Abstract
Objective
The rapid shift toward home- and community-based care in the US has intensified the demand for home health care, particularly as the population continues to age. Amid challenges such as workforce shortages and increasing patient needs, telehealth has emerged as a potential strategy to enhance care delivery and patient outcomes in home health settings. This literature review examines empirical studies published between January 2020 and April 2024 to investigate the status of telehealth use within the US in home health care settings.
Methods
A systematic search was conducted in PubMed and CINAHL for peer-reviewed studies published in English between January 2020 and April 2024. Quality of reviewed studies was assessed independently by reviewers using quality assessment checklists.
Results
Six quasi-experimental studies were included, examining various telehealth modalities in home health care. Tele-video, tele-calls, and remote monitoring were commonly used for patient education, symptom management, and interdisciplinary collaboration. Telehealth interventions were generally associated with high patient satisfaction, reduced acute care utilization, and improved communication between providers and caregivers. Study quality varied, with limitations in sample size, methodology, and outcome measurement affecting generalizability. Further research is needed to optimize telehealth integration in home health care.
Conclusions
These findings highlight the effectiveness of telehealth in delivering home health care and its potential to address current challenges. These findings also call for policy changes for expanded reimbursement models as well as large-scale pragmatic studies to enhance telehealth integration in home health care to support aging in place.
Keywords
Introduction
The Population Reference Bureau projects a 47% increase in the number of Americans aged 65 and older from 58 to 82 million by 2050. 1 The vast majority of these older adults prefer “Aging in Place”, 2 which underscores a growing need for home- and community-based care. This demographic shift is challenging the US healthcare system to adapt, emphasizing the role of home health care (HHC) in meeting both the care and social needs of this population. HHC encompasses a variety of medical services designed to optimize patients’ physical, mental, and social well-being within their home environments. 3 These services include but are not limited to skilled nursing care, physical therapy, occupational therapy (OT), speech-language therapy, medical/social services, and home health aids. In 2022, approximately 4.5 million Medicare beneficiaries received HHC, with the majority managing multiple chronic conditions, and over one-third diagnosed with Alzheimer's Disease/Alzheimer's Disease-Related Dementia (AD/ADRD). 4 However, home health agencies face difficulties in meeting rising patient care demands, reflected by high referral rejection rates primarily due to workforce shortage.5–7
A potential strategy to mitigate the shortage is by integrating telehealth, defined as the use of electronic information and telecommunication technologies to support long-distance clinical care. 8 A growing body of research has demonstrated that telehealth use improves efficiency and cost-effectiveness with better resource allocations, access to care, and patient satisfactions and outcomes (e.g., less unnecessary emergency room (ED) visits, lower rehospitalization rates).9–11 Indeed, telehealth has become essential within the US care system, particularly since the COVID-19 outbreak. The number of telehealth visits surged from less than 1 million in 2019 to over 53 million in 2020, 12 largely due to the CARES Act and CMS 1135 waiver, which lift certain restrictions on telehealth access for insurance reimbursements.13,14
However, telehealth adoption in home health settings remains limited, primarily due to policy limitations. Current CMS policy restricts direct reimbursement for these services to administrative expenses only. 15 Despite the challenge, the rapid advancement of web-based communication and remote monitoring technologies highlights the potential of telehealth to support “Aging-in-Place.” The implementation of these technologies could potentially save commute times for providers, expand care access in underserved areas, and enhance family caregiver involvement for better communication and decision-making. Embracing telehealth in HHC is not a question of if but when.
Given telehealth's potential in improving HHC but the limited understanding, we conducted a systematic review of existing research on telehealth use in HHC to reveal not only the current status but also inform future practices and policy on its implementation.
