Transforming Care: The Impact of COVID-19 on Telehealth Adoption in U.S. Home Health Care Agencies

Abstract

Background:

The COVID-19 pandemic accelerated the adoption of telehealth in home health care (HHC). However, the extent and sustainability of telehealth use among Medicare-certified HHC agencies remain unclear.

Objective:

To examine the adoption and utilization of telehealth modalities among U.S. HHC agencies following the COVID-19 pandemic.

Methods:

A nationally representative survey of 474 Medicare-certified HHC agencies assessed telehealth use, modalities, and purposes, comparing adoption patterns between urban and rural agencies.

Results:

Overall, 69% of agencies used telehealth, primarily for care coordination, virtual visits, monitoring, and care initiation. Urban agencies more often adopted video-based modalities, whereas rural agencies relied on audio-only modalities, reflecting broadband access and digital infrastructure disparities. Although telehealth utilization increased during the pandemic, some agencies later discontinued use.

Conclusions:

Telehealth supplements HHC but remains fragile without Medicare reimbursement and a strong infrastructure. Targeted investments and reimbursement policies are critical for equitable, sustainable integration of telehealth in post-acute care.

Introduction

Home health care (HHC) agencies deliver postacute services to a growing number of older adults who are homebound in the United States (U.S.).¹ These patients can particularly benefit from telehealth modalities, such as live video, mobile devices, and remote patient monitoring, which can support the delivery of health care, health information, and education.² In other health care settings, telehealth has been shown to enhance access to services, potentially improving patient outcomes and quality of life.^3,4 Despite its potential benefits, prior to the COVID-19 pandemic, only 16.5% of HHC agencies reported using telehealth for patient care.⁵ During the COVID-19 pandemic, Centers for Medicare and Medicaid Services (CMS) waivers under the public health emergency (PHE)⁶ allowed HHC agencies to provide services via telehealth, though virtual visits were not reimbursable and could not substitute for in-person visits. Despite these limitations, these waivers helped accelerate the adoption of telehealth in HHC as a tool to maintain continuity of care.

One recent study found that, during the pandemic, telehealth use peaked among HHC agencies primarily serving patients with dementia.⁷ Yet, many agencies later discontinued telehealth usage due to lack of reimbursement, technology limitations, and clinical appropriateness for certain patients. While informative, that study focused on a specific subset of agencies and did not examine current telehealth use by modalities or how adoption varies by agency characteristics. To address these gaps and to inform data-driven decisions about telehealth integration in HHC and identify implementation gaps requiring informatics-based solutions, we examined trends in the adoption of various telehealth modalities across a nationally representative sample of HHC agencies, and investigated agency-level characteristics associated with their implementation.

Methods

For this cross-sectional study, we identified a random sample of 1,501 Medicare-certified HHC agencies located in the continental U.S., Hawaii, and Puerto Rico using the 2019 Medicare Post-Acute Care and Hospice Provider Utilization and Payment Public Use Files,⁸ 2022 Q1 Provider of Services data⁹ and the January 2022 Home Health Compare file¹⁰ (data from July 2020 to March 2021), stratified by Census region (Northeast or other), agency ownership (nonprofit or profit/government), rural/urban location, and proportion of people of color (POC). To generate the POC served variable (>50% vs ≤50% White), we merged the 2020 Outcome and Assessment Information Set¹¹ and Master Beneficiary Summary File (MBSF)¹² data by beneficiary identification number and constructed the dichotomous variable using the Research Triangle Institute (RTI) Race Code¹³ by CMS Certification Number (CCN).

As part of a study exploring infection control and preparedness in HHC agencies, we conducted a nationally representative survey from November 2022 to March 2024.¹⁴ Survey respondents included agency administrators or clinical managers, and data were collected either on paper or online via Qualtrics. The survey included three items related telehealth adoption: (1) current use of telehealth modalities (i.e., video, phone, specific devices [e.g., wearable sensors, vital sign monitors, smart pill dispensers]) across various aspects of patient care (i.e., initiation of care/patient intake, virtual visits, care coordination with primary care providers or specialists, remote monitoring, and other services); (2) the perceived impact of the COVID-19 pandemic on telehealth usage; and (3) agencies’ experiences with the COVID-19 PHE telehealth waiver. We created a binary variable indicating whether an agency utilized any form of telehealth for patient care.

