Local Lessons Learned in Telehealth During COVID-19

September 29, 2021

Local Lessons Learned in Telehealth During COVID-19

ITUP Links and Resources

ITUP Policy Forum (includes recording of the event and power point slides): Telehealth During the COVID-19 Pandemic

The Digital Divide: Recognizing and Addressing Technological Barriers to Telehealth

Telehealth came up early and often in every ITUP 2020 Workgroup. The overnight expansion of telehealth to deliver care during the COVID-19 pandemic was widespread and ubiquitous across the state. It was born out of rapid policy changes (See ITUP’s fact sheet: Telehealth and COVID-19) and the necessity to keep people socially distanced and safe. Throughout the ITUP Regional Workgroups, we heard health care partners across the state discuss the transformative power of telehealth and how it enabled consumers to access health care when and how they wanted. The conversations also included discussions of ongoing structural and policy barriers to ensuring that California’s safety net population has access to high quality and culturally appropriate telehealth services.

Additionally, a persisting digital divide—meaning a lack of broadband, connectivity, and technological devices—(for more see ITUP’s Broadband for Health) across vulnerable communities in California was identified as a major barrier for patients and providers to use technology in health care. Addressing the digital divide requires increasing accessibility to broadband connectivity as well as technology and digital literacy for patients, providers, and others in the health care delivery system. This summary captures the best practices shared by local health care partners as well as the persistent challenges they report.

Crisis Management: Adopting Telehealth—What Worked Well

Crisis Response: Fast Transition to Virtual Care. At the onset of the pandemic, the health care system—including many clinics, and those helping consumers access Medi-Cal coverage—reported transitioning their in-person care nearly 100 percent to remote work and virtual care delivery. Participants discussed the transition to virtual care using telehealth to maintain patient relationships and meet health needs. Participants in the Central Valley, Los Angeles County, and Mendocino County, in particular, shared how their staff rapidly switched the majority of their visits to telehealth in a matter of a few weeks. One clinic representative from LA County noted that they did three years of telehealth in three weeks at the start of the pandemic. Another participant in Shasta County reflected that they had been doing telehealth for decades in rural counties for specialty care, but what was new during the pandemic was using telehealth for primary care as well.
Significant Investment in Connectivity Helped Reach Consumers. Workgroup participants in most regions highlighted the importance of distributing broadband accessible devices as a means for improving access to telehealth services during the COVID-19 pandemic. This was particularly important for low-income Medi-Cal members in the Central Valley where a health plan made mobile and internet-connected devices available to patients.
Telehealth as an Option for Consumer Health Care. Participants across the state reported that offering the choice of virtual (video or audio-only) or in-person appointments enabled providers to consider patient preferences and technology access when determining how to safely and appropriately deliver timely care. Participants in Mendocino reported as high as 75% of their primary care appointments and 100% of behavioral health appointments were conducted through telehealth, the majority of which were telephonic.
Improved No-Show Rates: Reduced Barriers and High Patient Satisfaction. Across the majority of regions, telehealth was reported to have improved access to care during the pandemic and providers want to be able to offer both telehealth and in-person options to consumers going forward. Workgroup participants brought attention to the advantages of televisits which reduced barriers for many patients, including the need for paid-time off, child care, transportation, and produced high levels of patient satisfaction, especially in behavioral health.
Behavioral Health via Telehealth Helped Reach More People in a Time of Increasing Demand. Nearly all of the workgroups discussed the positive impact of telehealth on the accessibility and availability of behavioral health care during the pandemic, when many clinics saw a rise in need for behavioral health services. One health center in the Bay Area reported not only a significant decrease in appointment “no-shows”, but also a major increase in the need for behavioral health visits overall.

Making Telehealth Meaningful Beyond the COVID-19 Pandemic—Barriers and Challenges

Technology and Broadband Barriers Continue to Limit Telehealth Access. Workgroup participants reported a wide variety of significant barriers. Specific barriers highlighted by participants include:
- Access to devices, such as a computer, tablet, and/or a phone (preferably a data-enabled smart phone, but includes mobile and landlines);
- Comfort and skills to use devices to access telehealth; and,
- Internet access through in-home broadband or data plans on smart phones when video visits were necessary.

While a majority of consumers like telehealth and want to continue to use it (see California Health Care Foundation’s Statewide Consumer Survey), there were reported instances of people needing technological help to access care via telehealth, especially within low-income communities of color, as reported in the Central Coast Workgroup. For more information on telehealth and broadband policies and access barriers, see ITUP’s Telehealth and Broadband and Health Basics Fact Sheets.

When is it Appropriate to Use Telehealth? Throughout the workgroups, participants discussed how and when telehealth should be used versus in-person care. Some had developed their own processes and protocols to address this issue. See the presentation by the Bay Area’s Native American Health Center during ITUP’s Telehealth Policy Forum for an example. As telehealth matures as a modality post-pandemic, the health system should consider creating best practices for deciding when care should be provided in-person or via telehealth and ensuring that care provided via telehealth is high quality and culturally appropriate.
The Future of Telehealth Reimbursements and Adoption is Unclear. While participants in all 10 workgroups emphasized the value of telehealth during the pandemic, many indicated uncertainty about the future of telehealth, including its permanence, reimbursement rates, and the need to address significant barriers for consumers.

Next Steps

ITUP continues to hear from health care partners across the state on how the expanded access to telehealth created a new way for consumers to have reliable access to care when they need it and in the manner that they want to receive care. Currently, California has extended the permitted telehealth flexibilities that impact the safety net population the most until December 31, 2022, regardless of when the public health emergency ends. In the meantime, as required by Assembly Bill (AB) 133 (Committee on Budget), Chapter 143, Statutes of 2021, the Department of Health Care Services (DHCS) is convening a Telehealth Advisory Workgroup to get stakeholder input, including ITUP, who was selected to be on the workgroup, on the future of telehealth in the Medi-Cal program.