Method
Data sources and searches
A thorough literature search was carried out in two electronic databases, PubMed and CINAHL, for studies published in English from January 1, 2020 to April 7, 2024. These two databases are used for their relevance to nursing and healthcare, high-quality and peer-reviewed sources, and comprehensive coverage. We included studies published between January 1, 2020 and April 7, 2024 with the purpose to capture research conducted in the wake of the COVID-19 pandemic, during which telehealth practices expanded exponentially under a range of influencing factors, including federal policy changes such as the CARES Act and the CMS 1135 waiver. The search utilized various terms either as major/medical subject headings or keywords to comprehensively capture the key concepts in this review. Specifically, terms for HHC included “home health,” “home healthcare,” “home care,” “Home Care Services,” “Home Health Nursing,” “Home Care Agencies,” “Home Health Agencies,” “Home Health Care+,” “Home Health Nurses,” “Home Health Nursing,” and “Home Health Aides.” Terms reflecting telehealth were “Telehealth+,” “Telenursing,” “Telemedicine,” “Telehealth,” “telemonitor,” “remote monitoring,” and “Remote Consultation.” After eliminating duplicates, our initial literature search identified 1122 potentially relevant articles.
Study selection and screening
Three reviewers (CM, XC, RL) independently conducted two rounds of screening to identify eligible articles. Articles were considered if they were original research investigating the relationship between telehealth use and patient outcomes or care quality in HHC in the US. Excluded articles included editorials, commentaries, opinion pieces, reviews, case studies, conference abstracts or proceedings, theses or dissertations, research protocols or white papers, policy documents, or qualitative studies. Based on these criteria, 1058 articles were excluded in first round screening of reviewing titles and abstracts. The remaining 64 articles were retrieved for full-text review. The reviewers independently evaluated full texts and excluded 58 additional articles, leaving 6 articles for this review. Any discrepancies in identifying eligible studies were resolved through team discussion. The screening process and results are illustrated in Figure 1.
Flow diagram for article selection.
Quality appraisal of reviewed studies
We extracted key data from each study for critique and synthesis, including research purpose/aims, study design and setting/site, study population and sample size, operational definition of telehealth, and findings on telehealth use and its outcomes. To assess the quality of the included studies, we used a modified version of the quality assessment checklists developed by the Agency for Healthcare Research and Quality for non-therapeutic studies. 16 Minor modifications were made to the original tools to better align with the focus of our review. Using the adapted checklist, we assessed the study design, internal and external validity, and the generalizability of the study. The quality assessment of each study was completed independently by at least two reviewers (CM, XC, RL) and discrepancies between reviewers were resolved via discussions.
Results
Characteristics of reviewed studies
Tables 1 and 2 present the characteristics of the reviewed studies. All six studies used a quasi-experimental design. The study setting/site included a single center/program (n = 2),17,18 multiple home health agencies (n = 1), 19 an individual healthcare system (n = 2),20,21 and a regional health network (n = 1). 22 Five studies used convenience sampling,17–20,22 while the sampling approach was not explicitly stated in one study. 21 The study population encompasses home health patients with diverse conditions such as cardiovascular,20–22 musculoskeletal, 19 cognitive, 18 and oncological 17 diagnoses. The sample size of participants ranged from 9 to 530, with the study involving 9 participants specifying that their samples were from two Medicare-specified HHC agencies. 19 Various data sources were employed, including remote monitoring data, patient assessment data, claims data, patient dairies, and surveys and/or interviews. Most studies used more than one data-collecting method to conduct their research.
Characteristics of reviewed articles.
Outcomes from reviewed articles.
Demographically, the studies covered diverse populations, though most participants were Caucasian, with smaller representations from African, Asian, and Hispanic groups. The age range predominantly exceeded 60, except for one study that included ages 40–71. 17 Gender distribution was balanced in one study, 21 while the others showed notable gender skewness.17–19
Telehealth use
Six articles explored different telehealth modalities. Four studies combined in-person visits with tele-video or tele-calls17,18,20,21: two used tele-video for assessments and patient education,18,21 while two other studies integrated tele-calls with messaging platforms.17,20 Telehealth methods of the remaining two studies19,22 were not described in detail but involved asynchronous communication between providers and patients/caregivers using specific technology platforms. Additionally, two studies explored telehealth's role in facilitating interdisciplinary collaboration among healthcare providers—including nurses, doctors, social workers, occupational therapists, and specialists—for Parkinson's disease and oncology patients, highlighting its effectiveness in enabling timely specialist consultations.17,18 Collectively, these modalities of telehealth provide patient education, health assessments, symptom and medication management, and support for activities of daily living.
