ABSTRACT
Background: Telemedicine systems were rapidly implemented in response to COVID-19. However, little is known about their effectiveness, acceptability, and sustainability for safety net populations. This study systematically reviewed primary care telemedicine implementation and effectiveness in safety net settings. Methods: We searched PubMed for peer-reviewed articles on telemedicine implementation from 2013 to 2021. The search was done between June and December 2021. Included articles focused on health care organizations that primarily serve low-income and/or rural populations in the United States. We screened 244 articles from an initial search of 343 articles and extracted and analyzed data from N = 45 articles. Results: Nine (20%) of 45 articles were randomized controlled trials. N = 22 reported findings for at least one marginalized group (i.e., racial/ethnic minority, 65 years+, limited English proficiency). Only n = 19 (42%) included African American/Black patients in demographics descriptions, n = 14 (31%) LatinX/Hispanic patients, n = 4 (9%) Asian patients, n = 4 (9%) patients aged 65+ years, and n = 4 (9%) patients with limited English proficiency. Results show telemedicine can provide high-quality primary care that is more accessible and affordable. Fifteen studies assessed barriers and facilitators to telemedicine implementation. Common barriers were billing/administrative workflow disruption (n = 9, 20%), broadband access/quality (n = 5, 11%), and patient preference for in-person care (n = 4, 9%). Facilitators included efficiency gains (n = 6, 13%), patient acceptance (n = 3, 7%), and enhanced access (n = 3, 7%). Conclusions: Telemedicine is an acceptable care modality to deliver primary care in safety net settings. Future studies should compare telemedicine and in-person care quality and test strategies to improve telemedicine implementation in safety net settings.
Subject(s)
Safety-net Providers , Telemedicine , Humans , Ethnicity , Minority Groups , Poverty , Telemedicine/methods , United StatesABSTRACT
BACKGROUND: Federally qualified health centers (FQHCs) rapidly adopted and implemented telemedicine during the COVID-19 pandemic. This study analyzes FQHC personnel accounts of care redesign strategies to support telemedicine implementation in 2020 and 2021, and identifies improvement opportunities. METHODS: We conducted semistructured, in-depth interviews with clinic personnel (n = 15) at 2 FQHCs in Northern California (December 2020-April 2021) to examine telemedicine adoption and use of audio-video and audio-only/phone telemedicine encounters. RESULTS: FQHC clinicians and staff reported that telemedicine implementation increased access to care and reduced appointment no-show rates. However, a reported reduced ability to develop and foster interpersonal connections negatively impacted clinician-patient relationships. Care redesign strategies included systems to triage appointment types (in-person versus virtual), work-arounds to screen for and address social and nonmedical needs, and new protocols to navigate privacy needs for first time telemedicine users. In addition, increasing remote monitoring capabilities was deemed an important priority for improving telemedicine use for marginalized populations. CONCLUSIONS: Telemedicine implementation in FQHCs involved care redesign to optimize virtual interactions and care processes. Guidelines and evidence-based practices are needed to improve telemedicine use in FQHCs, including strategies to support interpersonal connections; approaches to virtually screen for and address social needs; and protocols to further mitigate privacy issues. Future research is needed to identify when telemedicine can optimally supplement in-person care to improve patient outcomes and clinic efficiency, particularly in safety net settings.
