Introduction

The ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has triggered the coronavirus (COVID-19) pandemic and caused a significant strain on medical institutions, particularly in the acute care setting. This disruption of healthcare services has multiple contributing factors: limited availability of adequate personal protective equipment (PPE), the need for defined populations to stay at home, and the high risk of infection spread among patients and healthcare professionals at care sites^[1]. In order to follow the Centers for Disease Control and Prevention (CDC) guidelines on social distancing and limited group gatherings^[2][3], adoption of telehealth—including telemedicine—has increased rapidly^[4].

While the terms “telemedicine” and “telehealth” are sometimes used interchangeably^[5], our paper distinguishes between them in several ways. Telemedicine refers to the use of technologies and telecommunication systems to provide clinical healthcare services to patients who are geographically separated from providers. For example, this could involve use of an Electronic Intensive Care Unit (eICU) or Tele-ICU, through which remote intensivists diagnose and treat critical patients in rural areas via technology such as videoconferencing. Telemedicine has facilitated specialty care for patients who live in distant, often rural, locations^[6]. Telehealth is a broader term that can refer to clinical as well as non-clinical services. It also applies to the use of electronic information and telecommunications technologies to cover multiple health consultation activities—health monitoring and services, public health and health administration activities, and health education for patients and professionals. In this paper, we will refer to telehealth. Telehealth tools include video conferencing, e-mail, mobile or app-enabled technology, and technologies that transmit clinical information (data, image, audio, and video)^[7].

With the onset of the COVID-19 pandemic, the US Department of Health and Human Services (HHS) declared a Public Health Emergency that temporarily relaxed the existing restrictions on telehealth care^[8]. For example, Health Insurance Portability and Accountability Act (HIPAA)-covered providers may, in good faith, provide telehealth services to patients using remote communication technologies (including commonly used applications such as FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype) for telehealth services, even if the application does not fully comply with HIPAA rules^[8]. Accordingly, the Centers for Medicare & Medicaid Services (CMS) also temporarily expanded access to make it easier for people enrolled in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) to access medical services via telehealth during the pandemic^[9]. CMS expansion currently allows use of telehealth services for: i) patients located in their homes but outside of designated rural areas, ii) remote care, even across state lines, iii) care for new or established patients, and iv) billing for telehealth services (video- or audio-only) as if they were provided in-person^[8]. With these expansions enabling care during the COVID-19 pandemic, more than 9 million Medicare beneficiaries received a telehealth service between mid-March and mid-June 2020^[10]. Notably, telehealth services have also been applied to providing nutrition care for patients^[7],^[11][12][13]. Based on work with hospitals, clinics, and systems participating in the Malnutrition Quality Improvement Initiative (MQii)^[14], we sought to better understand how RDNs were able to care for their patients during the COVID-19 pandemic, with particular focus on the extent to which telehealth services were being used and potential solutions to the barriers that both RDNs and patients faced.

Feedback from the Field

A 20-question survey (see Appendix) was emailed to approximately 200 RDNs whose institutions participate in the Malnutrition Quality Improvement Initiative (MQii). This survey focused on RDN use of telehealth both before and during the pandemic. We received responses from 22 RDNs (19 from RDNs in clinical practice and three from food and nutrition service managers). 20 respondents reported their hospitals are now providing nutrition telehealth services and 2 are not. The 20 RDNs and/or teams currently utilizing telehealth reported using it to provide the following services:

1. Nutrition education
2. Nutrition counseling
3. Nutrition care plan development
4. Nutrition assessment
5. Recommendations for nutrition supplementation
6. Nutrition discharge planning
7. Nutrition screening

Responses offered insights into positive perceptions, areas for improvement, and potential solutions for future support of nutrition care delivery via telehealth (Table 1). RDN respondents commonly reported that telehealth had positive effects on overall nutrition care in their hospitals/systems and rehab facility. Some reported plans to permanently adopt telehealth for nutrition care after the pandemic is over.

