A recent study in the Journal of the American Medical Informatics Association finds significant association between the use of telehealth services and improved healthcare access and outcomes in communities negatively impacted by health disparities.

But to truly achieve those quality improvements – while tackling social determinant of health challenges and trimming costs – virtual care should be delivered with a bit more of a hands-on approach, said Dr. Rahul Sharma, emergency physician-in-chief at NewYork-Presbyterian/Weill Cornell Medical Center.

Sharma is a co-author of that JAMIA report – along with colleagues Dr. Brock Daniels, Christina McGinnis, Leah Shafran Topaz, Dr. Peter Greenwald, Meghan Reading Turchioe, RN, and Ruth Marie Masterson Creber, RN. It describes the value of a facilitated, mobile device-integrated telehealth program that combines in-home paramedic visits with video consults with emergency physicians.

We interviewed Dr. Sharma to explore the correlation between socioeconomic demands and higher burden of chronic disease and how increased telehealth services can address and minimize this gap. 

We also discussed the differences in telehealth needs, conditions and behaviors between communities facing few health disparities and those facing significant ones. And we learned how NewYork-Presbyterian/Weill Cornell Medical Center's telehealth services improved health literacy and outcomes in communities more impacted by disparities.

Q. What is the correlation between socioeconomic demands (high unemployment, rent burden, limited English proficiency, etc.) and higher burden of chronic disease? How can increased telehealth services address and minimize this gap?

A. Health disparities are intimately tied to social determinants of health, which can be defined as conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. Individuals living in areas impacted by adverse SDOH not only experience higher rates of chronic disease, they also tend to have worse clinical outcomes.

For example, factors like lower education levels, poor diet, smoking and insufficient exercise may contribute to developing heart disease. These factors, further exacerbated by unstable living conditions and underinsurance, often lead to inadequate medical follow-up, difficulties adhering to treatment plans, and ultimately earlier mortality compared to similar patients with heart disease.

These patients also have more avoidable healthcare utilization, such as more frequent emergency department visits, hospital admissions and 30-day readmissions.

Although adverse SDOH contribute differently to clinical outcomes, the more adverse SDOH a person encounters, the less likely they are to receive quality healthcare. Telehealth holds the potential to improve access to timely, high-quality care by reducing the need for transportation and providing more flexible scheduling of appointments.

However, the promise of telehealth has not been fully realized, particularly in populations with the greatest health inequities. In many cases, the same factors that lead to poor health and poor access to care contribute to low use of digital health services.

For example, web- and app-based services require hardware such as smartphones and broadband internet, as well as a certain level of health and digital literacy. Furthermore, competing necessities such as rent, food and childcare often assume greater importance in communities negatively impacted by adverse SDOH.

Therefore, it is crucial that health systems both increase their capacity to provide telehealth and conduct needs assessments in the target populations to thoughtfully design digital health services to confront the issues that video visits alone don't address.

Q. What are the differences in telehealth needs, conditions and behaviors between communities facing few health disparities and those facing significant ones?

A. Care-seeking behaviors, the type and stage of conditions for which care is being sought, and logistical or technical needs are meaningfully different among communities facing significant health disparities compared to those that are not. Competing demands and lower health literacy frequently lead to delays in access to care.

As such, patients living in communities with greater healthcare disparities often present with more advanced disease or with higher acuity illness.

Those living in lower healthcare disparity communities use telehealth more frequently for minor issues such as uncomplicated upper respiratory infection or routine primary care follow-up, compared to individuals in high healthcare disparity areas who present with multiple, often inadequately treated chronic illnesses.

Finally, while access to broadband and video-capable devices is increasing across the U.S., having access to this technology and the necessary proficiency does not always translate to using that technology for healthcare.

It is clear that characteristics such as older age, chronic illness, lower income, gender and ethnicity are associated with a lower likelihood of using telehealth, but the reasons for this are less clear. Two potential factors are: 1) Knowing the appropriate situation for using telehealth services, and 2) Trusting that one will receive appropriate care when using digital health.

