Cornell Scott-Hill Health Center in New Haven, Connecticut, as a community health center, always had faced a range of treatment barriers that made it difficult, if not impossible, for patients to attend in-person appointments pre-COVID – and for which telemedicine would have been a viable alternative.
Among these barriers: the lack of transportation or financial resources to pay for taxis or buses; lack of resources to provide child or dependent care in order to attend appointments; inability to take extra time off work to travel to in-person appointments; and physical limitations or illness that made it particularly challenging.
As a significant provider of behavioral healthcare, Cornell Scott-Hill has patients with fears or anxieties related to leaving their homes, driving, or going to healthcare facilities. It also has patients who experience paranoia when being in the community, and patients who reside in more remote areas of the state who could not easily access a behavioral health provider.
“Given the many challenges our patient population faces accessing in-person care, we have a higher no-show rate than is typical in other healthcare settings,” said Dr. Mark Silvestri, chief medical officer, medical and dental services, at Cornell Scott-Hill.
“Telemedicine technology provides a viable and valuable option on both a scheduled basis as well as when patients do not show up for their scheduled in-person appointments,” he continued. “If we are able to reach the patient by phone, we can, in real time, convert a scheduled in-person visit to a telemedicine visit to avoid prolonged gaps in care.”
Additionally, telemedicine can provide access, where it is limited or unavailable, to certain specialists (for example, gastroenterology), which can be impacted by all of the aforementioned challenges patients face, as well as in instances where there is limited access to specialty providers geographically and/or due to insurance network limitations.
“Prior to COVID, we had very limited use of e-consults and asynchronous telehealth services to support patients’ needs for certain specialty services,” Silvestri noted.
Pre-COVID, there were technologies available to support telehealth, but reimbursement was not uniform nor at parity with in-person or face-to-face visits.
“Due to the social distancing and isolation required in the early stages of the COVID-19 pandemic, payment became a reality and telemedicine instantly became a viable, indeed required, option,” said Bethany Kieley, COO at Cornell Scott-Hill. “Our patients depended on, and we depended on, telemedicine to provide care and treatment during COVID.
“With the resumption of in-person care, we continue to have patients who express a preference for telemedicine or who rely on it to assure continuity of care,” she continued. “We are literally able to meet patients where they are, which was essential during COVID, and has continued to be valuable in both medical and behavioral healthcare since in-person care resumed.”
Cornell Scott-Hill Health Center uses a combination of Doximity, Doxy.me and Zoom/MyChart Patient Portal to provide telehealth services.
Telemedicine technology has provided significantly more access to care in many ways.
“First and foremost, patients can be seen virtually while they remain in their home – eliminating the need for the physical ability to leave their home,” Silvestri explained. “Patients’ caregivers/supports no longer need to provide transportation to the patient, therefore, no longer requiring that appointments be scheduled to the patient’s and the caregiver’s availability, often no easy task.
“Patients seen virtually no longer have to bear the costs associated with transportation or hiring child/dependent care providers, to enable them to attend in-person appointments,” he continued. “Patients can even be seen in very tight timeframes, such as during their lunch hours while at work, or just before work; they can reduce lost work time; and they can reduce the amount of sick/vacation time they use and/or not lose as much in wages when not working.”
Patients can be seen in the safety of their homes, thereby avoiding fears/anxieties/paranoia related to past trauma or real threats in their communities to attend appointments.
“Patients residing in relatively remote areas who previously didn’t have easy access to a local medical or behavioral health provider now can receive regularly scheduled treatment services at home,” said Dr. Ece Tek, chief medical officer, mental health and addiction services at Cornell Scott-Hill.
Technology options that allow asynchronous access to specialty services via e-consults and tele-retinal imaging now are a standard part of care.
“E-consults, for example, allowed providers to ask targeted questions about a patient’s condition, at times avoiding the need for an in-person office visit in the first place,” said Dr. Michael Couturie, chief value and informatics officer at Cornell Scott-Hill.
“Tele-retinal exams performed in the patient’s primary care provider’s office allow patients to be screened for diabetic retinopathy, without needing to wait for an ophthalmology appointment to be available, which due to provider supply and/or insurance network restrictions can be challenging under the best of circumstances,” he added.
Diabetic retinopathy screening was particularly difficult during the early COVID-19 pandemic period, but the investment in developing workflows leveraging this tool continue to reap access benefits for patients, even as the pandemic recedes, he said.
“For telemedicine services to realize the potential outlined in these numerous scenarios, the technology offered needed to be something that patients could access easily, such as on mobile or nonmobile devices, with WiFi or cell reception, and without patients needing to be technically savvy while also being HIPAA-compliant,” Couturie noted.
The provider organization made the switch-over from in-person care to telemedicine at the onset of COVID nearly instantaneously, literally between a Friday and Monday in March 2020.
“When the decision was made that we needed to stop in-person visits, we developed a workflow, shared it with our staff, and Monday morning we began,” Tek recalled. “For patients with access to video technology, it was a smooth transition to virtual care, including video.
