Video visits – a key component of telehealth – hold both great promise and great responsibility. For health system leaders, it’s an opportunity to deliver high quality care to more people. However, if we’re not intentional about implementing this service, we risk exacerbating the existing health disparities in our communities. With us for this episode are Jason Cunningham of West County Health Centers (WCHC) and Jeffrey Glenn of Neighborhood Healthcare. Both have successfully rolled out telehealth video at their respective organizations by helping their leadership and providers align to make video visits a priority.
Listen and subscribe to the CCI Health Pilots podcast on Apple Podcasts, Spotify, and elsewhere. Below is a transcript of the episode, edited for readability.
EPISODE TEASER:
“I do think people who are comfortable on video feel like it’s better. And so, I think it’s now the default. It’s no longer an uphill battle for us. So, I think that we’re committed. I think we also know that there’s a future around integration. I think we’ve crossed over that hump of it being a “freak out” factor. Now it”s an opportunity.” [Jason Cunningham]
“…Back in the day, before the pandemic, I would walk through our facilities and at 5 o’clock they’d still be full of people. Now, there’s really nobody there, the parking lot’s empty. So, I think we’re just more efficient also by doing video. And like Jason said, telehealth should be an integral part of primary care.” [Jeffrey Glenn]
EPISODE INTRO:
This is our final Health Pilots episode of 2022! This episode is adapted from a recent webinar which kicked off the Telehealth Improvement Community Fund, an initiative of the Center for Care Innovations in partnership with the California Health Care Foundation. The Telehealth Improvement Community Fund, set to officially begin its offerings in January 2023. is the exciting new initiative to spread the adoption of promising telehealth practices focused on increasing video visits. Follow and check out CareInnovations.org to learn more and to attend our upcoming sessions featuring community exemplars in the Telehealth space.
Video visits, a key component of telehealth, hold both great promise and great responsibility. For health system leaders, it’s an opportunity to deliver high quality care to more people. At the same time, if we’re not intentional about implementing this service, we risk exacerbating the existing health disparities in our communities.
Our guests today feature Dr. Jason Cunningham, chief executive officer of West County Health Centers, which serves California’s Sonoma County. West County Health Centers brought their full care team and clinic operations into the digital world. Imagine how your care team can recreate the physical clinic in an innovative, digital space — all through Zoom. Our next guest is Jeffrey Glenn, chief operations officer of Neighborhood Health[care], which has 24 clinic sites across San Diego and Riverside in California. Neighborhood Health’s teams prioritize telehealth video visits to maximize clinic efficiency while reducing overhead costs, addressing digital barriers, and improving work-life balance.
Let’s get right into the conversation with our guests. I’ll pass it on to my colleague at the Center for Care Innovations, Elkin Salinas, as he dives into why their respective organizations are committed to prioritizing video visits and recommendations for others that seek to increase the use of video as a viable and accessible option for care.
Elkin Salinas, Center for Care Innovations (CCI):
What do you see as the main benefit of patients when video visits are given as the preferred option of care? And I wanted to start off with Jason – Dr. Cunningham – if you could share first, just from a clinical perspective, but also as an executive at West County.
Jason Cunningham, West County Health Centers (WCHC):
I think the video we have in, in my mind, our main product in primary care is relationship. Doesn’t matter how good a clinician I am, if I don’t have a relationship with a patient that they feel trusted, then it doesn’t work. And I think video offers that relational connection. It just is different. Certainly for basic updates. I’ve had long complex conversations about addiction and other things around the phone. I think it’s certainly possible to do that, but it’s easier to do it by video. And, you know, today I had a phone visit this morning and the patient, you know, had a rash.
I’m like, “Why weren’t you on Zoom? Can you get on Zoom?” And I helped him walk through Zoom. I looked at the rash and we were able to make it work. So some things literally can’t be done by phone. But bigger than that, I just think we need to think about primary care differently than the 20-minute office visit. We’re still stuck saying, “How does the telehealth fit into a 20-minute office visit?” That’s not the future of primary care. The future of primary care is teams doing the work, going out of the four walls, getting into the environment, doing education, figuring how to do behavior change. That does not happen with a provider doing a one-on-one visit. So you need to set up your platform, in my mind, where collaborative work can be done relationally and by video. And I think these video platforms, so doxy.me and Zoom or others, can allow the video experience to enhance what we want primary care to be – that coordinated relational primary care discussion.
