table 4.

Opportunities and Actionable Recommendations to Improve Tele-Palliative Care

Opportunities to improve tele-palliative care	Actionable recommendations
Address technological challenges for patients	Clinic staff can reach out to new patients to ensure they are ready to engage with a virtual platform. Clinic staff can virtually “room” the patient or be available to troubleshoot in a breakout room.
Enhance communication through tele-palliative care	Providers can engage with patients by maintaining eye contact and practicing proactive communication when they need to look away from the camera (e.g., communicate the need to look away from the screen to view the medical record or take notes).
Clarify and provide additional guidance for prescribing controlled substances	State policies should clearly define “palliative care” and the criteria for exemption from in-person visits requirements. Better guidance, including a standard of care, is needed around how to prescribe controlled substances safely via telehealth.
Promote patient-centered care for underserved patients through telehealth	The functionality of telehealth platforms can be enhanced to improve communication with patients (e.g., chat feature, closed captioning, ways to integrate a medical interpreter).
Increase access to palliative care for underserved patients	Health systems could partner with local providers to see patients in rural or remote areas more regularly and engage with the palliative care team. Health systems could partner with nonprofit organizations or government initiatives to provide broadband access in rural or underserved areas.

One of the main challenges providers described was restrictions on opioid prescribing, specifically state policy requiring an in-person visit every 90 days for patients receiving controlled substances. Many providers found this requirement to be an arbitrary and unnecessary challenge to efficiently deliver care. Providers noted that state regulations do not clearly define the criteria for a “terminal diagnosis” that exempts patients from the in-person visit requirement. Opioid prescribing policies that require in-person visits posed greater challenges for the most vulnerable patients, including those who are underserved because of financial reasons, rurality, and challenges coming to the clinic. Though we only spoke to providers in Georgia, this issue is not unique to Georgia; evolving laws and regulations concerning opioid prescribing through telehealth have posed barriers to tele-palliative care in other states.¹⁴ In addition to resources for palliative care providers regarding safe opioid prescribing in telehealth, standard policies and practices around opioid prescribing and telehealth are needed. State policies around opioid prescribing via telehealth should more clearly define “palliative care” and criteria for exemption from in-person visit requirements. Better guidance around how to prescribe controlled substances safely via telehealth is important to create a standard of care for tele-palliative care. These types of practice guidelines would be useful in measuring quality and safety for outpatient palliative care delivered via telehealth, particularly for vulnerable communities with limited access to palliative care.

Providers noted that access to a device was not typically a barrier to telehealth for underserved patients, but challenges with telehealth platforms remained an issue. A “virtual waiting room” may also help to ensure that patients are ready when the visit starts.¹⁵ Investing in these resources may ultimately reduce provider burnout and increase access to care, while also improving organizational efficiencies such as decreasing “no show” visits and cancellations. Health systems may also consider partnering with nonprofit organizations or government initiatives to provide broadband access in rural or underserved areas.

This study represents the perspectives of providers and staff (mainly physicians) at one large health system in the South. Results may not be generalizable to all palliative care programs across the United States, for example, policies for prescribing controlled substances via telehealth vary across states.

Conclusion

This study highlights provider and clinic staff perspectives on tele-palliative care for underserved patients in a “postpandemic” period. Providers were overwhelmingly positive about the use of tele-palliative care to promote patient-centeredness and increase equity and access to care for the most vulnerable patients.

Footnotes

Author Disclosure Statement

D.K. serves on the Board of Directors of the American Academy of Hospice and Palliative Medicine. The views presented herein do not necessarily reflect those of the Academy or its members.

Funding Information

This work was supported by a grant from the National Institute of Nursing Research (1R01NR020788-01).

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