Free and Charitable Clinic Perspectives on the Implementation and Utilization of Telehealth Services During the COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic challenged healthcare providers to adapt their models of care and leverage technology to continue to provide necessary care while reducing the likelihood of exposure. One setting that faced a unique set of challenges and opportunities was free and charitable clinics. In response to the emerging pandemic, The North Carolina Association for Free and Charitable Clinics (NCAFCC) offered their 66 member clinics access to a telehealth platform, free of charge. OBJECTIVE: This paper explores the varied perspectives of leaders in the NCAFCC member clinics regarding the implementation of telehealth services to facilitate continuity of care for patients during the height of the pandemic. DESIGN: This qualitative study is part of a broader research effort to understand and contextualize the experience of implementing and using telehealth services by North Carolina free and charitable clinics during and after the COVID-19 pandemic. The research team conducted 13 key informant interviews and employed thematic analysis and grounded theory to explore critical themes and construct a model based on the CFIR to describe the use of telehealth in free and charitable clinics. RESULTS: Twelve clinic managers and executive directors from free and charitable clinics across the state participated in the key informant interviews providing their unique perspective on the experience of implementing telehealth services in a free and charitable clinic environment during the COVID-19 pandemic. When examined within the lens of the consolidated framework for implementation research (CFIR), 3 key themes emerged from the key informant interviews: mission driven patient centered care, resilience and resourcefulness, and immediate implementation. CONCLUSIONS: This study aligns with existing literature regarding telehealth implementation across other safety net provider settings and highlights the key implementation factors, organizational elements, provider perspectives, and patient needs that must collectively be considered when implementing new technologies, especially in a low-resource, high need healthcare setting. The study showcases the implementation climate, resourcefulness, and mission driven approach that allowed many NCAFCC clinics to respond to an emergent situation by adopting and implementing a telehealth platform in a period of 2 weeks or less.

Free and Charitable Clinic Telehealth Adoption and Utilization During the COVID-19 Era: The North Carolina Experience.

Purpose: The emergence of the COVID-19 pandemic led health care systems and providers worldwide to rapidly adopt telehealth solutions to minimize risk and comply with isolation mandates. This article explores telehealth utilization trends in North Carolina (NC) free and charitable clinics-an ambulatory health care delivery setting where traditional third-party reimbursement policies are not a primary consideration. Methods: We surveyed NC free and charitable clinic administrators regarding clinic decisions to adopt an externally sponsored telehealth system, what services are provided by telehealth, clinic implementation processes, which populations used telehealth, how telehealth was incorporated into current clinic workflows, and perceptions of telehealth outcomes. Findings: Telehealth was rapidly adopted among free and charitable clinics after the COVID-19 outbreak. Reasons for implementing telehealth included the ability to continue providing services during a public health emergency and to increase access to patients. However, clinics report that telehealth utilization has dropped significantly since the initial pandemic surge. Patient and provider preferences for in-person services are a common reason cited for this drop. Free and charitable clinics report a strong interest in continuing to deliver services through telehealth. The majority reported continuing to offer telehealth services, but primarily as a supplement to in-person visits rather than as a replacement. They perceive that implementing telehealth has increased access to care but are less certain about the impact on cost of care and patient satisfaction. However, clinic administrators believe improvements in interoperability with other data systems, workflows, scheduling, and care delivery approaches are needed to achieve telehealth's fullest utilization. Conclusion: Telehealth can play a significant role in expanding access to services in the free and charitable clinic setting. However, continued refinements in the technology to facilitate integration with other systems and workflow processes are needed to reach its full potential.

Exercise Behaviors and Beliefs Among Pregnant Women in Rural Communities.

Exercise during pregnancy is safe and beneficial; however, most pregnant women do not meet evidence-based exercise recommendations. Further, data on pregnant women's physical activity are largely limited to women living in urban environments. PURPOSE: The purpose of this study is to examine beliefs and behaviors regarding exercise during pregnancy in pregnant and postpartum women living in rural communities. METHODS: Surveys were distributed in healthcare settings and via social media to pregnant and postpartum (< 3 months) women living in rural communities. RESULTS: Seventy-five women (28.1 ± 5.4 year) participated. Nearly all believed light (96%) and moderate (89%) intensity exercise are safe to perform during pregnancy, while fewer agreed vigorous intensity (52%) or resistance (40%) exercise is safe. Most (88%) believed women can continue their exercise regimen, and 73% believed that previously inactive women can begin training while pregnant. Only one-third of women met recommendations for cardiorespiratory exercise. The majority (66%) never engaged in vigorous exercise, and most (73%) did not participate in resistance exercise. CONCLUSION: Pregnant women in rural communities participate in light intensity exercise, but are largely not meeting guidelines for aerobic or resistance training. Knowledge related to safe exercises, particularly resistance training, during pregnancy is limited. Targeted education and programmatic planning are needed in this population regarding exercise guidelines.

Nutrition Practitioner Perceptions of Nutrition Education with Pregnant Clients.

