PrimaryOne Health is a federally qualified health center located in Central Ohio and is one of the largest FQHCs in the state.

PrimaryOne Health provides comprehensive primary and preventive healthcare services in accordance with the U.S. Department of Health and Human Services Bureau of Primary Health Care Federally Qualified Health Center Program requirements for uninsured, underinsured and other medically underserved central Ohio residents.

Prior to the pandemic, PrimaryOne Health dealt with regulations that prevented routine telemedicine visits with patients. Some of the regulations allowed visits from one physical location to another physical location; however, site-to-site visits didn’t help with any of the pressing patient care needs.

Successful pilot projects

"PrimaryOne Health completed pilot projects with the model of the previous regulations," said IT director Jeff McGlade. "The pilot projects were successful, but the visits were not billable and required facilitation on the patient side. However, once the pandemic started, the rules and demand for care changed in a way that let us quickly deploy telehealth services.

"When the pandemic began, in-person visits slowed down and, in some cases, stopped, due to the state of emergency, social distancing and patient risk," he continued. "When Ohio declared a state of emergency, PrimaryOne Health was receiving constant updates from different organizations."

"To perform the model of telehealth correctly, it was vital that the medical assistants, nurses, LPNs and other support staff were fully engaged in the intake process to ensure a smooth visit for patients."

Jeff McGlade, PrimaryOne Health

The National Association of Community Health Centers, the Ohio Association of Community Health Centers and the payers were updating on changes and even draft changes for PrimaryOne Health input.

"The regulations started to quickly change, and on March 20, 2020, Ohio released an emergency telehealth rule," McGlade recalled. "After recognizing the need, strongly desiring it, and even trying telehealth pilots for years, it suddenly became possible very quickly.

"The rule allowed telehealth services to be implemented and delivered in a way that had always been envisioned," he continued. "A telehealth team was quickly formed to digest and process the fast-changing regulations and to initiate a telehealth program to ensure high-quality patient care."

Developing a telehealth program

During this same time, PrimaryOne Health leadership and its board created a contingency plan that ensured patient access and the health of the organization. The plan tasked the team to develop a telehealth program, implement any technology, train all staff, and transition to primarily telehealth visits.

"The team quickly developed the plan and it went live," McGlade said. "A week after going live, PrimaryOne Health transitioned from zero telehealth visits to averaging 75% of total visits completed via telehealth. We were able to maintain this excellence beyond the duration of the stay-at-home order in Ohio, resulting in 51,000+ total telehealth patient visits in 2020, or 38% of total visits."

This was a dramatic increase from 2019, when telehealth accounted for 0% of billable visits.

"During this period, PrimaryOne Health attempted telehealth through all available specialties," McGlade reported. "This would not have been possible without the change in regulations and the ability to shift the amazing support staff almost overnight to a supporting role in the telehealth workflows.

"Specifically, to perform the model of telehealth correctly, it was vital that the medical assistants, nurses, LPNs and other support staff were fully engaged in the intake process to ensure a smooth visit for patients," he continued.

Focusing on payers

Items on the forefront for the telehealth team were accurate billing, sensible workflows and technologies to remove barriers so patients had friendly and easy access. With billing, the team was laser-focused on which payers reimbursed, the quantity and how visits should be accurately documented.

"A billing guide was developed including each payer and it was used to customize a telehealth shortlist in the EHR to make certain documentation was precise," McGlade said. "This process proved to be a repeatable practice that the team has used for other projects such as remote patient monitoring programs.

"Workflows were created from the billing guides," he continued. "The workflow started with the scheduling team, then transitioned to the medical assistants to perform intakes, and finally to the clinical staff. At the start of this project, the majority of the clinical staff were at home because of pandemic issues related to childcare and having to temporarily close some clinics for in-person, and other issues."

Some staff members were redeployed to support the telehealth processes. The team found that the best process for patients was to perform intake prior to the visit by support staff and then to let the patient know what to expect for the telehealth visit. The team found that the process needed continued tweaks and enhancements and quickly rolled them out after each meeting.

"Using technology was crucial to remove patient barriers and new systems were quickly adopted and deployed," McGlade noted. "After the transition to telehealth, the team quickly identified that clinicians had to go to the physical locations weekly for paperwork and signing any controlled prescriptions. In the matter of a few weeks, Electronic Prescribing of Controlled Prescriptions was rolled out to speed up prescriptions getting to the pharmacies.

"It was determined that to do telehealth with the unique patient base, a telehealth platform was needed that did not require a patient portal," he added. "The platform allowed PrimaryOne Health to send patients a text message with a link that initiated the video visit. An additional texting platform was deployed that was adopted by the call center and behavioral health department."

Patients and texting

The platform allows patients to text the main number, chat with a live person on the website and start up video visits. The behavioral health department uses this for texting their patients and for starting up video visits.

The FQHC uses vendor Blue Stream Health for telehealth, and vendor OHMD for texting.

"In early 2021, PrimaryOne Health started up a remote patient blood pressure monitoring program, in addition to the ongoing telehealth efforts," McGlade recalled. "Using previously learned practices of researching and building upon the billing process, a detailed plan was developed. The team ensured that technical barriers were addressed for the patients.

"A platform was found from a company called Unity Population Health that, like the telehealth platform, did not require a patient portal account," he continued. "The platform also removed the need for internet access for the patient."

PrimaryOne Health deployed blood pressure cuffs that have a built-in cellular connection and automatically upload the results to a tracking system that has a feed into the patient’s chart. Through this platform, patients can be easily contacted via text message reminding them to do their reading and checking on them for issues they may be having.

A successful program

"The program has been a success, and has allowed PrimaryOne Health to add patients into the program, regardless of if they have a patient portal account, or regardless if they have an internet connection," McGlade explained.

"Other groups considering telehealth should start with the billing and regulations, understand the need/demand, the barriers for the staff, and, most importantly, the barrier the patients may face," he continued.

By late May 2020, PrimaryOne Health started to slowly and safely transition back to in-person visits to meet patient demand. The transition put a demand on the intake staff that directly impacted the telehealth visits.

As the staffing demand and staffing shortages increased, PrimaryOne Health moved to mostly in-person visits by November 2020. The transition back to in-person visits has resulted in the current practice of about 15% telehealth visits versus in-person.

"Presently, a similar version of the original telehealth visit exists," McGlade noted. "Only established patients are seen via telehealth, and it is not required to complete any intake prior to the visit. We have been able to remove the intake process, but at the expense of having to limit the types of appointments we can provide with telehealth.

"Today in the medical group, telehealth is a popular option with established practitioners who have a panel of patients," he continued. "Someone who is seeing a full schedule four days per week is able to fill a fifth day with telehealth versus a practitioner doing the majority of telehealth. Telehealth has also become a way of helping with staffing issues."

Still very popular

Some practitioners have been deployed without support staff with telehealth in ways that would not have been possible in the past. Additionally, telehealth is still a very popular option with the behavioral health team, whose members have become very savvy in the ways they deliver care to patients.

"As an FQHC, we must ensure we are looking out for patients' barriers to care," McGlade explained. "Removing our patient barriers by ensuring all can access telehealth outside of the portal, and any patient can join our remote patient monitoring program, has been vital to our ongoing efforts.

"Not all patients have a smartphone with Bluetooth, with the patient portal on it for a blood pressure machine," he added. "By addressing the typical barriers globally, we can still interact with and treat the patient in ways that just make it easy for both the patient and our clinical staff."

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