Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic

“Before the pandemic, most health centers did not offer telehealth visits for primary care or behavioral health, in large part because of reimbursement policy. In spring 2020, dramatic policy changes removed many of the restrictions on telehealth delivery, and health centers responded by standing up large telehealth programs.

This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. The goal of CCA was to facilitate the transition to telehealth services by providing funding and technical assistance to 45 health centers in California. The study we describe in this report evaluated the progress of health centers that participated in CCA by exploring changes in telehealth utilization and health center staff experiences with implementation. [..]

Although overall visit volumes remained about the same from the prepandemic to the pandemic study periods, the share of audio-only and video visits dramatically increased during the pandemic, particularly for behavioral health. Monthly visit volumes during the pandemic study period (August 2020–August 2021) were largely similar to those of the prepandemic period (February 2019–February 2020),1 with the exception of reduced primary care volume during three months in summer and fall (August, October, and November 2020) and reduced behavioral health volume during two months in the fall (October and November 2020).

Audio-only visits were the highest-volume telehealth modality for primary care and behavioral health throughout the entire pandemic study period; at the end of the study period, however, audio-only visits were eclipsed by in-person visits for primary care but not for behavioral health. Audio-only visits for primary care peaked in April 2020 and remained the
dominant telehealth modality throughout the pandemic study period. However, by February 2021, in-person visits regained the position of dominant modality among the three modalities as audio-only visits declined. In the final three months of the pandemic study period (June–August 2021), 66 percent of total visits for primary care were conducted in person, while 30 percent and 4 percent were audio-only visits and video visits, respectively. For behavioral health, audio-only visits exceeded in-person visits and were the dominant modality of care delivery throughout the entire pandemic study period. In the final three months of the pandemic study period, 28 percent of total behavioral health visits were conducted in person, while 52 percent and 20 percent were audio-only visits and video visits, respectively. [..]

Because of challenges with the digital divide, many health centers found it helpful to actively address potential barriers to engagement in both audio and video by adding onboarding processes to screen patients for technology access, offering one-on-one support for information technology (IT) issues, and having providers use their relationships with patients to encourage telehealth use. Health centers found such processes particularly important in facilitating video visits, in addition to scheduling video as the default modality and setting targets for each modality. Patients with limited English proficiency participated in a significantly lower percentage of video visits. To address disparities in access, clinics engaged in a variety of creative solutions to address the digital divide. The population of patients who received health care prior to the pandemic (in August 2019) varied notably from the population of patients who received video visits in August 2020 and 2021, both in primary care and behavioral health. Most notably, patients who preferred a language other than English participated in 45.5 percent of total primary care visits in August 2019 but only 37.7 percent of video visits in August 2020 and 35.8 percent of video visits in August 2021 (p < 0.01). These differences might reflect variations in digital literacy, a lack of instructions in multiple languages, and a cultural preference for in-person care. In interviews, staff described difficulties providing comprehensive interpretive services within and outside the actual telehealth visit (e.g., in communications from the health center about the visit). [..]

Implications for Policy, Practice, and Future Study

  • Billing modifiers that differentiate between modalities are needed to further understand
  • The impact of audio-only visits on quality of care needs to be empirically tested.
  • Health centers can be supported in increasing access for patients with limited English
    proficiency and other populations with access challenges more generally.
  • Health centers should take steps to better support patients facing digital barriers.
  • Knowledge of what works in video visit implementation already exists, and health
    centers have many tools to grow their video visit programs.
  • Appropriate staffing is key to telehealth implementation.

Full article, L Uscher-Pines, N Arora, M Jones, et al., RAND Corporation, 2022.