Despite variations in telehealth modalities, three studies recognized remote monitoring as part of telehealth, collecting objective data such as vital signs and weight gains.20–22 This data was reported back to nurses and providers through patient portals and applications for follow-ups or interventions as needed.
How well telehealth was used, or telehealth adherence, was also reported in some studies. In two studies, patients’ adherence to telehealth protocols was tracked and remained over 78% on average.18,22 Additionally, the experience related to telehealth use was investigated (n = 5) through patient surveys. Findings showed that as patients gradually adapted to monitoring devices, retests requested by nurses reduced overtime. 22 Notably, in one study, 86% of patients reported that the telehealth platform was easy to use, while 56% agreed and 29% strongly agreed that education on using Zoom for virtual nurse visits (VNV) was satisfactory. 21 In another study, most patients reported “satisfied” or “very satisfied,” regardless of prior technological knowledge. 19
Effectiveness of telehealth (i.e., things changed due to the use of telehealth)
Various patient outcomes were examined to understand the effect of telehealth, including patient satisfaction, patient acute care use, and other outcomes (e.g., quality of life, function improvement, vitals status, cost).
Patient satisfaction is the most reported outcome across all reviewed studies. Five studies reported this outcome using various indicators/perspectives.17,19–22 In general, patient satisfaction with using telehealth to deliver care for them is positive. Most participants expressed high satisfaction with communication during VNV and the education received. Additionally, many patients would recommend this program to others (n = 3)19,21,22 and reported telehealth met their care needs or improved their health conditions (n = 4).17,19–21 Consequently, patients expressed notable willingness to pay out-of-pocket telehealth services and incorporate them into future care plans. 22 Notably, one study also assessed physician satisfaction, reporting a 100% satisfaction rate with the program designed for COVID patient home management. 20 Another study on cancer patients highlighted caregiver satisfaction, indicating that caregivers felt acknowledged and supported with telehealth use. 17
Patient acute care use is another frequently reported outcome, which was reported in three studies including hospitalization, rehospitalization, and ED visits17,20,22: one study employed telehealth to replace all in-person visits, 22 while the two other integrated telehealth in alongside in-person visits.17,20 In the context of COVID-19 management, hospitalization and rehospitalization rates after receiving telehealth intervention were at 9% and 3%, respectively, well below the average national rate of 20%. 20 Furthermore, Abraham et al. 22 reported a 57% decrease in ED visits, accompanied by an increase in unscheduled physician visits following telehealth implementation, contributing to higher patient satisfaction. Landau et al. reported seven readmissions within 21 days of the program, accounting for 47% of the oncology patients involved. 17
Several other outcomes were also reported. In two studies, overall quality of life was reported with mixed findings.17,18 In a study on Parkinson's disease, patients who received four additional virtual visits alongside their routine annual care maintained a stable quality of life, measured across eight factors: mobility, activities of daily living, emotional well-being, stigma, social support, cognitive impairment, communication, and bodily discomfort. 18 In contrast, those who did not receive the extra visits experienced a decline. 18 In another study involving oncology patients, caregivers’ quality of life was assessed using the Caregiver Quality of Life Index—Cancer (CQOL-C) and the Caregiver Reaction Assessment (CRA), revealing no significant improvement. 17 Physical function changes were also reported in two studies.17,19 In one study, the Canadian Occupational Performance Measure (COPM) and the Outcomes and Assessment Information Set (OASIS) were used to evaluate OT patients, collectively demonstrating a positive patient performance improvement. 19 Another study employed the Functional Assessment of Cancer Therapy—Bone Marrow Transplant (FACT-BMY) to assess functional changes among oncology patients, showing no significant improvements. 17 In addition to data from these assessment tools, other patient metrics indicated lower diastolic blood pressure, 22 reduced bodily discomfort, 18 and an increased sense of safety with virtual visits during COVID-19. 21
Assessment of study quality
Overall, our quality assessment indicated that most of the studies were well-organized and clearly written. However, several methodological limitations should be noted. In some cases, the use or implementation of telehealth lacked clarity. The sources and types of data used to assess telehealth utilization and its outcomes varied considerably, ranging from patient-reported surveys to electronic health records, introducing potential inconsistencies in measurement. Additionally, several studies conducted descriptive or bivariate analysis without adjustment for potential confounding variables, thereby limiting the internal validity of their findings. Additionally, outcome measures used to evaluate the impact of telehealth were often justified by the authors or alternative sources, such as administrative claims data, rather than using a gold standard. Furthermore, the generalizability of the findings was constrained by small sample sizes, convenience sampling methods, and the predominance of single-site study settings, which may not accurately represent broader populations or diverse healthcare contexts.