Jeffrey Glenn, Neighborhood Healthcare:
Yeah, I’ll echo what Jason said, and I’ll also point out, when I talk to our providers about the difference between the two – personal connection is really one of the most important aspects. Providers are taught: touch the patient, lay eyes on the patient, and listen to feedback from the patient. You can accomplish 2 of those 3 in a video visit as opposed to just one in a telephone visit. So I can’t tell you how many providers have told me underlying issues they’ve picked up just in body language of talking to a patient on video. They might tell you, “I’m fine, I feel great,” but when you look at them, you can tell they have lost weight. There’s a lot of things that can come out of laying eyes on a patient. So, I think that’s why they prefer it – and also because of the personal connection.
Elkin Salinas:
The second question I wanted to pose to you both and I could probably start with Jeff on this question. What were the major like iterations that you made in your system process to reach your current video visit workflow? And again, I think it’s really looking at I know you just shared it, but I think – what do you think was the most critical component to really getting to where you’re at today?
Jeffrey Glenn:
I think that for us, you know, was this the end-to-end workflow process where the first piece was you, you have to make sure you have to set the expectation for the patient, because I can’t tell you how many times in the beginning we called a patient for a visit and they were in the checkout line at Target, or they were in the drive through at, In-N-Out. You know, it just wasn’t conducive to a good visit either phone or video. And so we realized that we needed to back up a bit and make sure that when they called in for an appointment, that we gave them the expectation – be in a private location, make sure you have the technology. If you need to borrow a smartphone from a family member – please have it on site. We’ll teach you how the medical system will teach you how to use the link.
So was really that. And then reducing patient, I mean provider friction, because I can’t tell you again how many times they got frustrated after trying to connect after eight minutes in a 15 minute scheduled visit. And they just threw their hands up in there and they said, “get the patient on the phone.” So we really needed, and, and the integral part there was the Medical Assistant, because they play that middle ground between the patient and giving them the expectations right before the visit. And then also helping the provider ensure that when they walk in the room, like Jason said, the patient’s already on the screen, all you need to do is start talking.
Elkin Salinas:
Before adding more, Jason, what are your thoughts? Same question.
Jason Cunningham:
Yeah, we innovated the heck out of it before we presented it to the staff that I think about – it was kind of 80% cooked. We again, we failed. It’s, I didn’t use Doxy.me, which is interesting. That probably would’ve been fine with that too. But the eClinical works and the Doximity didn’t work for us initially, so we innovated the heck out of that Zoom and really worked it. So we felt like it was important. We had our workflows and then we piloted it quickly and got the, you know, workflows worked out and then we pushed it. And I think we decided that it was compelling and it was the leadership push to say – and it’s no longer the secondary option, it’s the push. And that raised the bar for people when they said, “Oh, it’s no longer an option for me. I can’t just do that.” And we were measuring it and we’re looking back on it. We had goals around it. Those were really important for us.
There’s also default, if it doesn’t work, fine, just go back to the phone. So don’t worry about it. You can, you know, go off. The getting staff involved, so it wasn’t the providers’ problem, the staff kind of setting it up, like Jeff’s talking about kind of teeing it up was really important. I wanted to comment too, on the cost, we did not invest significantly in hardware. So we have, you know, Microsoft cameras, and noise-canceling headphones were our main innovation. So the video visits happen at the provider desk rather than in the office, except we have some iPads walking around for that. But if you don’t have a good video connection, you don’t have connectivity, you don’t have very good bandwidth – those are things that would be deal breakers for sure.
Elkin Salinas:
“Reduce the friction,” right? Reduce friction for both the clinicians, importantly. And I think that that’s something that I heard from you, Jason. There is that “freak out” factor that is involved within the telehealth and televideo. But the only way to do that is really make sure that the video platforms are vetted and tested, meaning small tests of change before pushing it out and getting that clinician feedback and getting the data. I think that was the other thing. And data could be also qualitative – meaning, “What are people saying? Do people feel comfortable?” And I think that those are the things that I’m hearing. And I think Jeff, what I also heard from you was there is kind of like that leadership component of saying like, “this is what we want to utilize moving forward.”