OBJECTIVE: Nutrition education during pregnancy is associated with improved maternal and fetal outcomes. This study explored nutrition practitioner perceptions of providing nutrition education to this population and examined gaps in current practices. METHODS: North Carolina nutrition practitioners (n = 73) working with pregnant women were asked to complete a survey about their provision of nutrition services to pregnant clients. Data were analyzed for descriptive statistics. RESULTS: Cost (91%) and lack of time to cook (83%) were perceived as the largest barriers for clients to making dietary changes. Topics most requested by clients paralleled those practitioners identified as needs: weight gain (69%), lactation (63%), and general nutrition information (57%). Pamphlets (97%), posters (66%), telehealth (42%), and texting (38%) were accepted education methods. CONCLUSIONS AND IMPLICATIONS: Evidence-based education on weight, lactation, and general nutrition, using time and cost-efficient approaches, and embracing technology were desired by pregnant clients when receiving nutrition education from nutrition and other health care practitioners and may result in improved maternal and fetal outcomes.

Racial/Ethnic Differences in Diet Quality and Eating Habits Among WIC Pregnant Women: Implications for Policy and Practice.

PURPOSE: One of the major federal food assistance programs, the Special Supplemental Program for Women, Infants, and Children (WIC), serves approximately 1.5 million low-income pregnant women per year; however, limited information is available on their dietary habits. This is critical because low-income women are at higher risk of gaining excess weight during pregnancy. Thus, the study objectives were to (1) determine the overall diet quality of WIC pregnant women and (2) examine diet quality and eating behaviors by race/ethnicity and other sociodemographics. DESIGN: This was a cross-sectional study. SETTING: One of the 3 WIC offices in a north-central county in North Carolina, USA. SAMPLE: Pregnant women (n = 198) in the second trimester. MEASURES: Interviews included sociodemographics, food security, diet, and eating behaviors. Diet quality was assessed by the Healthy Eating Index (HEI) 2010 scores. ANALYSIS: Descriptives, bivariate analysis, and multivariate analysis. RESULTS: Average participant age was 26 years, and the mean HEI-2010 score was 56 of maximum score of 100. Specifically, African American women consumed significantly lower servings of whole grains (ß = -1.71; 95% CI: -3.10 to -0.32; P < .05) and dairy (ß = -1.42; 95% CI: -2.51 to -0.33; P < .05) compared with non-Hispanic white women. Hispanic women scored higher in daily intake of fruits (ß = 0.98; 95% CI: 0.17-1.79; P < .05) and for consuming empty calories in moderation (ß = 1.57; 95% CI: 0.06-3.09; P < .05). Frequency of intake of fast foods/outside meals was higher among African American women (57%, P = .025). CONCLUSION: Efforts are warranted to promote optimal nutrition among WIC pregnant women. Specifically, African American women are highly vulnerable to poor dietary habits during pregnancy. Further investigation of barriers/facilitators for healthy eating is necessary to address nutrition disparities among WIC pregnant women.

Predictors and outcomes of excess gestational weight gain among low-income pregnant women.

Low-income women were interviewed and their post-natal records were retrieved (n = 160) to assess prevalence of excess gestational weight gain and its socio-demographic predictors. More than half of the women (64%) gained excess weight during pregnancy, with an average of 10 lbs in excess of Institute of Medicine guidelines. Logistic regression indicated that women that started pregnancy at an obese body mass index; who were African American or having an unplanned pregnancy were at significant risk of gaining excess weight in pregnancy. Intervention to prevent excess weight gain during pregnancy is critical in addressing obesity epidemic in the United States and worldwide.

Interrelationship between food security status, home availability of variety of fruits and vegetables and their dietary intake among low-income pregnant women.

OBJECTIVE: To (i) determine differences in the availability of variety of fruits and vegetables (F&V) at home by food security status; and (ii) examine the inter-associations between food security status, availability of variety of F&V at home and frequency of F&V intake, among low-income pregnant women. Design/Setting Participants were interviewed to collect food security status, home availability of variety of F&V and frequency of F&V intake. Bivariate analyses, multivariate regression and exploratory mediation analyses were conducted using IBM SPSS Statistics version 23.0 and the PROCESS macro. SUBJECTS: Low-income pregnant women (n 198) were interviewed if they were ≥18 years of age, in the second trimester of pregnancy, and spoke English or Spanish. RESULTS: Low/very low food security was found among 43 % of participants. Compared with fully food-secure participants, very low food-secure participants reported a lower variety of fruits (P=0·028) and vegetables (P=0·058) available at home. Mediation analyses indicated that through home availability of variety of fresh F&V, food security status was associated with the daily intake of F&V (indirect effect (95 % CI): fresh fruits, -0·039 (-0·074, -0·013); fresh vegetables, -0·048 (-0·083, -0·023)). As food security worsened, the available variety of fresh F&V decreased, which was associated with lower intake. CONCLUSIONS: The study highlights the interlink between food security, home food environment and diet quality, and the importance of nutrition education intervention to promote a healthy home food environment and improved pregnancy outcomes among low-income women.