ABSTRACT
BACKGROUND: Safety net health care systems (which disproportionately serve racial/ethnic minority, low-income, and/or Limited English Proficient (LEP) populations) care for patients who face a multilevel “digital divide.” The transition to telemedicine prompted by the Coronavirus-19 disease (COVID- 19) pandemic facilitated continuity of care in some settings. However, most safety net health systems were left ill-prepared to address challenges to digital uptake among their patients, individuals who already face language and literacy barriers that negatively impact health access and health outcomes. Because there is little evidence on telemedicine implementation strategies in safety nets, we examined perspectives from leadership and frontline healthcare workers in the Los Angeles County Department of Health Services (LAC DHS), the second largest safety net in the United States, regarding facilitators and barriers for effective and patient-centered telemedicine implementation in a safety net setting. METHODS: We conducted 20 in-depth interviews with LAC DHS physicians, nurses, medical/nursing directors, and administrative leadership between October 2020 and December 2020. Interview scripts included questions about telemedicine experiences, technology, staff resources, needs, and facilitators for their implementation, (focusing on video visits). Qualitative analyses involved a deductive approach, with thematic summaries of transcript content using Atlas.ti software. RESULTS: Each of the 5 major LAC DHS centers (encompassing diverse health settings across all of Los Angeles county) were represented among the participants. Based on these interviews, a process map was developedoutlining the numerous staff and patient steps needed to achieve a single LAC DHS telemedicine video visit, alongside identified facilitators and barriers. Themes surrounding telemedicine implementation were identified at the patient, clinic/provider, health system levels with accompanying exemplar quotations. These included: preparedness for digital access and utilization (patient), staff empowerment to implement visits (clinic/provider), telemedicine technology infrastructure (system), among others. CONCLUSIONS: Telemedicine implementation in the safety net setting will require a team-based approach, and patient, clinic, and health system level themes must be considered when disseminating telemedicine services across safety net settings. In particular, participants emphasized prioritizing “hightouch” efforts to enroll patients in their health portal as an entry to digital health engagement/education, and facilitating access to telemedicine visits. Participants also highlighted robust workflows, having defined staff telemedicine “champions,” and multidisciplinary teams that could focus on telemedicine access for patients. Future research will also need to focus on safety net patients' experiences with telemedicine access and quality.
ABSTRACT
BACKGROUND: California is the most populous state in the United States (US), with 40 million residents and a global economy that would be the 5th largest. California is also known for dramatic disparities in wealth and healthwith some of the richest and poorest communities in the world just a few miles apart. As such, the traumas of the Coronavirus-19 disease (COVID-19) pandemic have fallen starkly and unevenly across this state. An equitable and just pandemic response calls for a “distributive approach” to close the gaps on these disparate COVID-19 experiences. The National Institutes of Health (NIH) responded in such a way-with the Community Engagement Alliance (CEAL) as an NIH platform for real-time communityengaged COVID-19 strategies. The NIH CEAL asked for the development of state teams to engage communities, and California was one of the first states to answer this call. STOP COVID-19 CA was established in September 2021 to advance equity in COVID-19 research, clinical practice, and public health for California's most under-resourced racial/ethnic minority groups. This study evaluates the early impacts of the Alliance, from the perspective of its participating sites and partnered community-based organizations (CBOs). METHODS: 11 university sites (and their 68 affiliated CBOs) were sent a qualtrics survey in August 2021. We requested at least one academic/CBO response from each of the 11 sites. We conducted a mixed methods evaluation of the responses: analysis of monthly acitivity reports from sites (9/2020-8/ 2021) and summary of their perceptions regarding impact. RESULTS: We received responses from 17 academic investigators and 17 CBOs. In the aggregate, STOP COVID-19 CA partnerships reported >18,000 surveys and 40 focus groups and reached an estimated 25,000 vulnerable Californians in >500 COVID-19 town halls and vaccine events. In the survey, academic and CBOs emphasized that the Alliance expanded community networks and broadened access to culturally specific COVID-19 messaging and vaccine outreach strategies. They noted accelerated knowledge sharing by learning from the successes and challenges of other sites' COVID-19 initiatives. Academic partners described leveraging the STOP COVID-19 CA network as a platform to reach local, state, and federal policymakers. CBOs expressed concerns about bureaucracy delaying funding for timesensitive COVID-19 CBOs-driven initiatives. Both groups also highlighted the potential for the Sustainability of this Alliance and the need for flexible resources to address the health disparities, conditions, and social determinants of health that predispose their communities to high rates and poor outcomes from COVID-19. CONCLUSIONS: STOP COVID-19 CA represents a new and potentially sustainable community engagement model for addressing disparities in multiethnic/multicultural and geographically dispersed communities.