So I think that those are really, really great points of how as you were rolling things out, as you were developing. And I think again, it sounds like both of you have made iterations, starting from one to kind of where you are at now, and I think probably even into the future. I like one of the things that you said, Jason, that Zoom may not be the option moving forward. But being able to test that, I think kind of getting to there and having that nimble process is a skill set or one of the things that leadership can provide in terms of that safety, saying, “Hey, we can fail, but let’s test it out.” And I think that that’s great to hear. The next question I had – I think it’s just like a very basic question, but can you share, in this case, Jason, why is your organization committed to promoting video visits?
Jason Cunningham:
You know, culture of relationship, culture of team – I do think people who are comfortable on video feel like it’s better. And so I think it’s now the default. It’s no longer an uphill battle for us. So I think that we’re committed. I think we also know that there’s a future around integration. You know, I had a visit with a patient and half the visit we spent with her bunny rabbit and she said, “This was my main, this was my main partner through COVID.” I would not have been able to see that in the 20-minute office visit. So there’s something also that adds – it’s enhanced. I can be in the patient environment. We have behavioral health specialists who are going into the grocery store with people. I mean, there’s something different when you get to say, “Oh, I can think differently now and I’ve got it.” But I think we’ve crossed over that hump of it being a “freak out” factor now. It’s an opportunity.
Elkin Salinas:
Yeah. That’s great. Jeff again, Neighborhood Healthcare. Why is Neighborhood Healthcare committed to promoting video visits?
Jeffrey Glenn:
Well, this is probably a unintended consequence, but out of convenience. I’ll tell you this, you know, with traffic in Southern California, as most of you have probably heard, it’s really just easier. And since we are committed to telehealth and we’re committed to video we have, and this is another iteration let’s look at the first two appointments in the morning [being] video in a hybrid, you know, arrangement. So those first two, we don’t have to worry about traffic some ‘cause you know, you get behind in the very beginning of the day, you’re behind all day long, generally. So it’s just at a convenience that we can connect them right at 8 o’clock in the morning and then like the last two before lunch, and that gets the MAs ready to go cleaning up all the rooms –
They get to lunch on time. I can’t tell you how much overtime we have reduced our spend because the first two, the last two in each session are really designated as video in a hybrid arrangement. So those last two… back in the day, before the pandemic, I would walk through our facilities and at 5 o’clock they’d still be full of people. Now, there’s really nobody there, the parking lot’s empty. So, I think we’re just more efficient also by doing video. And many
, and because that is the default for telehealth, but just telehealth overall. And like Jason said, telehealth should be an integral part of primary care.
Elkin Salinas:
That’s excellent.
Jason Cunningham:
Can I talk as a CEO?
Elkin Salinas:
Yeah <laugh>.
Jason Cunningham:
All right. So in the middle of the pandemic, we had a fire and we had to evacuate two of our health centers. We video at a fee-for-service model. If you don’t have video and phone, I think you’re not gonna be able to manage that change. We are a rural health center. It’s hard to hire and recruit providers up in this area. I can hire and recruit somebody in New York or in San Diego – I’m gonna steal from you, Jeff, somebody down there – to be able to video in. I’ve got providers who have got a year sabbatical in Panama and are still seeing patients through video.
Their video offers a little bit of a mitigating factor for the fee for service visit to be able to have providers in there. And then I do think we will find that audio is not going to be paid at the same level. And you’re seeing that, if you don’t get on board with video now, I think you’re gonna be behind. And so I think that’s another strategic, just from a straight CEO strategic perspective, we need to get video as a part of our default.
Elkin Salinas:
Oh, that’s excellent. Thank you for I think circling back, Jason, on that point cause I, I think what I’m hearing, just the two things to highlight: there’s that operational component, Jeff, that you raised in terms of like how it’s created efficiencies not only for your organization, but also for your staff and making it easier. And I think the other thing that you just raised, Jason, is right – getting, utilizing telehealth as a way to extend or augment your staffing. Meaning, you’re bringing in clinicians and providing services in ways that you couldn’t in the past. And also, there’s that policy piece, that reimbursement piece, but also kind of that equity piece which I think is really important. And when we think about equity, transportation is one of those, right? Social determinants of health – that I know kind of going back to that, I think that is also key and critical.
