COVID-19 has completely changed the telehealth landscape. In the wake of social distancing advisories, shelter-in-place orders, quarantine recommendations for suspected cases, and a terrifying lack of PPE, traditional in-person health care delivery has been forced to migrate to telehealth overnight.
TELEHEALTH AND COVID-19
BY LISA BARD LEVINE, MD, MBA AND MEGHAN GUIDRY
A CRITICAL CHALLENGE FOR THE U.S. HEALTH SYSTEM
The U.S. health care system is at a critical inflection point. For the approximately 100 million Americans who are uninsured or underinsured, access to comprehensive care continues to be a barrier to health and well-being. Many of these patients rely on free or low-cost community health centers (CHCs) for vital primary care. But too often, CHCs are not equipped to care for patients with complex or chronic conditions such as heart disease, diabetes, respiratory conditions, rheumatoid arthritis, Alzheimer's disease, developmental medicine conditions, and other illnesses that require the expertise of a highly trained physician specialist. Though clinics can offer referrals, patients frequently face barriers including long wait times, out-of-pocket costs, travel distance, and more—leading to patients going without the vital specialty care they need. This vicious cycle leads to worsening conditions, hospitalizations, increased emergency room visits, decreased quality of life, and even death—all of which could be avoided with timely access to the right care at the right time.
COVID-19 PANDEMIC: CHALLENGES TODAY, TOMORROW, AND FAR BEYOND
Compounding these existing challenges is the COVID-19 pandemic, which has rapidly spread across the country. While the situation continues to evolve daily, we know that in the days and weeks to come, our health care system will be pushed beyond its breaking point. Hospital and ER capacity is expected to be severely strained and exceeded, leaving fewer pathways for individuals to access the urgent care they need.
Efforts to mitigate the spread of this disease and protect those most at risk are also creating confusion about when and how patients should seek care for suspected infection, as well as for managing ongoing chronic conditions.
CHCs are experiencing new and unique challenges in this crisis, including: the need to adopt telehealth services or adapt to some telehealth mechanism; decreasing revenue and volume due to sequestration; delaying some needed chronic care management; furloughing or laying off staff, and; inadequate personal protective equipment (PPE) to keep both staff and patients safe during this pandemic.
Frontline primary care providers (PCPs) who dedicate their lives to caring for patients at all points of care are increasingly stressed, further burned out, terrified, traumatized, and becoming ill themselves. All these factors are magnifying a staffing challenge already present in CHCs that are often the only point of care uninsured and underinsured patients can readily access.
In addition, millions of Americans are becoming unemployed as this pandemic continues, leading to a concerning escalation in the number of Americans who will be un- and underinsured during and postCOVID-19. These individuals and families will soon be seeking care in already resource-constrained and staffing-limited CHCs. The very health centers who are struggling to make ends meet and challenged to sufficiently protect vital clinical staff and patients alike are going to see an explosion in demand. The number of PCPs available to work in these resource-constrained CHCs will also be diminished. Lack of access to specialty care for patients at CHCs will likely increase, making necessary clinical care and expertise even further out of reach from those who need it most. Combined, these factors have created a perfect storm that is rapidly pushing our health care system and society beyond their limits.
The challenge today and for the foreseeable future until this pandemic is eradicated is being able to match the supply of PCPs to the demand from patients – both COVID-19 and non-COVID-19 alike. This matching process has always been challenging and is magnified for medically and socially vulnerable populations. Clinics already resource-constrained will be stressed by the challenges of keeping their doors open, further exacerbating the existing gaps in care access.
Strained and maldistributed health care resources will expand and create larger gaps in supply and demand for vulnerable populations in the near future and far beyond.
TELEHEALTH AND COVID-19
For years, telehealth has been seen as a way to democratize medicine by driving down costs, increasing access to care, and making health care delivery more efficient. However, historically, adoption and utilization have remained quite low (~10%), and disproportionally low among underserved communities around this country. Changes in health care have traditionally been quite slow to adopt, far slower than most other industries. The rate of adoption of technology in health care follows the same pattern. COVID-19 has completely changed the telehealth landscape. In the wake of social distancing advisories, shelter-in-place orders, quarantine recommendations for suspected cases, and a terrifying lack of PPE, traditional in-person health care delivery has been forced to migrate to telehealth overnight.
These unprecedented factors have catalyzed a growing national interest in telehealth solutions for assessing, managing, and treating patients while keeping physical distance wherever possible. Clinics and health systems alike are redesigning operations and adopting telehealth to protect the clinical workforce and patients alike, and payers around the country are fast-tracking reimbursements so that care can be delivered in alternative virtual settings from traditional in-person points of care. A major driving factor supporting the need and value for telehealth is the federal government's telehealth policy changes that include the expansion of coverage across settings, the elimination of key state licensure requirements, and the loosening of HIPAA privacy requirements which permit everyday technology to be used to communicate (i.e. Skype, Facetime, or phones).