“For patients who did not have access to, or who didn’t have the technical savvy, to use video technology, we were and are able to conduct visits with them by phone,” Tek continued. “This has been critical to allow us to continue caring for our patients.”
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MEETING THE CHALLENGE
Cornell Scott-Hill’s clinical leadership and IT collaborated to identify viable, HIPAA-compliant platforms that were rapidly rolled out across the health center.
“Nearly simultaneously, Doxy.me, Doximity and Zoom were implemented to provide telemedicine and access to care to patients,” Couturie said. “Providers were encouraged to use whichever platform they and their patients found easiest.
“In the earliest days of providing telemedicine services, clinical and administrative support staff spent time proactively assisting patients with accessing their telehealth visit,” he continued. “Providers also had to do significant technology troubleshooting with their patients.”
In primary care, and to a lesser extent in our specialty clinics, telemedicine is an option used for chronic disease management and the initial evaluation of numerous acute issues, Silvestri noted.
“We began with Doxy.me, eventually moving to Doximity as our preferred platform,” he reported. “At present, it is not integrated with our current Epic EHR system. Although integration is possible, to date, we have not found it to be necessary.
“It does, however, integrate various clinical decision support tools – for example, UpToDate – as well as various charts and visual aids, and the ability to take screenshots is particularly helpful – for example, for rashes,” he continued.
“We also have been able to add our nursing colleagues to those able to use telemedicine in order to support medication management and review – patients simply can show their medications from their home – as well as for expediting triage of acute issues – for example, a patient calling in with a new rash can start a visit with our triage nurse, who can forward the image to a provider for review, thus expediting resolution of the clinical issue.”
Internal medicine providers have access to e-consult options provided via collaboration with Yale New Haven Health and through the Epic EHR.
“Furthermore, with expanded access to tele-retinal cameras in all of our internal medicine clinics, we are able to offer screening for diabetic retinopathy, as we have mentioned,” Couturie said. “These high-quality, high-resolution images are evaluated by a trained ophthalmologist, without the need for a full appointment, thus vastly expanding our capacity to screen these patients appropriately.”
During the period of the pandemic, when most of the organization’s care was provided via telemedicine, the medical no-show rate decreased significantly, although this has trended up again over the past 12 months.
“Our MyChart patient portal sign-up rate has increased to historic levels, which helps increase patient access to their data and their care teams, fostering more of an ongoing dialogue and increased patient awareness regarding their care,” Silvestri said.
“Another significant metric has been the increase in screening for diabetic retinopathy that has resulted from acquisition and installation of additional tele-retinal cameras,” he reported. “Thanks to increased screening, we’ve identified a number of cases of retinal disease that might otherwise have gone undetected. We are currently setting up a camera for our homeless healthcare team so they can do screenings in the field.”
In behavioral health, Cornell Scott-Hill Health Center has seen increased engagement and retention, and improvement in symptoms; the no-show rate also has decreased significantly, Tek said.
“Patients previously at risk of discharge for a pattern of nonattendance or who chronically missed appointments were able to remain engaged in treatment, and patients who needed to be seen more frequently but were previously unable to, due to the aforementioned reasons, were able to increase the frequency of their visits,” Tek added.
USING FCC AWARD FUNDS
Cornell Scott-Hill Health Center was awarded $713,726 from the FCC telehealth grant program.
“The FCC funding has funded the tools necessary to make the difference between widespread successful use of telemedicine and associated continuity of care for our patients and the alternative: gaps in care with adverse consequences for patients,” Kieley said.
“Specifically, the funding allowed us to purchase the tools needed for our staff to function at their best capacity to serve our patients, including: purchase of 18 tele-retinal cameras, purchase of an enterprise Doximity license, and purchase of equipment necessary to enable telehealth and/or remote work so we didn’t have to rely on employees’ individual access to personal equipment,” she continued.
Those purchases included 300 VoIP phones and 100 computers/laptops with supporting devices, such as web cameras, monitors and keyboards, she added.
“Additionally, we’re collaborating with the local public housing authority to pilot placement of telehealth access points in their communities,” she noted. “This will allow residents who have difficulty accessing telehealth services, whether due to technology limitations or lack of understanding, to take advantage of the convenience of telemedicine.”
These purchases will allow sufficient technology to remain in place even after the public health emergency is lifted, and COVID protocols and limitations diminish.
“The widespread use of telemedicine has demonstrated it is applicable and beneficial to the communities we serve in a wide array of circumstances and that it allows greater accessibility and convenience for patients, thereby providing short-term and long-term benefits,” Couturie said.
“After the public health emergency has concluded, and to a degree even before then, there will be a closer look at the impact of telemedicine on care, as there rightly should be, across the board,” he continued. “Operational outcomes and clinical outcomes will be examined, and we will learn from that data as individual institutions, even as the broader impact is assessed across populations nationwide.”
Going forward, the impact of the accelerated and expanded use of telemedicine, and the continuing reimbursement for telemedicine services, will allow it to be applied more broadly in day-to-day care and will influence how and whether telemedicine can continue to be a valuable and valued element in providing the best possible care to a wide range of patient populations, he concluded.