I wanted to pose this question and I start with Jeff, what recommendations small and large, can audience members, change agents make today, or in, you know, very, very soon that can make an impact to increase accessible video visits?
Jeffrey Glenn:
I think that really the, the integral piece for us was, you know, making sure we had Telehealth Coordinators that were experienced that could troubleshoot. Because then they can help the patients and they can help the providers. That was really one of our key takeaways. I think now that the hardware and software platforms are pretty well defined, and they’re accessible to really almost anyone. I think that’s not as much of an experimentation as it was, you know two years ago, two and a half years ago. So I think making sure that everybody’s trained properly and understands. I think almost everybody has done a Zoom call or a Teams call, every single employee of many of our organizations have done this or FaceTime, which is essentially the same thing on an Apple product. So they’re familiar with it. I think that, you know, it’s not as scary as it was two and a half years ago – at least from my perspective.
Elkin Salinas:
Yeah. And same question for you, Jason. You know, recommendations that you would make to this audience, and I think those that are looking to make improvements in video visits.
Jason Cunningham:
I think it’s compelling that Jeff and I both have a collaborative video platform. I really think you need to choose the video platform and be clear about that. And I don’t think it’s that expensive, and I don’t think you have to do huge changes in your systems. I think that’s one of the worries. You get a bigger system and you need to make this huge change agent. I think you should, I think testing out some of these off the shelf video platforms that are HIPAA compliant is a way for you to have a compelling “yes, we can” discussion. If you don’t have that and it’s glitchy and there people are hanging up and working and it’s really hard to do leadership and change. So that’s what I would say is – doxy.me, Zoom – whatever platforms you can use that would allow the video to be primary care collaborative.
Elkin Salinas:
There’s the platform, let’s remove the friction, let’s make it easier, but at the same time, how can you do it to promote what you’re doing in clinic? Kind of going back to like, how do we do integrated behavioral, other integrated services. And I think that’s a really great point.
This is a question from the audience. What kind of tech support do you provide your patients? It says, “We have found it difficult to teach elderly, non-English speaking patients how to use Zoom. We’ve tried it for group visits and it’s been great on average, but needs about 1.5 hours to train a single patient on how to download.” What would you share? I think in this case, maybe Jason, this is a question for you.
Jason Cunningham:
I think that we did have a dedicated line and a dedicated staff for when we first rolled it out for Zoom. There is commonly people who – I had a patient this morning couldn’t connect on the audio. And, so you need to have some kind of available resource so that the provider isn’t waiting. Mayne you have 10 minutes of downtime -your provider’s on, you’ve lost. So you’ve gotta have some way of connecting. And to Jeff’s point, you want to be teed up. Interestingly, we didn’t really need it that much. We didn’t have a lot of people accessing our tech support because we have our front office and our medical assistants who are able to say, “Oh, actually click the bottom left here” and “click on your connectivity, you know, speed test and see if it’s a connectivity issue.” They were able to do those basic tech support to make that work. There was another question too, about the integrated behavioral health not using medical assistants. Our behavioral health providers do Zoom where they join the main clinic space. We have our behavioral health providers just in a breakout room. So, the front office is their support in that Zoom visit. And that would be an option for you to get, ‘cause I do think your behavioral health providers are gonna need some support getting people checked in.
Elkin Salinas:
Well, thank you for answering that question. This is for Jeffrey. How much was the grant to purchase the devices you mentioned? I think that this is related to, again, that hardware piece.
Jeffrey Glenn:
Yeah. I think in the first cohort we participated, it was a very, it’s a long process. But I think we received a hundred thousand dollars in grant funding. I think it lasted over a year, maybe even 15 months. And it was intense. I think Jason, your team might have been in that as well. And, and I’ll tell you, a lot of homework, a lot of experiments, a lot of dedicated time. But again, we all really learned together. And I think that was the beauty of the program.