Probability weights by strata were applied to account for sample design and nonresponse. Weighted frequencies, means, and standard deviations (SD) were calculated and reported. Comparison analyses between urban and rural agencies were conducted using Pearson’s χ², Fisher’s exact test, or t-tests, as appropriate. All analyses were performed using Stata 17 (Stata Corp LLC, College Station, TX) with statistical significance defined as a two-sided p-value ≤ 0.05. All weighted percentages presented are based on the total number of respondents.

Results

A total of 474 HHC agencies participated in the survey, achieving a 32% response rate for this hard-to-reach population. Table 1 summarizes the weighted characteristics of survey respondents and the corresponding unweighted frequencies. Among respondents, 16% of HHC agencies were rural, 80% were for-profit, and 10% were hospital-affiliated. At the time of the survey, 70% of agencies reported using some form of telehealth for patient care. The majority of HHC agencies (60%) reported utilizing telehealth to connect patients with primary care providers or specialists, followed by 44% providing virtual home visits, 39% offering remote patient monitoring, and 30% reporting their use for patient intake or initiation of care. (Fig. 1).

Table 1.

Characteristics of Agencies Responding to the Survey

AGENCY CHARACTERISTICS	N = 474 (WEIGHTED N = 8,410)
	WEIGHTED %
Rural	16.02
Ownership
For-profit	80.44
Nonprofit	14.88
Government	4.68
Agency oversight
Hospital	10.66
Visiting nurse association	6.41
Medicare only	22.89
Operates Medicare hospice	5.86
Part of a branch	13.83
	MEAN (SD)
Nurse staffing
% RN	62.58 (22.82)
% LPN/LVN	19.69 (19.15)
% Home health aides	17.73 (17.82)
QoPC star rating	3.22 (0.93)
HHCAHPS summary star rating	3.44 (0.97)

RN, registered nurse; LPN/LVN, licensed practical/vocational nurse; QoPC, Quality of Patient Care; HHCAHPS, Home Health Consumer Assessment of Healthcare Providers and Systems (CAHPS^®).

Fig. 1.

Aspects of Patient Care for which Telehealth Modalities are Used at HHC Agencies. The percentage of agencies reporting use of telehealth for aspects of patient care (connecting patients to primary care physicians or specialists = very dark blue; virtual home visit = dark blue; remote monitoring = medium blue; initiation of care or patient intake = light blue; other = very light blue) is reported in weighted %.

When examining specific telehealth modalities used for various aspects of care, we observed notable variation (Fig. 2). To connect patients with primary care providers or specialists, 30% relied on phone calls, 26% utilized video, and 3% employed specific devices. For virtual visits, 25% of agencies used video, 17% used phone calls, and 2% used specific devices. In the context of initiating care, 12% used video, 9% used phone calls, and 3% used specific devices. For agencies remotely monitoring patients, 15% used phone calls, 14% relied on specific devices, and only 8% used video.

Fig. 2.

Telehealth Modalities Used by Aspect of Patient Care. The percentage of agencies reporting use of telehealth modalities (phones = blue; video = green; specific devices = orange; other modalities = yellow) for aspects of patient care is reported in weighted %.

The use of specific modalities varies significantly between urban and rural agencies. Urban agencies were more likely to utilize video technology for virtual visits (27% vs. 17%, p = 0.03), initiation of care/patient intake (13% vs. 3%, p < 0.001), and remote monitoring (9% vs. 4%, p = 0.03) compared to rural agencies. In contrast, rural agencies were more likely to use audio-only options for virtual visits with patients (25% vs. 15%, p = 0.01).

