Cleveland-based Neighborhood Family Practice is a federally qualified health center that sees more than 21,000 patients a year through 80,000 visits at its seven health center locations. It serves a diverse, impoverished population, including many former refugees and Spanish speakers.
For 40 years, NFP’s model was solely a face-to-face model of integrated care – primary care, behavioral health, dental, midwifery and pharmacy – that included meeting social needs, transportation barriers and access to care roadblocks.
Overnight, when the COVID-19 pandemic hit, NFP had to change the model.
“With a priority on safety for patients and staff, we stood up telemedicine in two weeks,” recalled Jean Polster, RN, president and CEO of Neighborhood Family Practice. “We chose to go with vendor doxy.me because it was website-based, required no downloads for our patients, allowed flexibility with our staff and was affordable.”
NFP uses an Epic EHR (through OCHIN, a health center-controlled network) and had access to Zoom through Epic’s MyChart patient portal, but determined it would be too difficult for its patients. At the time of the pandemic, it had a less than 40% adoption rate for the MyChart patient portal. It needed a universal solution for patients.
“Urban practices, particularly in Ohio, had not viewed telemedicine as a good fit pre-COVID, given the restrictions on use from a billing/reimbursement perspective,” Polster said. “With the relaxation of those restrictions in mid-March, that allowed us to use virtual care for patients no matter how close or far they lived from our clinic or other healthcare institutions. This regulatory change was critical to our success.”
NFP determined in early March that it needed to keep its 21,000 patients in its care, while simultaneously keeping them safe at home. Early in the pandemic, there was a stay-at-home order in place. There also was significant fear within NFP’s workforce, because the virus was so poorly understood. NFP needed to be flexible to meet the needs of employees impacted directly and indirectly by the pandemic and ensure their safety. Telemedicine and remote work immediately became the solution.
“The no-show rate in that department has been cut nearly in half. That has not only been because of increased demand for services, but the ease of use for patients.”
Dr. Charles “Chad” Garven, Neighborhood Family Practice
“As primary care providers, we recognized that chronic care cannot be ignored during a pandemic,” Polster explained. “We needed ways to expand our capabilities to deliver chronic disease management safely. Even before the FCC telehealth award grant we received, we purchased blood pressure cuffs, glucometers, pregnancy dopplers and other similar technology to get into the hands of our patients at home.”
If chronic disease were ignored for the first six months of the pandemic, staff were afraid a winter surge would be met with a chronic disease-complications surge.
“We also believed that certain at-risk groups were not engaging in the healthcare system due to fear of infection, barriers to access or other systemic reasons,” Polster observed. “We pursued a solution for what amounts to a traveling exam room, equipped with backpacks filled with laptops, remote stethoscopes, pulse oximeters, high-resolution cameras and vitals machines, in order to treat patients remotely.”
This would allow staff to reach their refugee patient population and those living in senior centers, and potentially get to patients who otherwise might have been left behind during a pandemic.
“In a matter of weeks, we had fully implemented that workflow into our medical, midwifery and behavioral health practices,” she said. “Initially, we did not have the equipment ideally suited for the job. This put considerable strain on the personnel onsite as we retrofitted to our current hardware. We had to repurpose old laptops, find unused tablets, [and were] often pleased when a provider was willing to use his or her own device to supplement the technology on-site.”
NFP also worked to have two screens available: one for the doxy.me application and one for the Epic EHR. NFP also had to incorporate its interpretation services for the almost 30% of patients who do not speak English.
“The solution we implemented for telemedicine was inclusive of video and telephone visits,” she noted. “NFP continues to see 20% of its patients using telephone only. This is a multifaceted problem of Internet access, computer access, skill and language barriers.”
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MEETING THE CHALLENGE
NFP has been able to dramatically improve its providers’ use of technology, given the FCC funds, said Dr. Charles “Chad” Garven, associate medical director of medical informatics.
“We have been able to recycle old, outdated laptops,” he said. “We have been able to improve bandwidth/access to our Internet, as well as support the often more than 50 providers at a given time streaming video content with patients. We have worked with Let’s Talk Interactive in building out their model, not only from a hardware standpoint with their soft packs, but also their software solution, which will allow us to greatly expand our access to vulnerable patients in the community.”