Elkin Salinas:
I think that’s something just to kind of reiterate something you mentioned earlier – I think you both [are] really leveraging those dollars, right? Are leveraging those funds that are out there that either are there to address equity or just kind of disparities. I know that the FCC even put out grants and funds to be able to kind of help with some of these connectivity [issues]. So I think that’s a really great point — yes, there are investments, but I think one of the things you’ve shared, Jason, is that you can start small. You don’t need to make hard investments or big investments in order to move things forward.
So, for clinicians that don’t see the value in video visits – how do you effectively support them to endorse the video visit modality?
Jason Cunningham:
Yeah, so going back to the metrics, we did tests of the telehealth, how many of them were video and phone, and we broke it down by providers, and it was clearly some providers who were easily doing that and others who weren’t even in the same environment. So we isolated those providers as opportunities for us to align. And most of it was being scared of failing. That was the main one; being embarrassed. It wasn’t about lack of desire for it. And then we said, “And this is what we’re gonna do,” it really was a leadership discussion, just like anything else, just like productivity, just like anything else, it became a, “This is how we as an organization are doing this.” And over time, I don’t have any problems anymore with our providers. They’re all doing it. So it is just a change management. And some of that’s just leadership. I happen to be a clinician, so it’s easy for me to say, “I know I struggle with it, this piece too. This is what we’re gonna do.” Some of that’s just leadership.
Elkin Salinas:
Excellent. That’s a great, and honestly topical. Aligning the organization and really kind of making that compelling message. I think, the thing to kind of just highlight from that response is looking at the data. So you need to be able to track the data, be able to see where do you provide that support. Jeff, I would love, you know, I think that audience would as well, what about for Neighborhood?
Jeffrey Glenn:
You know, video was a shiny new tool, you know, or toy, in the very beginning, and everybody thought, Well, this is gonna be great. It’s just like FaceTime. And the platforms were not that reliable back, you know, for the first few months. And then you have this bias against the program because they held on to what they experienced for the first couple of months. And it really, we’ve had to just do exactly what Jason said – we tracked each provider. We looked at the split between video versus phone and then we started, you know, sending the RMDs – the regional medical directors – out to have those conversations and to sort of reintroduce the product.
And also if there was additional training that the provider needed with their medical assistants. And we also found that it, you know, sadly as it is, you know, sometimes the age of the medical assistant could have impacted, you know, the acceptance of technology. And so, we maybe we had to make some changes to care teams. Our care teams right now have one scribe, two MAs – so there’s a case, we might have had to, to make some changes there to ensure that everybody felt supported. So, there was some maneuvering that had to occur to kind of get them to adopt.
Elkin Salinas:
We’re going almost on a third year of the public health emergency as we know it. But at the same time, one of the things that you just shared, I think, is critical – is that you’re reintroducing the product. You’re either doing that training, you’re doing that re-training, and that in the beginning, in the outset, there was kind of that initial training to that workflow. But we also understand that workflows may have changed and may have shifted. And I think that that’s an important thing to call out. I really like your reference earlier on of “how do you train your medical assistants?” And you referenced the University of Delaware telehealth training, which is great.
But also, kind of keeping in mind that there has been turnover, especially within the FQ space. So how do you develop those systems to be able to train not only your MAs, but also your clinicians on how that works, but also your frontline staff. There’s making sure that from a leadership perspective that all those things are being addressed and brought up. Have either of you tested whether it’s better to keep the providers schedules as hybrid – let me see – whether it’s hybrid or it being fully virtual, Meaning like, how within your organization, you’re seeing the modality of televideo, whether it is hybrid, whether it’s something in the morning, whether it’s something in the afternoon, just the way that you both approach that. And I think I’ll start with Jason on this question.
Jason Cunningham:
Primary care just is too unpredictable in my mind. And so it’s hard to say you only have telehealth, you only have video. The only exception as we do have some providers who are literally out of the state or out the country. And we do have them obviously as video, but right now, this morning I had, you know, nine patients and two of them were phone, you know, four of them were video and two of them were, or however the rest of them, were in-person. So that’s just part of regular business. I did wanna, and I think that’s the way we’re gonna go. I know other people have done it differently. I did wanna plug what Jeff said too, that the one-hundred thousand dollars came with the community and the homework.
