Phone and video visits with clinics have been invaluable to patients during the pandemic, but down the track, there’s a distinct possibility that government reimbursement for phone visits may be phased out. Safety net clinics want to start transitioning patients from phone calls to video visits just in case. But are they asking patients the right questions in their haste to make the switch?
That’s an concern California clinics are considering as they assess their patients’ digital literacy.
During the swift ramp-up to telehealth ushered in by the pandemic, health clinics like CommuniCare Health Centers, Golden Valley Health Centers, Los Angeles Department of Health Services, and North East Medical Services embraced simple, efficient, and cost-effective solutions to help serve their patients remotely and deliver quality, compassionate virtual care accessible to all as part of CCI’s Connected Care Accelerator. Learn about their different approaches below.
Communicare Health Centers: Assessing digital literacy
CommuniCare Health Centers began by taking the pulse of its patients’ digital literacy levels. As the staff considered who to flip from phone visits, they wanted to know if patients had the technology skills and equipment to participate in video consults.
Figuring that out was key, given the health centers’ demographics. CommuniCare Health Centers serves a largely rural area in the farmlands of the Central Valley in Northern California, including Yolo County and the town of Dixon in neighboring Solano County, and the larger population centers Davis, Woodland, and West Sacramento. It serves more than 24,000 people annually. More than half identify as Hispanic and 1 in 10 identified as a migratory/seasonal worker. Most earn below the federal poverty level and almost 40% are best served in a non-English language.
Before testing, the health center assumed most of its patients would struggle with video visits, so by default they were being scheduled for phone consultations.
But that assumption proved wrong. The centers’ electronic health records trainer and training coordinator conducted a survey to check this assumption, using a video visit education script so as not to place an additional burden on frontline staff. In one month, the centers were able to convert 137 out of 200 visits from phone to video. The training script was tweaked during the course of testing, then the final version was rolled out to front office staff. The health centers increased video visits from 8% in March 2020 to 32% and counting.
In the course of the pilot the care team learned:
- Keeping the script short was best; otherwise patients lose interest.
- Receiving a tutorial on how to start a video visit via text message was vastly preferred by patients over a phone tutorial by a staff member.
- Training front office staff on how a video platform works is also important. Staff who understand the platform can more easily explain its use and benefits to patients.
Golden Valley Health Centers: Tapping in-person appointments to discuss video visits
“Problems with video visits mostly have to do with tech. The patient handout on video visits was helpful….going over it during the appointment helps.” –Care team member
Golden Valley Health Centers used the opportunity of in-person appointments to engage with patients about considering a virtual appointment for follow-up visits. The centers also used the time to provide any technical assistance necessary.
The Golden Valley network serves patients in Merced, Stanislaus and San Joaquin counties, a rural service area that’s home to one of the most productive agricultural regions in the world. The health centers’ patients come from historically underserved low-income and immigrant communities, including Latino and indigenous migrant and seasonal farm workers.
Golden Valley wanted to see if scheduling patients at the clinic level (rather than through the call center) would help prepare patients and address potential concerns around virtual appointments. Staffers made sure that patients received a video visit handout and, if patients had a phone or another device with them, staff members could help set up the initial online appointment. Of course, this only worked if a patient had the device they planned to use with them at the time of their in-person visit.
And staff time is a factor: Patients can need anywhere from just a few minutes to much more time with assistance reviewing what to expect from a video visit and offering technical support..
LADHS: Testing a screening tool for video visits
“The patients I talked to said they would be willing to do because of the flexibility –and the pandemic. ” –LADHS substance use counselor
The Los Angeles Department of Health Services is an integrated health system made up of 28 locations in Southern California. DHS serves a wide variety of diverse communities, typically individuals with socio-economic challenges. The health provider wanted to test a screening tool to convert patients to video visits. The tool focused on questions to ask patients regarding their willingness to participate as well as challenges that might serve as barriers. It also asked questions to determine social needs and the supports available to patients, should they need assistance.
Here’s what they learned:
- Patients do need an adequate device data plan and equipment to participate – and adequate hardware to ensure connectivity stability.
- Most patients in the 18 to 50 age bracket had good capability and comfort using smartphone devices.
