Providing Telehealth Visits to Underserved Communities Case Study

Patient using phone for telehealth visit with provider

At the onset of the COVID-19 healthcare crisis, Unity Health Care, Inc., a Federally Qualified Health Center (FQHC) in Washington D.C., found itself bracing for the ensuing pandemic. The patient population has many of the demographic characteristics that make them more vulnerable to the effects of the virus than that of the general population:

89% of the patient population is African American/Black and 19.8% Hispanic/Latino
72.6% of patients have income at or below 100% of the federal poverty level
10.6% of patients are homeless
Three of the health center’s 27 health services sites are within D.C. correctional facilities

By mid-March of 2020, without telehealth visits available, patient visits had plummeted to one third of the normal rates as the nation went in to lock down. Due to shelter in place orders, patients were avoiding visits to the health center, reducing the chance of disease transmission.

However, this introduced another problem. How would patients with non-urgent problems, especially those with chronic diseases, be managed, maintained and supported throughout the course of the pandemic? As the nation moves further into the pandemic, the picture of the devastating impact on people of color is becoming clear. In the District alone, as of May 2020, African Americans are 47% of the cases in District, but represent 78% of the deaths attributed to COVID-19.

Unity also anticipated increased staff call outs due to COVID-19 illness or exposure and expected staff would struggle with the burden of burnout, fear, child care and homeschooling. In the face of reduced staffing and reduced patients, the challenge was to determine how to continue to offer high-quality care for the community and still generate sufficient patient services revenue in order to continue operations. This had to be achieved in a way that would protect patients and staff from unnecessary exposure to infection in the community, on public transportation and in the clinics, as well as minimize the use of personal protective equipment that was in such short supply.

Telehealth was the solution. In recent years, the health center had received several grants directly and in partnership to pilot telehealth models and technology. The FQHC reimbursement model, coupled with the District’s telehealth regulations that did not recognize a patient’s home as an originating site, made direct-to-patient telehealth a financially unsustainable model. Ultimately, the pilots did not lead to a viable business model, which at the time, was frustrating for the organization. However the pilots did yield a foundation of knowledge that included experiences of what applications and technologies did and did not work. It also allowed the organization to develop and test clinic workflows and customize the EHR for a telehealth environment.

A breakthrough came when the Medicaid Authority in D.C., in recognition of the need for enhanced access to care while maintaining social distancing, implemented an emergency rule recognizing the patient's home or location as a reimbursable telehealth (video and audio) originating site. Due to the D.C. Medicaid parity law, audio and video telehealth visits are reimbursed at the same rate as in-person visits. This facilitated the ability to conduct direct-to-patient telehealth visits.

With the change in the reimbursement model, the organization went from conducting nearly zero telehealth visits to over 800 visits daily within a space of 30 days. As the District approaches the peak of the pandemic, Unity is now seeing nearly 1,000 patients a day virtually.

Keys to Success

While still in its early days of realizing the full benefit of telehealth with its patients, the organization has been able to launch telehealth within a couple of weeks, at the same time that many organizations are trying to determine how to stand up their programs. In the case of COVID-19, where a mere few weeks can result in exponential spread, reducing the start time by weeks or even days can save lives. The majority of this fast start is attributed to a few key factors.

Environment of Innovation

Unity has fostered innovation regarding its health information technology since the implementation of its EHR over a decade ago. Like most FQHCs, the organization has had to find a way to work with very limited resources. As a result, the technology is being viewed as a way to leverage and extend resources. Unity believes critical to fostering an environment of innovation is effective change management. Effective change management allows for better utilization of the organizations existing technology resources, in effect reducing the effort needed to manage them day to day. When the day-to-day operations are better managed, it allows the organization to direct the remaining energy to be creative and innovative. To that end, each year, the organization commits in its health information and technology roadmap to review and pilot emerging technologies. Once a technology is placed on the roadmap, the health information technology strategy team works to creatively secure the resources, such as grant funding, to research and pilot the technology. Telehealth was an example of one of those emerging technologies that was primed and ready for implementation because it had been on the roadmap.

The organization is a two times HIMSS Davies winner. This achievement is illustrative of the collaboration—bolstered by the change management framework—between providers and technology groups. These groups are committed to work together to achieve a system that best supports patient care. Without engaged providers to collaborate with technology teams, innovations will never get out of the idea phase. The organizations chief medical informatics officer (CMIO) had served as the provider champion of telehealth. His firsthand knowledge of the telehealth pilots gave credibility to the demands made on providers to adopt the new technology and model of care for the COVID-19 emergency very quickly.

Aligned Incentives

In order to support the adoption of technologies, incentives must be aligned. Until there was a mechanism for the reimbursement for telehealth, the technology lay dormant. Once the District enacted the emergency measures to reimburse telehealth visits, the organization was able to move forward with integrating the technology into its care model. While telehealth was enacted as an emergency measure, tremendous value is seen in telehealth for population health management and for patients who suffer from chronic disease. Because of the benefit already experienced by its patients, even after the emergency is lifted, the hope is that reimbursement continues for telehealth visits through FQHCs.

Challenges and Lessons Learned

The launch of telehealth during the COVID-19 pandemic has been a lifesaver for the organization and its patients, however, there have been both organizational and patient challenges during the deployment. Here are a few illustrations of the challenges and how they were mitigated.

