Even before St. John's Well Child and Family Center in Los Angeles had the resources to provide large-scale COVID-19 testing, it was clear that its service area of South L.A. and Compton would be at significantly higher risk for COVID-19 infection and complications than other areas of L.A. County.

THE PROBLEM

This region is densely populated. It has high levels of poverty, has a large immigrant population, is primarily Latino and Black, and is over-represented in essential jobs that cannot be performed remotely. These populations experience high comorbidities, including hypertension, diabetes, heart conditions, asthma and behavioral health issues.

"Adoption of new technology among members of the communities we serve is slow due to varying levels of technological literacy – especially among older patients – and extremely limited resources," said Jim Mangia, president and CEO of St. John's Well Child & Family Center.

"Additionally, most telehealth implementation historically was focused on addressing the needs of rural communities for specialty care, which is a very different context than ours."

The COVID-19 pandemic accelerated the implementation of telehealth for St. John's Well Child and Family Center due to the stringent "safer at home" order from local government as well as the need to meet residents' healthcare needs while protecting the safety of both providers and patients.

"Reimbursement for telehealth services also was a concern, since the federal government did not issue any guidance at the beginning of the pandemic, though it has since permitted billing of primary care telehealth services," Mangia said. "We are hopeful the federal government will maintain this policy, as the need for these services shows no signs of slowing down."

PROPOSAL

The proposed project was the establishment of a robust telehealth system for both COVID-19 and non-COVID-19-related services. However, while determining what that system should look like, St. John's staff had to address their patients' ongoing healthcare needs in a way that was mindful of the local government's "safer at home" order.

"Therefore, we turned to existing technology as a stop-gap," Mangia explained. "Using telephones and readily available video apps like WhatsApp and FaceTime, St. John's started implementing telehealth services. Most of the consultations centered on COVID-19 questions and education."

While conducting an assessment of existing IT infrastructure, staff identified gaps that needed to be addressed prior to full implementation of telemedicine services. These included updating software, installing additional servers, installing additional Wi-Fi equipment and purchasing more computers for providers.

"Adding telemedicine to our menu of service modalities has increased the number of new patients we can serve while increasing access for existing patients who do not require an in-person visit."

Jim Mangia, St. John's Well Child & Family Center

For example, St. John's plans to implement telehealth through vendor healow's technology, which interfaces with its eClinicalWorks software, including an EHR. However, staff learned that they first needed to upgrade their eCW system before they could work with healow.

"As a temporary solution while we upgrade, we started using Doxy.me for telehealth due to the simple user interface," Mangia said. "Patients do not have to download an app and can just use their telephones. Patients can already access some primary care services – medical, dental and behavioral – without physically being in our clinics."

This is especially significant given that the majority of patients are hourly workers who have difficulty taking time off for in-person visits. It eliminates the need for those without cars to use public transportation during a pandemic, he added.

"As part of implementation, St. John's secured remote patient monitoring devices to track patients with pre-existing conditions such as diabetes and hypertension," he noted. "However, the pandemic changed our focus for now; we are using them to monitor COVID-positive patients with preexisting conditions. Once the pandemic is under control, St. John's will change the focus of RPM to improving outcomes for people with pre-existing conditions."

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MEETING THE CHALLENGE

To implement telehealth, even with just the aforementioned interim technologies, St. John's had to redesign patient visit workflows, which were tested and further refined before implementation.

"We purchased additional equipment and licenses and trained all our staff," Mangia recalled. "When a patient calls into our agency, the call center offers the option to conduct a remote visit and schedules accordingly. The patient is automatically reminded of an upcoming appointment via text and email. Patients also are educated on the process to access Doxy.me through their connected devices – often their cell phones."

Complementing telehealth implementation was the distribution of RPM equipment, including a thermometer, pulse oximeter and tablets, in order to facilitate the measurement of patient vitals. RPM is used to monitor COVID-19-positive patients with preexisting health conditions such as diabetes, hypertension and respiratory illness.

"RPM technology is distributed to patients, who are educated on proper usage and frequency of use, [which is] three times daily," Mangia said. "When they register an abnormal reading, the patient is contacted by VitalCare RPM for a follow-up, either by conducting a second reading through the RPM technology or [by] providing advice to seek medical attention at a hospital or emergency room."

Unfortunately, both Doxy.me and the RPM solutions are not integrated with eClinicalWorks. However, the RPM devices are integrated by Bluetooth technology with VitalCare, which staff has access to in order to review patients' vitals.

RESULTS

St. John's Well Child and Family Center knows that, nationwide, people have avoided seeking face-to-face healthcare for chronic conditions during COVID-19. Without the primary care telemedicine program, the provider organization's patients – especially those with chronic conditions – certainly would be facing even greater healthcare disparities than before, Mangia stated.

"Adding telemedicine to our menu of service modalities has increased the number of new patients we can serve while increasing access for existing patients who do not require an in-person visit," he said. 

"This has enabled tens of thousands of South L.A. and Compton residents to receive COVID-19 related care and education, as well as care for other health issues. Since April 2020, St. John's has completed approximately 93,000 telehealth visits serving over 56,000 unduplicated patients."

RPM, which has been distributed to 400 patients, also has provided a better means of monitoring at-risk patients who tested positive for COVID-19, he added.

USING FCC AWARD FUNDS

In mid-2020, the FCC's telehealth funding program awarded St. John's Well Child and Family Center $382,331 to treat patients in South Los Angeles and the City of Compton through remote patient monitoring, video consults and voice consults.

"Funds from the FCC grant have been used to transition telehealth provision from telephonic and videoconferencing apps to dedicated software solutions for healthcare provision," Mangia reported. "The grant has funded the IT infrastructure necessary to support telehealth, including servers, Wi-Fi access points, computers, server software and software licenses for 17 clinics in South Los Angeles and Compton."

St. John's also purchased 400 RPM units for patients.

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