Discussion
Summary of key findings
This study systematically reviewed published literature on telehealth use in HHC and its impact on patient outcomes in the US. Despite the small number of eligible studies identified, our review has some important findings, including (a) telehealth modalities varies widely, with limited tele-video visits; and (b) telehealth generally has a positive impact on patient satisfaction and various patient outcomes (e.g., acute use, quality of life).
In this review, we found tele-calls, patient monitoring, and asynchronous communication were more frequently used than tele-video visits, likely due to reimbursement policies, convenience, technological barriers, and patients’ privacy concerns. Medicare telehealth flexibility, extended by the Consolidated Appropriations Act of 2023 from audio-video services to include audio-only services until 2025, has increased audio-only telehealth usage.23,24 In addition to policy considerations, telemonitoring facilitates vital sign checks, improving accessibility and enabling timelier care than routine video visits, particularly benefiting providers who rely on intermittent assessments. Technological barriers, including limited Wi-Fi, device access, and difficulties installing video software, may also reduce tele-video service utilization. 19 Furthermore, privacy concerns also pose a barrier to tele-video use. For instance, one study reported that exposure of patients’ bodies on camera during OT sessions deterred video-based care. 19 Consequently, tele-calls provide a practical alternative, particularly for older adults and socioeconomically disadvantaged populations, enabling more effective healthcare delivery. 25
Older adults are often perceived as less likely to engage with telehealth due to limited technological exposure and initial hesitation. 26 In reviewed studies, for instance, noted patients reporting stress, anxiety, forgetfulness, outdated devices with poor visual quality, and unreliable Wi-Fi connectivity 19 —issues especially prominent among elders living alone with little prior technology experience. 25 Contrary to these concerns, this review found high adherence and usability among older adults despite limited prior technology experience. 21 This success can be attributed to factors such as pre-program technological education, support from family members, and reinforcement of platform navigation during visits. Overall satisfaction with telehealth was strong among older adults, with them expressing a willingness to pay out of pocket for these services and recommending such programs to others, citing faster responses to care concerns as a key benefit.
Besides patients, patient families/caregivers also found telehealth advantageous in HHC. Caregivers appreciated actively participating in patient care (e.g., managing hygiene, diet, and symptoms), strengthening their relationships with patients. 17 Other studies suggest that, with nearly 120 million older adults needing home care—mostly provided by unpaid family caregivers—technology-enabled interventions, such as mobile apps and connected sensors, can empower caregivers by delivering timely information and enhancing communication with healthcare providers. These tools keep caregivers informed about care plans, increasing confidence and reducing uncertainty. 27 Telehealth also has significant potential to reduce caregiver stress through improved accessibility, eliminating the need to take time off work or commute with patients to appointments. This flexibility can enhance caregivers’ overall well-being and reduce the burden associated with in-person visits.
Telehealth significantly enhances teamwork among healthcare providers. Studies in this review show that telehealth supports interdisciplinary collaborations among care team members (e.g., social workers, occupational therapists, and movement disorder specialists) by reducing geographic and logistical barriers, facilitating easier communication and decreasing travel demands.18–20 Physicians noted its particular usefulness in overcoming practical challenges like bad weather affecting in-person visits. 19 Beyond convenience, by reducing travel time, telehealth also gives providers more time to focus on patient care, reduce healthcare costs, optimize resources, and improve efficiency, ultimately benefiting patient outcomes. These findings underscore telehealth's value in fostering collaboration and enhancing care quality at both individual and systemic levels.
