LEADERSHIP PERSPECTIVES ON TELEMEDICINE IMPLEMENTATION IN THE LOS ANGELES SAFETY NET DURING THE COVID-19 PANDEMIC

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.