PROJECT SUMMARY/ABSTRACT Expansion of Medicare coverage of telehealth services during the COVID-19 public health emergency (PHE) removed many of the barriers to telehealth provision in nursing homes (NHs). In 2020, 58% of Medicare Advantage (MA) plans covered additional telehealth benefits in NHs, beyond those reimbursed by Medicare fee-for-service (FFS). Over three years after the pandemic's onset and given that Medicare waivers supporting telehealth use in NHs will end in December 2024, new evidence is critically needed to assess the impact of telehealth on long-standing gaps in access to specialty care and overall quality of care for NH residents with Alzheimer's disease or related dementias (ADRD). For long- stay NH residents with ADRD, who make up over half of all NH residents, increased telehealth provision may allow more timely access to routine and specialty care, provide clinicians and caregivers with an important layer of audiovisual information to make more informed patient-centered decisions, and facilitate communication between residents, providers, and caregivers. While telehealth has the potential to reduce potentially avoidable hospitalizations and emergency department visits for NH residents through these mechanisms and others, there may be unintended consequences of broader telehealth use, and challenges to using telehealth for residents with ADRD. The overall objectives of this study are to leverage the natural experiments surrounding changes in access to telehealth among Medicare FFS and MA-enrolled long-stay NH residents, to examine how telehealth has been used to supplement or replace in-person patient care and to measure the relationship between telehealth use and the quality and cost of care. We will focus on the following specific aims: (1) To examine how telehealth is and has been used for long-stay residents with ADRD, using qualitative methods to generate nuanced insights into multiple predictors of, barriers to, and constraints on use. We will conduct semi-structured interviews with NH medical directors and resident caregivers to explore multiple implementation domains, including NH characteristics associated with telehealth provision.; (2) To characterize the uptake and patterns of telehealth and in-person care from 2018 through 2024 for long-stay NH residents with ADRD; and (3) To measure the relationship between access to telehealth among long-stay NH residents with ADRD and the utilization, quality, and cost of care from 2018 through 2024. This application is innovative because it will be the first to measure telehealth use for long-stay residents enrolled in both Medicare FFS and in MA. It will also be the first to quantify the potential benefits of increasing access to telehealth services in NHs for long-stay residents with ADRD. The findings from our mixed methods approach will provide nuanced qualitative insights on NH leadership decision-making surrounding telehealth, frontline facilitators and barriers to telehealth at multiple levels, and the degree to which family members and caretakers may benefit from telehealth. The proposed research is significant since Medicare coverage of many telehealth services is set to expire in December 2024. This project will shed light on the potential impacts of reducing access to telehealth for NH residents and individuals with ADRD. Importantly, it will also inform NIH goals for expanded research on the use and efficacy of telehealth to improve the delivery of care for people living with ADRD.

PROJECT NARRATIVE Medicare coverage expansions for telehealth and increasing demand for telehealth services during the COVID-19 pandemic have led to a surge in telehealth use in nursing homes (NHs), which may impact the delivery of care for long- stay residents with Alzheimer's disease and related dementias (ADRD). This project will examine how telehealth is provided in NHs and its impact on the utilization, quality, and cost of care for long-stay NH residents with ADRD that are Medicare Fee-for-Service beneficiaries or are enrolled in Medicare Advantage. The results of this study will provide critical evidence to clinicians, payers, and policymakers on the uptake and impacts of telehealth use in these facilities and how telehealth is used in long-stay residents with ADRD.