When asked whether the COVID-19 pandemic impacted their overall telehealth usage, 31% of agencies reported increased usage, 9% adopted telehealth for the first time, 11% reported no change, and 3% reported a decrease. Agencies were also asked to describe pandemic-related changes across specific care domains (Fig. 3). The most frequently reported increase was for care coordination to connect patients with primary care providers or specialists (23%), followed by virtual visits (21%) and remote patient monitoring (15%). Only 7% reported an increase in usage for initiation of care. Regarding new adoption, 5% of HHC agencies introduced telehealth for virtual visits, 4% for care coordination, and 1% for remote monitoring. Notably, no agencies reported newly adopting telehealth for the initiation of care, likely due to the Medicare restrictions during the COVID-19 PHE. Additionally, given the limited flexibilities allowed by the COVID-19 PHE waivers, 11% of the agencies reported no change in their telehealth usage for connecting patients with other providers, 5% for virtual visits, 10% for remote monitoring, and 11% for initiation of care. Very few (3%, 2%, and 1%, respectively) agencies reported a decrease in telehealth usage for connecting patients with other providers, initiation of care, and remote monitoring during the pandemic.

Fig. 3.

Changes in Telehealth Usage Due to the COVID-19 Pandemic by Aspect of Patient Care. The percentage of agencies reporting changes in use of telehealth (increased = very dark blue; newly adopted = medium blue; no change = light blue; decreased = very light blue) is reported in weighted %.

Discussion

Our nationally representative survey found that 69% of HHC agencies utilized some form of telehealth for patient care, with the majority using it for care coordination, virtual visits, and remote monitoring. While 31% of the agencies increased telehealth usage during the pandemic, 3% reported a decline in usage, indicating some reduction as the PHE pressures eased. These patterns in our study mirror those observed by Mukamel et al., who found that many agencies serving dementia patients discontinued telehealth postpandemic due to concerns about lack of reimbursement, technology limitations, and appropriateness for certain patients.⁷ While telehealth can extend provider reach and improve care coordination, it cannot be used among HHC providers to conduct start-of-care assessments or replace in-person visits due to Medicare regulations.¹⁵ In the HHC setting, telehealth can serve as a supplement to in-person care, offering additional support between visits, as clinicians are not in patients’ homes around the clock.

However, our study extended and complemented Mukamel’s study in several important ways. First, while their sample focused on agencies serving a high percentage of patients with dementia, our study offers a nationally representative view of telehealth adoption and use across a broader cross-section of HHC agencies. Second, instead of emphasizing longitudinal adoption and discontinuation trends, our survey provides granular insights into how specific telehealth modalities, such as video, phone, and remote monitoring devices, are used across various aspects of care delivery, including patient intake, remote visits, and care coordination.

Most importantly, we identified persistent disparities in the types of telehealth technologies used, with urban agencies more likely to adopt video-based services, whereas rural agencies relied more heavily on audio-only options. These differences likely reflect ongoing structural inequities such as gaps in broadband access, device availability, and varying levels of digital literacy in rural areas. Unlike Mukamel’s study, which focused primarily on adoption patterns over time, our study highlights functional use and modality-specific variation, offering more actional insights for telehealth implementation and policy reform.

Additionally, our study showed that a small but meaningful proportion of agencies ceased telehealth use after the pandemic, highlighting the fragility of its integration into HHC without sustained policy and reimbursement support. While telehealth can enhance provider reach and care coordination, its role in HHC remains constrained, particularly as it cannot be used for start of care assessment or to substitute reimbursable in-person visits under Medicare policy.¹⁵ Therefore, telehealth in HHC should be seen as a supplement to, rather than a replacement for, direct care.

To promote long-term, equitable integration of telehealth, policy efforts should focus on reimbursement for HHC services delivered via telehealth, invest in digital infrastructure, particularly in rural and underserved communities, and support capacity-building for telehealth implementation. Informatics researchers and health systems must also work to develop tools that are adaptable across varying levels of digital maturity among agencies.

Conclusions

This study provides a nationally representative snapshot of telehealth use in HHC following the COVID-19 pandemic, revealing widespread adoption but considerable variation in how modalities are used. Unlike prior research focused on adoption trajectories among niche agency populations, our findings underscore functional uses of telehealth and highlight disparities driven by geographic and infrastructural inequities. To promote long-term, equitable telehealth adoption in HHC, policymakers should prioritize Medicare reimbursement reform, broadband expansion, and targeted implementation support for resource-constrained agencies.