Although telehealth care access proved beneficial for some patients during the pandemic, in-person options were essential to promoting health equity and trust.

By Sara Heath

November 10, 2020 – While the COVID-19 pandemic forced other healthcare organizations to spend March and April shuttering their doors and transitioning to telehealth care access options, Cahaba Medical Care in Alabama was doing the opposite.

The federally qualified health center (FQHC) with ten clinics, a fleet of school-based providers, and two community-based centers in the Birmingham area knew that in order to promote health equity, they couldn’t shut down completely.

Of course, telehealth gained international notoriety during the pandemic for helping to connect patients to care during strict stay-at-home orders. It helped Cahaba in this way, too. But leadership also knew that telehealth care access couldn’t tell the whole story for every patient.

Cahaba Medical Care serves a largely Black, traditionally marginalized population, according to Ernestine Clements, MD, a family physician at the organization’s West End location. This is a poverty-stricken area and has been as long as Clements, who grew up in the region, can remember.

“So in our particular community, we have a high unemployment rate,” Clements told PatientEngagementHIT. “We are in a food desert as well. And even though we’re in an urban area, our mass transportation system is not as great as some of the bigger cities.”

In other words, patients visiting Cahaba are at high risk for social determinants of health, with many presenting with more than just clinical needs. This was true even before the pandemic, when Clements and her colleagues worked to meet social needs that pushed beyond traditional medical care.

“We offer pretty much everything for our patients,” Clements explained. “We try to be a one-stop-shop, providing mental health services, primary care services, procedures that we can do here, lots of them. We provide some specialty services. We offer food and clothing if needed. We try to really be a resource for the community that we’re serving here.”

And then COVID-19 hit.

Like nearly every other primary care clinic in the nation, the pandemic introduced a host of problems, most of them related to patient safety and care access. At the start of the public health emergency, the Department of Health & Human Services put out advisories encouraging medical practices to shut their doors to non-urgent and non-emergency healthcare services.

Most healthcare organizations heeded that call, supplementing primary care appointments and chronic disease management with telehealth care access. According to some studies, telehealth use increased by over 1000 percent year-over-year in April.

But given its traditionally marginalized population, Cahaba knew that route wasn’t going to work. Tapping telehealth, which the FQHC had already implemented before the pandemic, is of course an ideal option for keeping patients out of the clinic and reducing virus spread.

But it’s not a great solution for patients who don’t have the means—either technological or otherwise—to use the tool.

“For those who are able to access telehealth and the patient portal, it’s been great to make sure we’re staying connected through this whole pandemic,” Clements acknowledged. “We’ve had uptake as far as patients just using the telehealth modality to have the actual visits. But we did see those folks who didn’t have access as far as they might not have WiFi, smartphones, computers, and things like that.”

This trend has been seen outside of Cahaba, too. In September, research in the Journal of the American Medical Informatics Association showed that older adults and Black and Hispanic patients were less likely to utilize telehealth during the pandemic than their White peers. Black and Hispanic patients were more likely to use clinic care, like that being offered at Cahaba, or go straight to the emergency department.

In some cases, patients might be more poised to utilize telehealth than they know, Clements said. When patients present in the clinic, Clements always asks them about what types of technologies they have.

“So some of them may even have a smartphone, they just don’t know how to use it,” Clements explained. “We take that opportunity to say, ‘Hey, this is what you need to do for this. If you don’t have an email, we can help you get to set up with an email so you can access us via that as well. And then this is how you do this visit on your phone,’ and things like that.”

Keeping their doors open did more than just ensure all Cahaba patients, not just the ones with computers and smartphones, can get care. This was also a huge issue with keeping patient trust.

Trust in the medical establishment has become a huge talking point, as more healthcare leaders zero in on racial health disparities and work to address racism in medicine. Notably, many Black patients report a lack of trust in healthcare, largely stemming from personal experiences with racial bias and centuries of mistreatment of Black and Brown bodies in the medical system.

Clements said she is in a unique position as a Black physician to address the question of trust. Representation matters, and the fact that her patients can relate to her creates an innate sense of trust between them.

“So sometimes me just telling them how it is, it’s taken on a different level versus someone that they may not trust,” she said.

And it’s that very question of trust that made it important Cahaba stayed open to in-person visits during the pandemic. So many other clinics had to shut down, but Cahaba was able to remain a consistent place patients could visit for help.

“For this community, it really has had so many organizations and different types of medical providers come in and out of the area,” Clements said. “It was a big thing for us to actually stay open during the pandemic. That spoke volumes to our patients because a lot of primary care providers, they closed down, or they switched only to telehealth, which for some, and especially in this particular community, they would’ve lost access to their provider.”

Cahaba managed this largely by segmenting its patient populations into COVID-19 visits and well-visits or visits for other health ailments. Staff members were relegated to either domain, helping to keep a lid on the virus and preserve PPE in certain settings.

Of course, trust is important outside of in-person care, too. For those patients accessing healthcare via telehealth, many for the first time, understanding how this technology worked was essential. For Clements, maintaining pre-pandemic levels of trust meant emphasizing exactly who was going to be on the other end of those technologies.

Whenever Clements referred a patient to a telehealth visit or patient portal secure message, she made sure to stress it would be her, and only her, on the other end of the computer.

“Because a lot of times, particularly in this community, they have this thing where they fear they are going to get tossed around to this provider or that provider, then this provider again,” she said. “But they know when I’m telling them, ‘You’re going to see me, you’re going to see me,’ we have that type of trust built already there. Just making that connection patients are actually going to be with the provider who they know and who they have a relationship with, it really does help.”

Ultimately, these approaches situate Cahaba to continue meeting patient needs well into this third wave of the pandemic.

“With Cahaba, we were able to do a hybrid model for our patients,” she continued. “For patients who had to do in-person, we were here. For those who had the capability to switch to telehealth, that was offered for them as well. The fact that we stayed open was a big thing for us to build that trust within this community.”

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