For example, one study found that Black patients were four times more likely to seek in-person care rather than use telehealth relative to white patients for similar COVID-19 related urgent care complaints. Moreover, trust in health systems and providers enables appropriate care-seeking behavior; developing trust is more challenging when care is provided virtually.

Q. How did your telehealth services improve health literacy and outcomes in communities more impacted by disparities?

A. NewYork-Presbyterian and Weill Cornell Medicine launched Community Tele-Paramedicine, which is a form of mobile integrated telehealth to provide acute and chronic care to largely medically underserved populations in 2019.

Since then, we have conducted more than 5,000 home visits to patients throughout the NewYork-Presbyterian network of hospitals resulting in reductions in unnecessary ED visits and unplanned hospital readmissions within 30 days of discharge.

At its core, CTP is facilitated telehealth. We enroll patients at-risk for preventable healthcare utilization, many of whom live in communities negatively impacted by adverse SDOH, and proactively engage with them through nurse care managers. By identifying care gaps and symptoms early, the CTP team can intercede and prevent a patient's condition from deteriorating to the extent that 911 is the only option.

As an example, if a patient living with heart failure misses an appointment because of a lack of transportation, runs out of medications because they can't afford them or begins to retain fluid and experience more shortness of breath, our team can identify these issues, as any remote monitoring program might, as well as intervene in the home, something most traditional remote monitoring or standard telehealth programs cannot do.

Our team of community paramedics, who have received additional training in chronic disease management, motivational interviewing and facilitating telehealth encounters, brings all necessary equipment to the home to perform the video visit with an ED physician. The medics can assess for leg edema, listen to lung sounds, obtain vital signs, perform diagnostic tests and administer intravenous medications to treat symptoms under the virtual supervision of our ED physicians.

NewYork-Presbyterian care managers can arrange for transportation to appointments, order pill packs and place referrals for home services. Facilitated telehealth offers a window into our patients' lives and living conditions, allowing for more directed and contextualized disease education adapted for that patient's circumstances. Those circumstances may not have been immediately obvious if the same encounter was conducted in the ED or a primary care office.

Anonymous surveys filled out by CTP patients demonstrated more than 90% agreed they better understood how to take their medications, knew when their follow-up appointments were, felt less anxious they would need to return to the hospital, and that CTP provided a quality of care similar to going to the hospital.

We also conducted in-depth qualitative interviews with CTP participants to better understand how participation in the program impacted their care. Patients living in high health disparity communities frequently reported improved understanding of their chronic conditions and more confidence in their ability to manage those conditions.

Interestingly, when the thematic data was analyzed according to the level of disparity of the community in which they lived, those in lower disparity areas more frequently described CTP as a "more convenient option" to in-person care, whereas the prevailing theme among those in higher disparity areas was of CTP as an essential part of their care.

Q. Why is health engagement so important in communities with high disparities?

A. Another theme that emerged from our qualitative research was that those patients living with chronic illness in high disparity areas consistently identified CTP as a sign of an engaged health system that cared about them and their health. Proactive outreach and digital-first care options result in more low-cost, convenient and effective interactions while also potentially driving patient loyalty.

Facilitated telehealth visits build trust, foster patient-centered care, and allow providers to simultaneously evaluate and intervene using the in-home component, while maximizing the efficiency of the more costly virtual physician.

A key to the success of the program is undoubtedly our community paramedics. As trusted community members, they have the requisite respect and credibility to engage with patients in high and low disparity communities.

And while our program employs community paramedics, other community healthcare workers such as visiting nurses, home health aides and community health workers can be similarly employed to facilitate telehealth, depending on the required scope of practice for the program and local regulations.

Ultimately, health engagement is beneficial for both health systems and patients when it results in higher-quality care, better outcomes, improved patient loyalty and lower costs.

While facilitated telehealth programs carry higher capital and operational costs, are limited in their scalability relative to nontraditional telehealth programs, if implemented within the proper financial setting, such as a self-insured or shared-risk accountable care organization, and directed toward patient populations most likely to benefit like algorithmically defined high cost, high-need groups with a high degree of safely preventable healthcare utilization, they can be cost effective.

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