In addition, telehealth was associated with improved patient outcomes. Findings consistently demonstrated benefits including stabilized vital signs, reduced hospitalizations and ED visits, and lower healthcare costs.20,22 Telehealth also improved patient quality of life, likely due to enhanced accessibility and convenience. Additionally, telehealth interventions in OT specifically contributed to safer, higher-quality performance in self-care tasks and mobility. 19 These outcomes indicate that telehealth can address immediate clinical needs and support long-term health maintenance and functional independence.
However, variations in study design, telehealth modalities, and patient populations highlight the need for additional research to identify optimal strategies for implementing telehealth interventions across diverse settings and conditions. The positive findings further emphasize the importance of integrating telehealth into standard care practices to meet evolving healthcare demands.
Limitations and challenges
Our review has several limitations. First, the search only used two databases, PubMed and CINAHL. While these databases are highly comprehensive and search terms were carefully selected with assistance of an experienced librarian, we acknowledge that some eligible articles may not have been included. Second, only papers published in 2020 onward were included, reflecting how the COVID-19 pandemic significantly reshaped telehealth practices, policies, and attitudes among providers and patients. Third, the small number of eligible studies included in this review as well as some methodological concerns of these articles (e.g., small sample size, single-site) limit the generalizability of our findings. Despite these limitations, we believe this review provides valuable insights into the current state of telehealth use in HHC. Moreover, the small number of relevant publications reflects how policy can influence the adoption of innovative care delivery approaches, even when evidence from other care settings demonstrates their benefits.
Implications
Our study has several implications for future HHC practice, research, and policymaking. First, ensuring user-friendly technology is essential for improving outcomes and satisfaction among HHC patients. For example, participants recommended providing one-click hyperlinks to simplify telehealth access. Also, future research should identify the optimal balance between telehealth and in-person visits to enhance care outcomes and cost-effectiveness. While routine follow-ups, patient education, and remote monitoring can effectively be conducted via telehealth, activities such as initial evaluations, physical exams, and hands-on treatments require in-person visits. Given the resource-intensive nature and limited accessibility of in-person care, particularly in remote areas, determining the appropriate integration of these modalities is essential to maximize telehealth's potential. Additionally, though challenges like coordinating healthcare teams and navigating varied insurance reimbursement policies across states exist, future studies should conduct large scale, pragmatic studies for broader applicability. Collaborations among local healthcare systems on larger-scale projects could further enhance generalizability, though such initiatives require financial investment and policy support from state governments and legislative bodies. Policy changes in reimbursement methods are also essential. Adequate coverage for telehealth services in HHC ensures financial sustainability and encourages broader implementation. Future research outcomes can inform policies by highlighting telehealth's benefits, supporting widespread adoption in HHC settings.
In summary, by critically evaluating recent empirical evidence, this systematic review provides one of the first comprehensive assessments of telehealth use in HHC, highlighting the current state of tele-HHC and its positive impact on patient outcomes. Although challenges like technological barriers and privacy concerns limit tele-video visits, other modalities such as tele-calls, remote patient monitoring, and asynchronous communication have demonstrated effectiveness—particularly among older adults and caregivers—in enhancing patient outcomes, satisfaction, and care team collaboration. Our findings provide evidence supporting telehealth integration into HHC delivery and highlight the importance of reimbursement policy reforms to facilitate broader adoption.
Footnotes
Author contribution
Conceptualization: XC; data curation: XC, RL; project administration: XC; writing—original draft: XC, RL; writing—review and editing: XC, RL, CM.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Ma is currently funded by the National Institute on Aging (1R03AG070581). National Institute on Aging (grant number 1R03AG070581).
Date availability
All data used in this systematic review are from publicly available sources. The included studies and their respective datasets can be accessed through their original publications, which are cited in the manuscript.