And I think that’s a really important thing to say. What CCI and CHCF and CPCA and others are doing is saying, “We’re going to give you support, but there’s also going to be a process you go through to make sure you’re moving along.” And I think that’s really important and there’s enough dollars that I’m like, go for it. But it’s also, then you have to have a team. The team has to meet, you have to do that. There’s something about those grants that keep us moving. We all have 2% margins. We’re all strapped. And so, I just want to continue to encourage those of you in policy and change management – those do matter. Those grant funded collaboratives matter, which is to tee up for this, those of you who want to participate, it does make a difference.
Elkin Salinas:
Jeff, I wanted to obviously to have the last word before we wrap up this panel, but again, thoughts on hybrid care, thoughts on how that is done, how you’re seeing it at Neighborhood Health?
Jeffrey Glenn:
Well, we’ve really,,, there’s been a lot of experimentation. I will say this. You know, we went to the providers and said to a large degree, you know, they’re on a hamster wheel all day long, every 15, 20 minutes. So, giving them preference over how they want their templates built was important for sites that didn’t have a lot of walk-in patients, it was easier to have a fairly stable template. But, I will say that we became somewhat strategic going back to first two in the morning – video – last two at the end of the session. So 2, 6, 2 – same thing in the afternoon that we seem to settle into kind of a rhythm for most of our providers. It can be disrupted with walk-ins of course, but largely, they like to build their templates and, and stay consistent with the way the template is set up. Things come up like you know, Jason said, but by and large we try to stay pretty confined to those templates.
Elkin Salinas:
You have found that rhythm, and I think it’s through the process of going through these different iterations. And so really, and I think it kind of is something that maybe Jason echoed is, there are different ways to approach it, but it sounds like at least at Neighborhood Health, you have found what works for you, and your clinicians, and your patients as well. I just wanted say thank you both for one, answering the questions – also sharing your perspectives. And one of the things to highlight, Jason, that you brought up is that those dollars do count, right? The funding is definitely a component that’s valuable. And so is the community, meaning, I think there’s something that you shared, I’m trying to remember right now…
“Share selflessly and steal shamelessly,” I believe I got it correct <Laugh>. And I think that that’s great. And I think that that’s what this community is all about – the Telehealth Improvement Community Fund. As we’re making changes and we know that telehealth will change, there are things that are coming up in these workflows and things with patients. That we could all learn from each other. I think that we’re still, for some of us, trying to find that groove, what works well. But from what I heard there is this component of aligning your leadership. Of making that compelling message of why video is better and sustainable. Really making sure that the video platforms are something that the clinicians can trust. And two, one of the things that I kept on hearing, really teeing it up –
What is the plan B if that doesn’t work out, and making sure that there is that support but really having the plan B, but also what support you can provide, kind of that armchair T.A., technical assistance, if it is needed. I think the other thing that I heard from what you all shared is really leading, or let’s say forming a multidisciplinary team, getting that input, doing tests of change – those pilots. And this is all on how to align your leadership. But I think the last component, and I think probably the most compelling, especially for clinicians or staff that may not be able to kind of see the forest within, you know, and not the trees, is looking at data. So, setting goals and using data to learn is what I heard.
And I think that as we move forward the data is important, but also that qualitative information. So, I just wanna say thank you so much to both for sharing your thoughts on how you both at West County [Health Centers] and Neighborhood Health[care] are aligning your organization to prioritize accessible video visits. So, I want to say thank you so much.
EPISODE OUTRO:
That wraps our final episode of Health Pilots for the year. Stay tuned as we come back in 2023 with a slate of new episodes featuring more voices from our community across all the Center for Care Innovations programs, initiatives, and beyond! Visit CareInnovations.org to learn more, follow us on LinkedIn to stay updated with us, and subscribe to the Health Pilots podcast.
And finally, be sure to check out our 2022 Year in Review, which we’ve linked to in the show notes. See the great strides we’ve made toward creating fair, just, and inclusive opportunities to be healthy. Get an inside look at our extraordinary collaborations this past year with you, our community – in resilience, addiction treatment, virtual care, behavioral health, and innovation.
We thank you again for listening, wishing you all the best as you close out 2022. We’ll catch you in the next one.