Discussion

While it is too early to know the long-term impacts of the COVID-19 pandemic on the US healthcare delivery system, our survey results give us early information about how telehealth can enhance nutrition care. Although the number of our responses was small, we were able to draw on the reported experiences of the MQii Learning Collaborative hospitals and other clinicians to identify opportunities that may help promote quality nutrition care via telehealth and better prepare for future challenges to their practice. The COVID-19 pandemic of 2020 has expedited the adoption of telehealth by many health systems. Information from our survey indicates that telehealth can be an acceptable alternative to in-person clinic and even inpatient visits. In fact, telehealth can enable healthcare providers to maintain usual caseloads and provides patients with uninterrupted healthcare access. Furthermore, telehealth offers opportunities for evaluation and education that might not exist in the face-to-face visit system. For example, telehealth visits have given RDNs the opportunity for longer assessment time with patients and the ability to “look in” their home environments to potentially observe their refrigerators and pantries, allowing further examination of their diet and nutrition habits. In other studies, telenutrition interventions have improved weight loss outcomes in cardiovascular disease patients in a pilot randomized controlled trial^[15] and improved weight status in obese patients^[16]. Telehealth has specifically been an effective resource for improving diabetes self-management in ethnically diverse and rural populations^[17]. A systematic review and meta-analysis reported telenutrition for patients with chronic disease improved diet quality and dietary adherence when compared to face-to-face dietary counseling^[18]. Being challenged by a catastrophe such as the COVID-19 pandemic presents an opportunity to create innovative nutrition solutions; telehealth is one of those.

Perhaps the most critical need to continue expanding access to nutrition telehealth services is advocating to policymakers that MNT is essential for comprehensive and effective patient care. Discussions about healthcare reform need to consider all aspects of care that can be delivered effectively through telehealth means both during and beyond the COVID-19 pandemic. Medicare telehealth requirements that existed prior to the pandemic only covered nutrition services via live-video conferencing and under specific circumstances regarding the patient’s and practitioner’s physical locations. With the onset of the COVID-19 pandemic, CMS has lifted many of these restrictions^[8], resulting in an drastic increase in patient telehealth visits^[4]. Research from the University of Pennsylvania Perelman School of Medicine found that 67% of patients surveyed viewed their video and telephone appointments held during the peak of the COVID-19 pandemic as “positive and acceptable substitutes to in-person appointments”^[19][20]. Our survey respondents reported positive patient experiences related to patients not needing to travel, find parking, sit in waiting rooms, take time off from work or childcare, and/or miss other appointments. It is well documented that the use of telehealth can also improve clinical outcomes, reduce costs^[17][21][22], satisfy patients with their nutrition care, and leave individuals with positive perceptions/attitudes^[23][24]. Further nutrition-specific research is needed to show such improved outcomes among different patient populations, including the comparison of patients between urban and rural areas. Access to technology—particularly for low-income patients, older patients, and those in rural areas—continues to be a concern for telehealth expansion and could prove a barrier for telenutrition, as well ^[25]. Changes to healthcare policy should focus on continuing to expand access to telehealth nutrition services by changing payment policies, allowing cross-state licensure of providers, and providing funding to underserved communities to increase their connectivity and access to telehealth services as well as other changes that expand MNT (Table 2).

Recommendations

Our survey respondents reported positive experiences as well as challenges to using telehealth; they also shared recommendations that underscore a need for continued exploration of the patient, provider, economic, and policy implications of telehealth use. It is still unknown how the rapid and drastic switch to telehealth services during the pandemic will affect providers, payers, and patients financially as well as the percentage of visits that will ultimately return to in-person format. To advance health information technology policies and practices, further research should investigate how nutrition services via telehealth compares to other telehealth services as well as how to overcome barriers and identify the best path forward for providing effective and efficient nutrition care. This can ensure the appropriate patients have ready access to the care they need, regardless of where they reside. Continued research should also explore patient preferences and options for improving their reception to telehealth as well as determining the optimal applications and means for integrating with in-person visits for facilitating transitions of care. We call on healthcare professionals and legislative leaders alike to work together to extend policy and payment changes that will support nutrition care provided via telehealth as appropriate throughout and beyond the COVID-19 pandemic.