Organizational

Telehealth was launched at the same time that the organization’s more than 250 providers, as well as other health center staff were fanning out throughout the District to provide care to patients either remotely, or at locations such as COVID-19 screening tents or at hotels that the District contracted to address health needs of homeless with COVID-19 who were at risk. There were challenges getting staff set up, ensuring that they understood the application, the technology, the workflows and the rapidly changing laws allowing for telehealth. A number of strategies were deployed to address this:

Creation of a portal dedicated to communicating all aspects of how to conduct a telehealth visit, which included regulations, workflows, documentations, technology and use of the applications. Providers were encouraged to communicate through the portal so that lessons learned could be shared quickly and broadly. The CMIO was responsible for addressing provider concerns and engaging teams and staff in quickly addressing roadblocks.
Amplification of lessons learned through direct emails to staff and other channels created to communicate regarding COVID-19.
Dedication of over 12 hours of technical support for providers to help them with remote access of applications.

There was also a challenge because patients were scheduled to visit the health center for appointments and were not expecting a telehealth visit. Patients had to be contacted quickly to inform them that their in-person appointment would be converted to a telehealth visit. This was accomplished by having the patient scheduling center and other support staff contact patients in advance to notify them of the change.

Patient

The organization is always working to improve its patient population’s access to care. In today’s online world, access to care includes access to technologies and the internet. The result is that with new technologies, there can be new barriers to care. Technology can help to eliminate some existing barriers to care such as transportation, lack of paid sick leave and child care needs, but lack of access to devices and connectivity and limited tech literacy can create new barriers. Patients had no warning that their next visit would be a telehealth visit and therefore received little coaching about the visit.

In launching telehealth more broadly with its patients, the organization has discovered that some of the telehealth technology is complicated for patients to use. For example, some applications require several steps such as the patient having to download an app to their phone and log into the app, or requiring an email address to conduct the visit. This was a barrier for some patients. Unity experienced more success with patients and televideo visits when the application had the ability to send patients SMS messages with links to connect. Also, the organization has been able to engage patients who are unable to connect by video by conducting the visit through an audio-only visit. Unity advocated with its EHR vendor to add features such as the SMS text message connections for patients and has had good response from the vendor for the requests for changes.

Though there were technical challenges with connecting to patients, Unity feels optimistic about the ability of telehealth to go beyond the basic care of the patient to significantly improve the overall relationship with patients. There are some concerns that perhaps poor and minority patients will be suspicious of health information and technology. It has been the organization’s experience that the majority of patients are pleased about the use of technology for their care. Most patients appreciate that the organization has invested in technology to provide for their care and in effect has invested in them. This is seen with the adoption of the EHR and other health IT. With that in mind, telehealth holds the possibility of enhancing the relationship with the healthcare team and the patient.

The Future of Telemedicine

Thus far the telehealth program has been largely provider-driven and the majority of visits have been conducted using audio-only technology. Initial workflows were simple and focused on the patient-provider interaction. This allowed for the rapid expansion of telehealth capacity to a patient population with limited access to technology. Further engaging other staff members, with a goal of making telehealth visits resemble, as closely as possible, an in-person visit is a critical next step in the development of a telehealth program. Identifying patients with the technology necessary to conduct video visits and assisting them in navigating any barriers to utilizing this modality will also be a focus. Plans in the near term include:

Training staff to assess patients’ capacity to conduct video visits, assist patients with connecting to a test visit prior to their scheduled appointment and troubleshooting any technology issues that may arise.
Providing additional written or verbal patient education to patients about what to expect during a telehealth visit and how to best prepare for the visit
Training medical assistants to initiate telehealth visits to collect chief complaints and other clinical information from the patient, conduct screenings for depression and substance use, and walk the patient through measuring vital signs if the patient has devices available at home.
Identifying patients with chronic conditions such as hypertension and diabetes. Determining if they have monitoring devices such as blood pressure monitors and glucometers at home and assisting them in obtaining these devices if they do not.
Utilizing telehealth visits, when possible, to help patients who are at high risk for poor outcomes from COVID-19 understand how to avoid viral exposure and know when testing is needed. Recognizing that patients may have higher viral exposure due to homelessness, high density living situations, or living with or being an essential worker, prevention guidance that is customized to their risk level may be required.

Longer term, Unity plans to look at the impact that telehealth has on health outcomes. There is the tremendous potential in continued use of telehealth for care coordination, chronic care management and integration into the population health management strategy. For these reasons, Unity plans to advocate that telehealth services be made available for patients beyond the emergency rule brought about by COVID-19.

Conclusion

Telehealth visits have allowed the organization to continue some very critical, but not always urgent visits with patients during COVID-19. Before telehealth, the choices would have been limited to having the patients risk returning to the health center for care or having the patient foregoing services until a later date. With vulnerable patient populations both of these options were significant risks. Telehealth has allowed for a middle ground. It has allowed Unity to continue to care for and connect with these patients in an effort to keep them as safe and healthy as possible during this time.

The views and opinions expressed in this content or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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Tags: Emerging Technologies, Population and Public Health, Technology, Care

Published on June 4, 2020