The three most critical challenges patients and PCPs are facing today are finding availability, access, and answers. Many challenges with health care delivery and access will be related to COVID-19, but others will be related to the management of ongoing chronic medical issues or other unrelated but urgent problems. Telemedicine can help with all these challenges. Telehealth can create access and support where it didn't exist before while maintaining physical distance –thereby extending the reach of care to where it's needed most. Telehealth also doesn't require specialized technology or equipment. It can be delivered via phone, smart phone, tablet, and any computer so long as broadband internet is in place for video-enabled calls.
Telehealth is already proving to be a lifeline during this unprecedented crisis, but we know temporary ad hoc solutions are not the lasting answer. A robust telehealth infrastructure could protect vulnerable patients by keeping them out of clinics and emergency rooms, triage patients virtually to assess for COVID-19, and treat patients with non-COVID-19 chronic or complex conditions virtually and locally to preserve limited hospital beds and health resources. Furthermore, telehealth enables right-sizing where and how care is accessed by connecting front line PCPs to expert guidance and maintaining the social distance necessary to protect our communities. Assessing patients for COVID-19 infection through telehealth – as well as treating chronic or complex conditions virtually – can help ensure patients get appropriate and thorough care while protecting PCPs, effectively deploying health care resources, and lessening the risk of transmission.
Telehealth does have some limitations. Testing such as blood draws, laboratory tests, MRI imaging, and more still require close in-person visits. Similarly, certain conditions require PCPs to lay physical hands on patients to assess, diagnose, and determine recommended courses of treatment. Additionally, social infrastructures and access to non-medical resources can impede telehealth.
Some communities lack broadband internet or reliable access to video capabilities, which makes phone the only mechanism of communication. The closure of public computers with internet access found in local libraries and other public places, and limitations on cell phone minutes and data, makes access to communicating challenging for communities across the country. But despite some of these limitations, the benefits of broader telehealth implementation and usage, particularly in a pandemic such as now, are significant and undeniable.
Going forward, The MAVEN Project is continuing to monitor this tenuous situation and we are prepared to rapidly respond as this continues to evolve. mavenpro-ject.org/covid •
A NATIONAL MODEL OF TELEHEALTH TODAY : THE MAVEN PROJECT
The MAVEN Project (Medical Alumni Volunteer Expert Network - mavenproject.org) supports PCPs in delivering exceptional comprehensive care to patients seeking care at community health centers nationwide via telehealth. We do this by recruiting and retaining a corps of experienced volunteer physicians from top-tier medical school alumni organizations such as Harvard, Tufts, UCLA, UCSF, Stanford, Yale, Cornell, Duke, and many more. Our volunteers work closely with PCPs to educate, advise, and enhance in-place care capacity. Leveraging telehealth technology, our provider-to-provider model enables volunteers and PCPs to consult on patient cases, determine effective treatment courses, manage complex and chronic conditions, and offer guidance to early- and mid-career chronic conditions, and offer guidance to early- and mid-career PCPs to support them professionally and personally while enhancing their capacity to deliver comprehensive care locally.
The foundation of this work is a high-touch program comprised of three core strategies that work in tandem to enhance comprehensive patient care while supporting PCPs professionally and personally:
1. Consults: consults between PCPs and physician volunteers on de-identified patient cases. We offer live video and phone consults, and asynchronous eConsults, which allow PCPs to email volunteers about anything from followup questions to advice on a proposed course of treatment.
2. Education Sessions: focused on practical clinical care, these sessions occur in group settings and use a "grand rounds" model (often a case study or a disease-specific session) followed by rich Q&A sessions. Many of these sessions offer Continuing Medical Education (CME) credits.
3. Mentoring: sessions between PCPs and volunteers support professional development and provide confidential spaces to ask questions. We offer two mentorship tracks: 1) clinical mentorship where PCPs are partnered with volunteers who have deep primary care experience, and; 2) leadership mentorship where clinic leaders are paired with volunteers with expertise in management and clinic operations.
Because these activities all happen virtually through our telehealth platform, we can safely support providers across the country and enhance their capacity to effectively manage and triage patients — ensuring that the right care can be delivered to the right patients at the right times through the right channels.
A benefit of our provider-to-provider model is our ability to more efficiently support frontline PCPs on an outsized number of patient cases while providing vital expertise that can be applied to future cases. Our recent impact data reflects our ability to support PCPs in confirming or augmenting proposed courses of treatment, reducing referrals, and keeping care local to the clinic. We also know that the unique educational components of our services can produce what we call the "multiplier effect," where information and knowledge gained from one case consult or education session has been shown to be applicable and helpful to (directly and indirectly) up to 19 additional patients.
The MAVEN Project is powerfully positioned to support CHCs in both ongoing clinical care enhancement and in mitigating the impact of COVID-19. Our primary goal in response to this pandemic is to continue providing uninterrupted services for a growing number of partners to preserve vital community continuums of care.
Additionally, we support virtual assessment systems, deploy needed education resources, and help to recruit and deploy volunteer physicians. The MAVEN Project has supported clinic partners along with the patients and communities that they serve via weekly educational sessions related to COVID-19, led by infectious disease experts and epidemiologists with over 30 years of experience. These sessions provide key updates and allow for real-time Q&A. We have also launched educational sessions led by psychiatry volunteers to help manage anxiety for patients and providers alike. Finally, we have volunteers with expertise in infectious disease in our corps. These volunteers are available for video consults and eConsults.