The Institute for Family Health based in New Paltz, New York, is one of the largest federally qualified health center networks in New York State. It operates 32 community health centers located in medically underserved communities in the Bronx, Brooklyn and Manhattan, which have been exceptionally hard hit by the COVID-19 pandemic, and in Ulster and Dutchess counties, 90 miles north of New York City.
Together, these centers provide roughly 650,000 visits annually, including critical primary care, behavioral health, dental care and care-management services to more than 115,000 patients of all ages, regardless of their ability to pay.
In New York City, the institute is at the forefront of serving low-income patients and other disadvantaged groups. Approximately 41% of its New York City patients are Black and 46% are Hispanic/Latino. Additionally, many are low-income and lack access to care, with 43% on Medicaid and 15% uninsured.
“Since the advent of the COVID-19 pandemic, our primary and preventive care services have become even more vital: They help to ensure that high-risk, vulnerable patient groups get the ongoing care they need, and to avert avoidable ER and hospital use, thus maximizing the availability of hospital resources for critically ill COVID-19 patients,” said Elizabeth Lever, CIO at the Institute for Family Health.
“In mid- March, the institute began transitioning our services to telehealth whenever possible, in an effort to abide by Governor Cuomo’s stay-at-home order and keep our staff and patients safe, although these services are limited by our current equipment and software capabilities.”
"We were delivering roughly 1,800 telehealth visits per day. Unfortunately, roughly two-thirds of our visits were via telephone only. Most payers reimburse significantly less for a phone visit than a video visit."
Elizabeth Lever, Institute for Family Health
Data has shown that the vulnerable communities served by the institute – including Blacks, who make up nearly half of the institute’s patient population; Hispanics, who make up more than one-third; and low-income essential workers – are especially at risk for COVID-19 infection and death. Specifically, in New York City, Hispanics account for 34% of fatalities, while they make up only 29% of the population, and Blacks account for 28% of fatalities, while they only make up 22% of the population.
In New York State, excluding New York City, Hispanics account for 14% of fatalities, while they only comprise 12% of the population, and Blacks account for 17% of fatalities, while they only comprise 9% of the population.
In addition, the institute’s patient population includes many people with underlying medical conditions, and many individuals who continue to work in essential-services jobs during the crisis. Furthermore, in New York City, the spread of COVID-19 often is exacerbated by multigenerational families living in small apartments.
MEETING THE CHALLENGE
“In mid-March, as soon as New York’s Governor issued the stay-at-home order, the institute’s leadership, clinicians, health information technology staff, clinical operations staff and communications staff worked to rapidly develop and deploy basic telehealth functionality across our organization,” Lever recalled.
“Our goal was to enable patients to access many of our primary care, mental health and social support services by video or phone while remaining safely at home,” she said.
The institute did not have an existing telehealth infrastructure that could support the scale of services that it needed to transition in the timeframe that it needed to do so, nor did it have funds to invest in either infrastructure or equipment. Within a few days, however, the HIT team coordinated an initial telehealth implementation leveraging doxy.me services, using free, individual accounts.
In a very brief period, 450 providers and support staff were configured for individual doxy.me accounts, and the institute transitioned 90% of visits to telehealth. The overwhelming majority of clinicians were working from home, using their personal cell phones and laptops to deliver telehealth visits to patients.
“At the height of the pandemic in New York State, we were delivering roughly 1,800 telehealth visits per day,” Lever noted. “Unfortunately, roughly two-thirds of our visits were via telephone only.
“The reasons for this are myriad,” she explained. “Some patients lack access to video equipment and/or WiFi; others had smartphones but insufficient data capacity for a 20-minute visit; or many simply could not manage the necessary technological skill to get on a video call. Unfortunately, this has resulted in a significant loss of revenue for the institute, as most payers reimburse significantly less for a phone visit than a video visit.”
The institute applied to the FCC for funding to implement needed information services and internet-connected devices/equipment in order to serve patients through secure telehealth throughout the pandemic and beyond.
“We hope to assure that telehealth visits are user-friendly for patients; fully integrated with our electronic health record system; able to handle the volume of visits we need to deliver; and sufficiently robust to minimize outages and failures,” Lever said. “These changes will ensure that the institute’s 115,000 patients of all ages, as well as any new patients, have ongoing access to high-quality care via ongoing, reliable, remote access to care for medical, mental health and care management services, with minimal system downtime.”
With resources provided by the FCC COVID-19 Telehealth Program, the institute will optimize its telehealth offerings, thus preserving access to as many services as it can through telehealth. It will provide telehealth services throughout this time, but will increase the effectiveness and reliability of the telehealth system as it incorporates each FCC-funded service and/or device, Lever said. Specifically, she added, the institute will:
- Purchase, install and set up information services and devices/equipment.
- Configure additional server and data storage capabilities.
- Configure the EHR system to assure seamless access to telehealth capabilities so that providers can readily switch between in-person and telehealth visits.
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While the institute is still in the early stages of implementation of the upgraded systems, it has developed a number of metrics it intends to use to evaluate the impact of this effort going forward.
Specifically, it will track the following:
- The number of patients who receive high-quality care through the institute’s telehealth services, tabulating primary care, behavioral health care and care management services separately. To date, from mid-March through June, the institute has provided 54,850 behavioral health visits and roughly 76,695 medical visits to patients via telehealth.
- The number of patients at increased risk for COVID-19 due to preexisting conditions (for example, hypertension, diabetes, HIV, congestive heart failure, asthma, chronic obstructive pulmonary disease and autoimmune disorders) who receive telehealth services.
- The percentage of system uptime, with the goal of having telehealth services available without disruption 99.99% of the time.
USING FCC AWARD FUNDS
Earlier this year, the institute was awarded $729,118 for telehealth services. Specifically, FCC funds are being used to:
- Purchase and install hardware to ensure the institute’s network can provide the connectivity/bandwidth to telehealth services from its clinical locations.
- Purchase and install computers that include cameras and microphones to provide telehealth services from its health centers.
- Purchase and implement a doxy.me clinic account, which offers features that are critical to sustaining the telehealth services and enhancing the engagement of patients, such as:
- Integrating doxy.me clinic into the electronic health record to streamline access for clinicians.
- Providing just-in-time reminders, along with a link to join the visit, which supports engagement rates.
- Permitting text and email reminders to patients from within the platform.
- Offering additional features such as group visits.
- Supporting the residency-training and other teaching programs by allowing trainees and preceptors to join a visit with a patient together.