NYC Health + Hospitals is the largest safety net health system in the United States, serving more than one million patients annually, including the most vulnerable New Yorkers.

THE PROBLEM

Once the COVID-19 pandemic struck, the health system needed to be able to treat the surge of patients with urgent care needs virtually so they could keep them safely at home and away from the overwhelmed emergency care system. To ensure all New Yorkers could access this new service, NYC H+H also needed a telehealth vendor that enabled it to offer virtual urgent care to all patients in their patients' preferred language and without a clear need for the Internet or a smartphone.

NYC H+H also needed to adapt to meet the evolving care expectations of healthcare consumers who were encouraged by their positive experiences with telehealth during the pandemic. Consumers have come to expect an array of options bringing care closer to home, including virtual urgent, remote patient monitoring and mobile delivery.

"Our virtual urgent care experience, Virtual ExpressCare, has allowed us to better meet the needs of our patients where they are while reducing the impact of structural barriers they have in getting care," said Erfan Karim, senior director of mobile integrated health at New York City Health + Hospitals. "We want our patients to know that we will be available to them 24/7 for their physical, mental, emotional or other health needs they may have.

"We see the changes in healthcare delivery during the pandemic staying, and paralleling other industries bringing shopping, entertainment and personal finance directly to the home and into the hands of consumers," Karim added.

During the peak of the pandemic, along with other New York City health systems, NYC Health + Hospitals launched a 911 call diversion intervention with the New York City Fire Department Bureau of Emergency Medical Services.

The 911 call volumes surged from an average of just over 4,000 calls per day to more than 7,000 calls per day. It was crucial to offer lower-acuity 911 calls a telehealth option, where clinically appropriate, to avoid potential delays of New Yorkers receiving lifesaving care from both ambulances and crowded emergency departments. In order to launch this service, NYC Health + Hospitals needed a telehealth platform that could flexibly support audio and video modalities.

"The pandemic also presented new access to care challenges and opportunities to rethink what blended digital and in-person care could look like if built around the patient experience," Karim said. "NYC Health + Hospitals streamlined how patients could access monoclonal antibody treatment, a novel treatment that reduces the risk that patients with COVID-19 develop severe symptoms that lead to hospitalization or death.

"COVID-19-positive patients were identified through multiple channels and were connected to Virtual ExpressCare over the phone or at expresscare.nyc," Karim continued. "ExpressCare evaluated patients for clinical stability and eligibility for MAB, and providers were able to discuss the risks and benefits of this therapy. NYC H+H patients would then be scheduled for same- or next-day clinic-based infusion therapy."

PROPOSAL

NYC Health + Hospitals chose vendor Bluestream Health to power its virtual urgent care experience, given this technology's ability to be configured to NYC Health + Hospitals' particular workflows. The Bluestream Health system allowed for multiple entry points over either video or phone/audio. The phone access was critical, given NYC Health + Hospitals' role as the safety net health system to New Yorkers.

In addition, the vendor supports out-of-the-box comprehensive interpreting services and the ability to integrate with interpreter vendor services. This is especially important to NYC Health + Hospitals, given the diversity of its population and the need to provide care in more than 200 languages.

MARKETPLACE

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MEETING THE CHALLENGE

NYC Health + Hospitals' Virtual ExpressCare has a multitude of entry points to meet the needs of patients, including the web, via expresscare.nyc, homeless shelters, 911, NYC Health + Hospitals' call center and nurse triage, NYC Health + Hospitals' MyChart patient portal, NYC Test & Trace Corps, and via its remote patient monitoring programming.

The goal is to provide on-demand, convenient virtual urgent care to reach the patient where they are and keep them safely in their home.

Bluestream Health is integrated with a range of NYC Health + Hospitals solutions to offer a comprehensive virtual urgent care experience. For example, Bluestream Health is integrated with the expresscare.nyc website so patients can use "Save My Spot" and schedule a time for their virtual urgent care encounter.

Bluestream Health also is embedded in NYC Health + Hospitals' MyChart patient portal, allowing a patient one-click access to an urgent care provider.

RESULTS

In its first year, NYC Health + Hospitals treated more than 16,000 patients through Virtual ExpressCare. The service was crucial in preserving New York City's emergency care system.

NYC Health + Hospitals supported FDNY EMS to avoid more than 1,300 unnecessary ambulance trips through their partnership around 911-based telemedicine. Bluestream Health was critical in having a telehealth product that can support phone and video pathways to its healthcare partners, Karim said.

"Virtual ExpressCare as a key value driver for NYC Health + Hospitals aims to serve episodic care needs, avoiding higher cost hospital utilization, and to connect patients into primary care," Karim noted. "So, it is critically important to show that the service was able to meet those episodic care needs on its own right. Virtual ExpressCare has been able to help five out of six patients avoid a subsequent trip to an urgent care center or hospital emergency department within seven days."

ADVICE FOR OTHERS

Just like implementing any broad scale healthcare strategy, it is critical to think of patients and providers first, Karim advised.

"While telehealth largely has been successful across the industry, patients report frustrating experiences navigating getting healthcare when they need it," Karim noted. "They also struggle with accessing telehealth and the need to download apps or fill out forms at the time of a visit.

"Patients may face structural challenges in not having access to affordable broadband Internet or to a smartphone," Karim added. "For example, 30% of New Yorkers do not have access to affordable broadband. In any event, it is critical to understand how you can mitigate the different failure points for patients with respect to your telehealth system."

Regarding providers, it is critical that one accounts for current workflows and how providers use their current systems, Karim further advised.

"It is not feasible to ask providers to support multiple workflows and processes to deliver patient care at scale," Karim said. "This will also be a new experience for most providers, so you also have to train and work with providers so they feel comfortable and supported such that they are happy with their ability to offer care over telehealth.

"Also, successful implementation of telehealth is not a one-step process, but a journey that requires ample time and resources to get it right," Karim continued. "Telehealth is not an out-of-the-box solution and some customization will be required for your different use-cases or workflows. It is critical to have the mindset to intentionally test and scale your telehealth solution."

Finally, despite the regulatory flexibilities from CMS and state payers during COVID-19, coverage and reimbursement for certain telehealth modalities including audio and remote patient monitoring have limitations, which healthcare providers must account for in program operations.

"Virtual ExpressCare has been a valuable, high-quality care alternative to unnecessary, costly 911 and ED use," said Christopher Philippou, senior director of strategic operations and development at NYC Health + Hospitals. "It is important that policymakers recognize that parity of coverage and of reimbursement for telehealth with in-person care is critical to closing health equity gaps.

"To ensure that remote patient monitoring is accessible to vulnerable populations, coverage and reimbursement should consider that the true value of this programming is associated with a provider being able to monitor patients' total health, which includes symptoms and physiologic data, to prevent clinical decompensation," he concluded.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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