More than 69,000 people are homeless in Los Angeles County, with many thousands in the tents and encampments lining the streets of metropolitan LA. Among the health care organizations serving the unhoused and low-income communities is the Los Angeles Christian Health Centers. a faith-based health provider that operates two full-time clinics, eight part-time satellite clinics, and four street teams in different neighborhoods of the city: Watts, downtown Los Angeles, South-East LA, and Boyle Heights. The safety net health organization, which is partnering with CCI’s Virtual Care Innovation Network, specializes in caring for people experiencing homelessness and other underserved communities.

The centers’ flagship clinic, Joshua House, provides comprehensive dental care, healthcare and wrap-around services to residents in local shelters and  permanent supportive housing​. Its street medicine team brings healthcare from the clinic—including STI and hepatitis C testing, COVID-19 and monkeypox vaccines, and wound, skin, and other basic medical treatment—to the streets, overpasses, and riverbeds where thousands of Angelenos live in tents, boxes, and other makeshift dwellings.

But the LACHC is also concerned about chronic, potentially life-threatening diseases such as diabetes. As part of its mission to provide quality, comprehensive health care, Los Angeles Christian Health Centers wants to improve health outcomes for its patients with uncontrolled diabetes, which worsened during the pandemic. Many of the centers’ patients with diabetes have other illnesses as well as challenges such as food insecurity and low health literacy. When COVID-19 became a public health crisis, many of these patients had difficulty coming in for care or participating in virtual care, which undermined their ability to manage their diabetes — even with outreach from staff and volunteers. During the pandemic, the centers’ rate of untested or poorly controlled diabetes rose by 21 percent. This was especially worrisome because untested or poorly controlled diabetes can interfere with health outcomes and quality of life for patients and can lead to life-altering complications.

So this year the organization has prioritized tackling the problem through telemedicine. The clinic offers telehealth appointments via the platform Doxy.me, and provides a brief and informative instructional video on how to access these visits on its website. Patients can join appointments via mobile phone (video/phone), home phone, or computer (video).

The health clinics’ goal, for its pilot project as part of the Virtual Care Innovation Network, was to improve the rate of diabetes control among its patients by 10 percent as calculated by percentage of rate of change – a marker that it achieved. Its numbers improved from a baseline of 44 percent with untested/uncontrolled diabetes to 40 percent within the pilot period, and they have continued to improve since then.

Patients saw the value in telehealth visits. Said one: “I get a phone call every two weeks with the opportunity to go over my medicines and to control blood sugar. It’s better to have these visits over the phone.” The organization alsodubbed the program a success: Some 25 percent of pharmacy patients with uncontrolled diabetes agreed to try telehealth. The pilot would likely have made even more progress, observes Jose Luis Orozco, LACHC’s quality improvement coordinator, were it not for the typical pandemic problems: COVID surges and staffing shortages. “We may have seen faster change without those challenges,” says Orozco.

The challenges of telehealth and diabetes

From the provider perspective, there are a lot of plus sides to telehealth. “I have a much higher show rate,” said Katie Johnson, a former clinical pharmacist at LACHC. “I had many no-shows in person; on telemed the patients usually answer my calls,” she explained. “Patients do not have to take time off work, they often take a break to answer my call. The visits are much faster for me and the patients.” Frequent follow up is easier, and patients are more willing to speak frequently, too. At one of the organization’s sites, space had always been an issue; telemedicine eliminates that hardship, added Johnson.

 

Discussing the downside of virtual visits, Johnson notes that sometimes it can be difficult to communicate or “reach” a patient via phone versus in person. Offering physical handouts isn’t an option; in addition, in some telemedicine visits, patients may be distracted or have a side conversation with a co-worker or family member. And it’s not possible to conduct glucose checks or blood pressure checks (at least without remote patient monitoring in place) as is the case in person. Likewise, lab work—such as A1c tests or urine checks—obviously aren’t an option via a virtual appointment and patients may not go to a lab to get those glucose tests done.

Patients flagged that, too. “Every time I would go in. I would have my blood sugar checked and [the pharmacist] would see how high or how low it was or if there was anything else going on,” a patient explained. “It would immediately be checked out and addressed instead of having to wait to be seen in person after a phone visit.”

Physician assistant and diabetes care champion Irene Kim shares many of the same pros and cons. She appreciates being able to verify and finetune the medications her patients are taking. She likes knowing what glucometers they are using to try to improve glycemic control. And she values the higher frequency of follow-up visits and the consistency that brings, especially for patients who might typically no-show and/or live far from the clinic. More frequent visits also allow for reminders about dietary changes and eating habits too, though it’s harder to use visual aids for diabetes care or diet education.

Other drawbacks: Teaching patients how to start using injectable medications requires an in-person visit, as does picking up new medications. Sometimes it can be hard to gauge how a patient feels about a new medication, says Kim, or to develop quite the same rapport with a patient virtually.

The centers figured out early on which patients the pilot would work best with. “Many of our patients experiencing homelessness do prefer in-person care or interacting with our street medical team,” explains chief medical officer Katy White. “The patients who seem to do better with diabetes virtual visits were the ones who were motivated to change.”

When the pilot began, some patients had barriers that the clinic staff weren’t aware of. Given those factors, the centers developed a motivational assessment screening tool to better serve their patients and direct them to the appropriate care team members and resources. The assessment asks patients if they are experiencing any barriers such as money, housing, transport, food security, time, and motivation. It also asks patients to self-assess their level of motivation in controlling diabetes.

“Just using the motivation tool helps me identify patients who would benefit from more visits,” says White, who adds that the assessment instrument is integrated into the centers’ electronic health records, which makes it easy to guide patients to the appropriate resources and people.

For the most part, patients expressed satisfaction and gratitude for frequent virtual visits and providers helping them to take responsibility to reach their goals. The bottom line: Anything that helps patients get uncontrolled diabetes under control is a win. “When I know that [the provider] will be communicating with me, it keeps me accountable for taking my medications and other lifestyle changes,” noted another patient. “I feel motivated to keep up with my regimen.”

Lessons Learned

Know your patient population — and tailor THE telehealth program accordingly

In LACHC’s case, their target patients have many competing priorities and concerns, including basic survival. They could be difficult to reach; some change their contact details frequently or don’t have ready or consistent access to the Internet. Phone visits proved more successful in many cases than video visits.

Success depends on the efforts of an interdisciplinary team

It takes a village: care coordinators, physicians, pharmacy department, nursing staff,  medical assistants, street medicine specialists, drivers and call center employees, and quality improvement experts all play a role in the success of pilots like this one. Monthly meetings to brainstorm creative ways to improve care for this chronic condition is key.

Designate a diabetes care champion

It’s important to have a leader who focuses on provider training and enhances patient and provider communication.

Create a motivational assessment

For a chronic condition like diabetes that demands dietary and physical activity changes, medication compliance, and self-monitoring, it’s helpful to have a tool to gauge how to streamline care and provide appropriate referrals.

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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.