- Patients 50+ had difficulty navigating Zoom independently and required training.
- Monolingual patients had increased difficulty navigating a smartphone device.
- The majority of patients surveyed disclosed that they did not use their wellness portal and expressed concerns with privacy and confidentiality issues.
- In some cases, staff required training to conduct video visits too.
- Barriers such as lack of access to the appropriate equipment can interfere with the process.
The DHS also found that most of its patients were willing to participate in video visits and most had access to equipment, which they had thought would be a barrier. Some had limited data plans, though, that were inadequate for video visits; others lacked 4G broadband data speed capability on their smartphone, which is necessary to conduct a video consult. They also discovered that some patients needed in-person support, typically monolingual seniors. “The patients I talked to said they would be willing to do it because of the flexibility –and the pandemic,” says Mario Godinez, a substance use counselor, who noted that most of his patients have smartphones but lack the 4G broadband data speed necessary to conduct video visits.
North East Medical Services: “Mock-Zoom” trainings valuable
‘I can do video visits. I can make it. I will bring my wife tomorrow to come learn the Mock-Zoom Training.’ –NEMS Patient
North East Medical Services wanted to figure out how to offer an effective training session for patients new to Zoom video visits – and to see if these training appointments would have any impact on its Zoom appointment conversion rate. So it decided to create a Mock-Zoom Training Appointment session that patients could attend to get one-on-one help with navigating Zoom.
NEMS operates 13 clinics throughout the San Francisco Bay Area, with its main clinic located in Chinatown/North Beach. The health service, which sees 65,000+ patients annually, serves a mostly uninsured, low-income community and offers linguistically-competent and culturally-sensitive health care services in many languages and dialects, including Cantonese, Mandarin, Toishan, Vietnamese, Burmese, Korean, Spanish, and Hindi.
The organization’s training sessions were primarily completed in-person with health education staff walking patients through the process. From September 2020 through January 2021, the health education team hosted more than 320 mock Zoom trainings across five sites.
During this time period the team discovered that patients were less willing to convert their upcoming in-person appointments to Zoom as many wanted to come in-person to receive a flu shot. Fewer patients than expected were interested in scheduled Zoom training sessions, and some needed more than one training session to get comfortable with the platform.
The electronic health records team provided data on Zoom appointment retention rates of patients who completed the training and found that the greatest drop-off of patients using Zoom occurred after the initial Zoom visit. If a patient proceeded to a second visit, though, they were more likely to continue to use Zoom over time. One major challenge with the center’s largely elderly population: patients did not know their log-in and password details, as many of them had their cell phones set up by their children.
One tip the team found helpful during training: Explaining why a patient needs to click each link or button. A staffer found using analogies proved helpful. For instance: “You must click ‘Join Meeting’ to enter the room. If you don’t, it’s like you’re standing there at the doorway; you are very close to me but you haven’t entered the room so we can talk. You need to open the door and come in.”
Importantly, celebrate the victories. “Mock-Zoom Training is ‘good’ to learners. I shared the joyful experience from a man with limited English proficiency after providing the training,” says one NEMS health education assistant. “He turned from frustration to satisfaction, saying: ‘I can do video visits. I can make it. I will bring my wife tomorrow to come learn the Mock-Zoom Training.’”
The COVID-19 pandemic upended the way California delivers health care. Health care systems completely restructured their services to keep both their patients and employees safe. Federal policymakers acted quickly to expand coverage and payment for virtual care. The California Department of Health Care Services also dismantled previous barriers to telehealth and began requiring Medi-Cal managed care plans to pay providers for telephone and video visits at the same rate as in-person visits.
As a result, many California health care providers rapidly pivoted from in-person visits to virtual patient visits. For these organizations, this shift has been transformational, as they’ve adopted new technology, overhauled workflows, and redefined team member roles.
The Connected Care Accelerator — a partnership between CCI and the California Health Care Foundation, with additional funding from the Blueshield of California Foundation — selected 40 safety net healthcare centers in California to participate in a 12-month program that provided funding, methods, tools and hands-on technical assistance to enhance virtual care initiatives. In a series of case studies, CCI showcases the most sustainable and impactful solutions and shares advice for fellow safety net clinics who want to integrate similar virtual care strategies.
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