In early 2020, as the COVID-19 pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Researchers investigated changes in telehealth utilization and health center staff experiences with implementation.

Cover: Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic
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Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic

Results from the Connected Care Accelerator Initiative

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, et al.

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Research Questions

  1. How did the utilization of different types of telehealth visits among health centers change during the pandemic?
  2. Did greater use of telehealth during the pandemic affect access to care for different populations of patients? Were certain populations underrepresented among telehealth users?
  3. What were health center leaders' experiences with telehealth? Specifically, what organizational changes were made to support telehealth use? What barriers did they experience in expanding telehealth programs? What consequences arose from telehealth use for patients, clinics, and staff?
  4. What were the promising practices of health centers that successfully delivered a high percentage of video visits?

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care.

This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make 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 that was 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. In this report, researchers review recent literature on telehealth implementation in safety net settings. 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. 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 is implemented in a way that ensures high-quality care and health equity.

Key Findings

  • Although overall visit volumes remained about 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 full 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 with the percentage of patients who typically receive primary health care services. To address disparities in access, clinics engaged in a variety of 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.

Recommendations

  • 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 quality of care to inform sustaining the temporary changes to reimbursement policy. The impact of audio-only visits on quality of care needs to be empirically tested.
  • Health centers should be permitted to serve as distant sites on a permanent basis.
  • 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.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Summary of Key Findings from the Research Literature

  • Chapter Three

    Trends in Telehealth Use in Connected Care Accelerator Health Centers: Results from Quantitative Analyses

  • Chapter Four

    Health Center Leaders' Perceptions of Telehealth Implementation: Results from Semistructured Interviews

  • Chapter Five

    Provider and Staff Attitudes About Telehealth: Results from Surveys

  • Chapter Six

    Implications for Policy, Practice, and Future Study

Research conducted by

This research was funded by the California Health Care Foundation (CHCF) and conducted by the Access and Delivery Program within RAND Health Care.

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