The NFP behavioral health team has gone 100% remote. It has used the technology solutions at home, and its volume has skyrocketed.
“Gone are the days of a laptop next to an iPhone that is balanced on a tissue box on a desk at home,” Garven said. “We now have been able to support more permanent solutions for them. The no-show rate in that department has been cut nearly in half. That has not only been because of increased demand for services, but the ease of use for patients.”
A single mom with kids at home can go upstairs and have a visit with their counselor, a visit in the past that would have been canceled due to childcare issues.
“Our midwifery team has expanded access to patients, despite having to temporarily reduce in-person encounters with their expecting moms,” he explained. “We have moved our group prenatal classes to a virtual platform. We have been able to get higher risk moms BP cuffs and scales in order to more confidently manage their pregnancies during the pandemic.”
NFP’s wellness nurses and dietary teams have been able to provide support to patients during the pandemic. They have discussed the “refrigerator biopsy,” where they have been granted more access to a patient’s home than they had ever been granted before. The visit now provides staff an eye-opening perspective into what patients have access to and develop a solution that is achievable and individualized.
“NFP is in the process of a pilot involving hypertensive patients and a remote monitoring technology integrated into our EHR,” Garven said. “Patients are enrolled in a program, set up with the BP cuff by our on-site support staff, and then they have sequential visits with a medical provider, PharmD and dietician. Early results are promising for those who have been successful in engaging in the program. We have been able to manage hypertension effectively, quickly and safely.”
NFP has become an organization offering a tailored blend of telemedicine and face-to-face care, given an individual patient’s needs. It is busier than it has ever been, with the same amount of staff, so the organization knows this is what its community is asking of the health center.
The telemedicine program is combined with a population health approach that includes outreach to patients. This also has helped patients understand how remote visits fit into their plan of care.
“We compare our visit volume month by month over each year,” Polster explained. “In looking at our visit volume, we had an expected dip in visit volume during the most restrictive period of the COVID-19 stay-at-home order for March/April/May. By June 2020, we surpassed June 2019 visit volume by 12%, July by 20%, August by 8% and September by 18%. October and November are even busier.”
NFP through November is only seeing around 40% of visits in person. Staffing has not risen. Costs of drugs and supplies also are much lower now.
“In May, NFP began its testing program incorporating telemedicine prior to the test,” Polster said. “The testing volume has been steadily rising with each surge of demand. NFP also began using JotForms and a text messaging platform called Well to communicate with patients easily and allow for form completion and signatures remotely.”
NFP’s patient experience is excellent, and no-shows are down, Polster added.
“We have met our patient demands, not just for COVID-19-related issues, but have taught them that we have a virtual platform that gives them quality access to their providers,” she said. “For our patient population, we were not sure that would be possible, but our safety net population has adopted it.”
Early in the pandemic, NFP offered a voluntary furlough for eight weeks, which 20% of the workforce accepted. Given its successes in implementation and return on visit volume, the organization was able to hire every furloughed staff member back in May.
NFP is back at full strength, at a time in the pandemic when many have not been able to do so. Many staff members (30%) are working remotely full- and part-time. And NFP is upgrading its telecommunications infrastructure and phones to expand remote work in 2021.
USING FCC AWARD FUNDS
Neighborhood Family Practice was awarded $244,282 to provide telemedicine, connected devices and remote patient monitoring to patients and families impacted by COVID-19 in the City of Cleveland’s West Side neighborhoods, targeting low-income patients with chronic conditions.
“We have been able to expand our direct hardware access for providers at all levels,” Garven said. “We have a multidisciplinary team that recognizes telemedicine is here to stay and in order to do that we needed to improve our onsite hardware. This step is largely complete.”
Next is to rapidly expand the home monitoring equipment through the devices purchased. The focus will be on chronic disease management and high-risk pregnant women.
“We now have the ability to deploy our services out into the community with real hardware solutions,” Garven said. “We will pick up the exam room out of our office and move it to the community. COVID’s impact will be felt by our vulnerable patients for many months beyond vaccines and stay-at-home orders. We think that the technology is adept enough to have a comprehensive exam and visit with providers in the patient’s place of residence.”