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In March 2020, many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering high volumes of telehealth visits to maintain access to care. The resulting telehealth safety net services led to rapid changes to technology, workflows, and staffing to accommodate telehealth visits.
To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation.
While the focus has been given to health disparities, different perspectives, including race, income, provider reluctance, and consumer preference for audio or video technology, have been examined. RAND researchers led by Lori Uscher-Pines, Natasha Arora, Maggie Jones, Abbie Lee, Jessica L. Sousa, Colleen M. McCullough, Sarita D. Lee, Monique Martineau, Zachary Predmore, Christopher M. Whaley, and colleagues reviewed recent literature on telehealth implementation in safety net settings in a RAND report. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff.
Key Telehealth Implementation Findings
The most notable findings of this large-scale telehealth implementation study included the following:
- Although overall visit volumes remained roughly the same from the prepandemic to the pandemic study periods, the share of audio-only and video visits dramatically increased during the pandemic, particularly for behavioral health.
- Audio-only visits were the leading telehealth modality for primary care and behavioral health throughout the pandemic study period. At the end of the study period, however, audio-only visits were eclipsed by in-person visits for primary care but not for behavioral health.
- The use of video visits varied substantially across health centers, particularly for behavioral health; health centers that delivered numerous video visits and replaced audio-only visits with video visits over time had some common promising practices.
- Patients with limited English proficiency participated in a significantly lower percentage of video visits compared to those who typically receive primary health care services in-person at a clinic. To address disparities in access, clinics engaged in various creative solutions to address the digital divide.
- Perceptions of whether telehealth provided an acceptable level of care were relatively positive; however, there were differing views on its sustainability and its impact on equity and quality.
- Key facilitators of telehealth implementation were leadership support, patient willingness to use the technology, platforms that were easy to use and access, a sense of urgency within clinics, changes in reimbursement policy, and training opportunities for staff.
FQHC Telehealth Recommendations
The researchers made the following suggestions regarding telehealth implementation:
- More work is needed to understand how telehealth helps and hinders health equity and to improve equitable telehealth access.
- Billing modifiers that differentiate between modalities are needed to further understand disparities.
- Data are needed to understand the impact of audio-only visits on the quality of care to inform sustaining the temporary changes to the reimbursement policy. The impact of audio-only visits on the quality of care needs to be empirically tested.
- Health centers should be permitted to serve as distant sites permanently.
- Health centers need resources, time, and support to successfully implement telehealth.
- Health centers can be supported in increasing access for patients with limited English proficiency and other populations with access challenges.
- Health centers should take steps to better support patients facing digital barriers. Knowledge of what works in video visit implementation already exists, and health centers have many tools to grow their video visit programs.
- Appropriate staffing is key to telehealth implementation.
Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth implementation ensures high-quality care and health equity for FQHC telehealth but also in other settings.
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