Subject(s)
COVID-19 , Telemedicine , Humans , COVID-19/epidemiology , Pandemics , Telemedicine/methods , Health Personnel , Ambulatory Care FacilitiesABSTRACT
BACKGROUND: Despite guidelines from the American Academy of Pediatrics (AAP), many pediatric practices still do not have standardized screening processes in place to identify children with developmental delays. From April 2014 to April 2017, six federally qualified health center (FQHC) sites in Northern California implemented an intervention to increase (a) standardized developmental screening at recommended intervals and (b) follow-up care and support for early intervention services. METHOD: The intervention aimed to optimize each site's screening processes, supported by an automated electronic tablet-based system. To improve follow-up support, social workers were hired to conduct follow-up clinical assessments, provide psychosocial education and treatment, provide referrals and case management support, and collaborate with service partners. We analyze operational and implementation data to characterize site adoption, patient reach, implementation processes, and intervention effectiveness. RESULTS: During the intervention's final year, when tablet-based screening was adopted, the sites screened an estimated 6,550 children ages 0-18 at 23 intervals in three domains (developmental, autism, and psychosocial/behavioral), compared to a baseline where they screened ages 0-3 at four intervals in one domain. Screening rates increased from 65.3% to 75.5% after automation was extended from the first to the second site, then to 91.8% after automation was expanded to the remaining sites. Follow-up visit rates ranged between 74% and 88%. CONCLUSIONS: Implementation of a multicomponent developmental and behavioral health screening and follow-up care intervention enabled FQHC sites to meet AAP recommendations and provide follow-up support. Disseminating the intervention may support population-level improvement in early detection and intervention for developmental delays and behavioral health concerns. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Subject(s)
Aftercare , Psychiatry , Humans , Child , Early Intervention, Educational , Referral and Consultation , Educational Status , Mass ScreeningABSTRACT
In March 2020, federal and state telehealth policy changes catalyzed telemedicine adoption and use in community health centers. There is a dearth of evidence on telemedicine implementation and use in these safety net settings and a lack of information reflecting the perspectives of patients with limited English proficiency. We conducted in-depth interviews with clinic personnel and patients during the pandemic in two federally qualified health centers that primarily serve Chinese and Latino immigrants. Twenty-four interviews (clinic personnel â= â15; patients who primarily speak a language other than English â= â9) were completed remotely between December 2020 and April 2021. Interview scripts included questions about their telemedicine experiences, technology, resources and needs, barriers, facilitators, language access, and continued use, with a brief socio-demographic survey. Data analyses involved a primarily deductive approach and thematic analysis of transcript content. Both FQHCs adopted telemedicine in a few weeks and transitioned primarily to video and audio-only visits within two months. Findings reveal third-party language interpretation services were challenging to integrate into telemedicine video visits. Bilingual personnel who provided language concordant care were seen as essential for efficient and high-quality patient telemedicine experiences. Audio-only visits were of particular benefit to reach patients of older age, with limited English proficiency, and with limited digital literacy. Continued use of telemedicine is contingent on reimbursement policy decisions and interventions to increase patient digital literacy and technological resources. Results highlight the importance of reimbursing audio-only visits post-pandemic and investing in efforts to improve the quality of language services in telemedicine encounters.
ABSTRACT
BACKGROUND: Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE: The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY: Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS: System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (ß = 0.20, p = .005), innovation culture (ß = 0.26, p < .001), and patient engagement strategies (ß = 0.57, p < .001). CONCLUSIONS: Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS: Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.
Subject(s)
Group Practice , Medical Informatics , Physicians , Humans , Mass Screening , Patient ParticipationABSTRACT
Policy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity. CONTEXT: One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. METHODS: We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices' participation in value-based payment models; and (3) measures of practices' capacity for innovation. We used multivariate regression models to examine predictors of social risk screening. FINDINGS: On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices' overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices' capacity for innovation. CONCLUSIONS: Our results indicate that implementation of social risk screening-an initial step in enhancing awareness of social needs in health care-is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.
Subject(s)
Food Insecurity , Ill-Housed Persons , Physicians , Practice Patterns, Physicians' , Cross-Sectional Studies , Humans , Mass Screening , Organizational Innovation , Risk Factors , Surveys and Questionnaires , United States , Value-Based Health InsuranceABSTRACT
Area Agencies on Aging are increasingly partnering with health care organizations to address the health-related social needs of older adults and contribute to multisector coalitions that promote community health. Using survey data for the period 2008-13, we examined the potential health impacts of establishing such partnerships. Partnerships with hospitals located in an agency's service county were associated with a reduction of $136 in average annual Medicare spending per beneficiary, while partnerships with mental health organizations in an agency's service county saw potentially avoidable nursing home use fall by 0.5 percentage points. When agencies were funded participants in livable community initiatives-multisector coalitions to promote the well-being and health of older adults-potentially avoidable nursing home use fell by nearly 1 percentage point. Our results suggest that investments in health and human services partnerships through Area Agencies on Aging can yield health returns among older adults, in the form of reduced health care use and spending.