Written by: Center for Care Innovations

Like so many other safety net clinics during the pandemic, Tri-State Community Health Center began offering telehealth services so that patients could connect with primary care providers and team members through secure and safe real-time video or audio appointments. “As with any other health center, there were lots of bumps in the road when COVID-19 first started,” says Maria Sotnikova, the chief operating officer at the center. “Telehealth gave us a lot of opportunities to continue to provide a high quality level of patient care.”

The Tri-State Community Health Center, part of the Virtual Care Innovation Network, operates in California, Arizona, and Nevada. It’s a federally qualified health center, with clinics in San Bernardino, Riverside, Los Angeles, and Mohave Valley Counties, among others. Founded in 2014 to provide essential health care services and other support to community members in underserved areas, the center has seven clinics and two mobile services serving 20,000 people. The center works with vulnerable and low-income populations, including those living at homeless shelters or in board and care homes. Notably, the employees at Tri-State speaks nine languages between them. 

Needles, California (Credit: Shutterstock)

Among the low-income communities that Tri-State serves is Needles, a small city in the Mojave Desert with striking rock formations and mountain peaks nearby that gave the area its name. The city – created in 1853 as a place for railroad laborers working on the country’s first transcontinental railway – sits on the western banks of the Colorado River, near the California border with Arizona and Nevada.  Telehealth can be especially valuable in rural areas such as Needles, since it enables patients to meet with providers from home or work rather than driving or commuting long distances to a clinic. Providers and patients alike have learned that virtual appointments offer many of the same benefits as in-person visits, while saving travel time, lowering the risk of infection, and improving continuity and coordination of care. 

Although some conditions require in-person care, Tri-State is able to use telehealth for a myriad of health complaints, including allergies, asthma, conjunctivitis, coughs, colds, flus, sinus infections, fevers, bladder and urinary tract infections, hypertension, and minor injuries. Discussions of lab results, medication refills, parenting concerns, and behavioral health services for mental health issues are also often handled virtually.

Telehealth, of course, has its challenges. Patients new to this kind of service—and initially, that was pretty much everyone—needed support to access technology for online visits. They also needed help navigating platforms such as Zoom and patient portals and troubleshooting Bluetooth blood pressure monitoring equipment, in addition to connectivity issues for video and audio access. Providers, too, need education and technical support.

As part of CCI’s Virtual Care Innovation Network, the center wanted to simplify and streamline remote patient visits for providers and patients. To meet the demand for them, the center made a commitment to invest in telehealth services. It hired its first in-house IT specialist to handle technology problems, set up systems, and educate staff and clients. It helped call center staff come up to speed on video visits and how to prep patients for them. It brought on two primary care providers solely for the purpose of conducting telehealth appointments.

By trial and error, the center also learned that it pays to spend money on infrastructure as well as people. Among other things, the center upgraded from 13-inch laptops to 27-inch screens to conduct telehealth appointments, following patient feedback that it was harder to see and hear providers on smaller screens.

Figuring out telehealth kinks in real time

The center’s goal included doubling the productivity of telehealth providers by increasing the average of two patients seen per hour to four. It also aimed to improve provider record completion rates within 48 hours of a visit from 32% to 80% to ensure timely reimbursement and up-to-date patient health records. The providers met both those goals.

Providers more than doubled their patient record completion rates, with a jump from 32% to 80% of records filed within 48 hours of a visit (green line). (Credit: Tri-State)

But they didn’t do it alone. Telehealth providers are supported by the call center team, IT department, triage nurses, medical assistants, and other team members. Support is crucial, says Sotnikova, adding that all the policies, procedures, systems and infrastructure need to be in place—what she calls “all the pieces of the puzzle”—so that health providers feel confident and comfortable promoting telehealth to vulnerable patients, including the unhoused. It needs to be seen as easy, smooth, and seamless to access care to get all parties on board, she says.

Both providers and patients needed assistance navigating technology challenges and continued education on how best to use all the features of virtual health care, she adds.

Sotnikova also notes that the health center was able to provide care in underserved areas such as Needles, where the need for behavior health services is now being met via telehealth. “We are creative and do our best to reach patients wherever we can,” she says. “Ongoing communication between patients and providers is very important.” Center medical assistants, for instance, travel to homeless shelters and board and care centers with mobile telehealth equipment so patients can connect with providers remotely and regularly. As it turns out, telehealth can help make that connection less challenging for all.

Lessons Learned

Commit to investing in telehealth for the long term

Having the right equipment and staff for the task at hand helps to promote buy-in from both patients and providers.

Address access issues

It’s not enough to have tech tools at the clinic. Bring telehealth equipment where it’s needed – to homeless shelters and board and care facilities, for instance. Make sure low-income clients know how to access free cell phones and data plans.

Provide on-going assistance

To support this work, consider the long game: Team members and patients need sustained education to make telehealth a continued success.

The Virtual Care Innovation Network is a community health collaboration founded and funded by Kaiser Permanente in partnership with CCI, National Health Care for the Homeless Council, the primary care associations in each of the nine states in which Kaiser Permanente provides care, and regional associations in California. Its goal is to design or redesign virtual care models so they continue after the pandemic abates and beyond. VCIN seeks to solve some of the complex challenges associated with the implementation, improvement, and sustainability of virtual care, also commonly known as telehealth or telemedicine,



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