Henry J. Austin Health Center, a federally qualified health center in Trenton, New Jersey, was having problems with payment options.

THE PROBLEM

Regulations had been passed in New Jersey requiring reimbursement for telemedicine services. But the major payer sources, while aware of the new regs, had not made any changes in their reimbursement process to pay for services provided through telemedicine.

There also were limits on how the telemedicine service could be provided. Initially, the patient had to be seen in the office before a telemedicine visit could be provided. The provider and the patient could not be off-site at the same time during the telemedicine visit. One of them was required to be on-site for the visit. Financial limitations were a significant barrier to implementation of any type of telemedicine service.

"Technology also created barriers to implementation of telemedicine services," said Lee Ruszczyk, senior director of behavioral health at Henry J. Austin Health Center. "Prior to the pandemic, HJAHC was providing tele-psychiatry visits. These services were paid for by a grant. The platform required that the patient present in the office since the provider was remote. The technology that was used did not allow for the patient to have the visit occur on their devices."

The technology also used a lot of staff time and energy to set up and coordinate the visits. The tele-psychiatry services were using extra staff resources and were not cost-efficient. Patients did report a positive experience using telemedicine, and their attendance increased from in-person visits.

"Cost of implementation also is a barrier for a non-profit organization," Ruszczyk explained. "HJAHC had recently received funding for the hardware and software necessary to begin the implementation of telemedicine prior to the pandemic. Finally, making any type of change in how services are delivered is a long and arduous process. It takes ongoing monitoring and enforcement to ensure that the change is made."

PROPOSAL

There were bureaucratic, systemic issues that take time to overcome. Reimbursement for service for a non-profit agency is a huge barrier, Ruszczyk said. Lobbying the various healthcare companies to implement the necessary reimbursement changes was just occurring prior to the pandemic. Those changes would have needed to be in place before telemedicine services could be provided.

"Second, having the necessary funding available for software and hardware for a non-profit agency is key," Ruszczyk said. "Non-profit agencies are fiscally lean with little to no extra funding available for additional projects. Grant funding needed to become available for this type of project. The process of applying and obtaining funding needed to be completed prior to any type of implementation. Again, funding had just recently been obtained prior to the pandemic."

The agency had identified that telemedicine services were going to be a priority for the practice when it came to healthcare delivery. However, the aforementioned changes needed to occur prior to implementation.

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MEETING THE CHALLENGE

The primary motivation for the change to telemedicine occurred with the onset of the COVID-19 pandemic. The societal change of social distancing to deal with the pandemic required for the health and welfare of both patients and staff that everyone remains at home whenever possible.

This guidance led to the initial fiscal barrier for reimbursement being immediately lifted. Healthcare companies and states were instructed to eliminate all rules and regulations that had been blocking reimbursement for telemedicine services. Both patients and providers could be home to provide essential medical and behavioral health services. Once this barrier was eliminated, it cleared the path for implementation of telemedicine.

"HJAHC has a commitment to the well-being of both its staff and patients," Ruszczyk said. "It became clear to the senior administration that it was necessary to move the entire organization to a telemedicine platform to provide safe services to the Trenton community. The IT department identified Doxy.me as the platform of choice. It allowed the agency to function temporarily on a free platform until the necessary contracts could be obtained and executed." 

Once this was accomplished, the transition to the clinical platform was smooth since all providers had used the free platform, Ruszczyk reported. The Doximity Dialer was identified as an appropriate option for staff to use without their personal information being seen by patients. The transition to a telemedicine platform occurred in a week's time. All staff were provided with the necessary equipment. Arrangements were made for those staff without internet services.

"The organization had been using an electronic health record that allowed all personnel to access it from home when necessary," Ruszczyk explained. "The IT department also had other foundational aspects in place such as a VPN service where agency files could be accessed from home."

The final part of the equation involved constant communication and evaluation by the staff. Meetings were initiated in the morning and at the end of the day to discuss workflows. Discussion occurred on what was working and what needed to be adjusted and changed. This process occurred for about the first two weeks and then moved to end of the day daily meetings. Staff's jobs duties were shifted to accommodate the technology changes and the manner in which services were delivered.

"The staff's dedication to the patients was the last ingredient," Ruszczyk said. "The entire staff of HJAHC is deeply dedicated to the patients. This dedication allowed for everyone to work through the difficulties that occurred during the transition. All staff members chipped in to help each other. Challenges were overcome together."

RESULTS

It was evident with the onset of the pandemic that there was going to be a significant reduction in the dental services that were going to be provided. It was also projected that there would be a reduction in overall productivity for the health center. The budget was adjusted by senior administration to project the impact of the transition to telemedicine.

"The fiscal projection of productivity for all providers, medical and behavioral health, was 75%," Ruszczyk noted. "However, with all of the above processes in place as well as everyone's hard work, the average productivity is above 100%. All providers besides dental are working at above the pre-pandemic capacity. More clients are being seen than before the pandemic." 

Providers are completing telemedicine visits as well as telephonic, he added. The technology that was chosen is easy to use and reliable, he said. The patients and providers are able to use the technology with a minimal amount of difficulty; it also has been easy for staff to provide the instructions to the patients for the visits, he said.

ADVICE FOR OTHERS

"There are a number of technology as well as non-technology factors that need to be evaluated," Ruszczyk advised. "The technology needs to be easy to use and reliable. It should be user-friendly for everyone involved. It should also be easy to relay the directions to the patients so that they are comfortable using the platform."

Cost needs to be reasonable and affordable: Given the current state of affairs with the economy, this is an important factor, he added. It should also be applicable across professions: Both medical and behavioral health personnel are using the platform, and it has to be able to accommodate all professions using it, he advised. 

"Non-technology factors involve the rules and regulations that govern reimbursement," he concluded. "If they are not in place for telemedicine, it is going to be a difficult process to sustain. Sustainability is a key factor when making the transition."