The Volunteers in Medicine’s Clinic of the Cascades in Bend, Oregon, is one of 92 VIM free clinics nationwide. The Bend clinic installed an electronic health record in 2004 and has a long history of adopting health IT.

THE PROBLEM

There are around 200 volunteers at the clinic who care for an uninsured population of primarily Latinx patients. The ripples of COVID-19 hit especially hard in this community, where many lost jobs in the hospitality and tourism industries. Further, most volunteers are over 60 and at higher risk of COVID-19 complications.

The clinic was notified about a year and a half ago that its current EHR vendor was no longer going to support the application, and that its current hardware components were expiring. Through a partnership with local St. Charles Health System, the Bend clinic installed an Epic EHR. It went live on Epic on January 23, 2020.

The Bend clinic’s previous EHR system was not accessible remotely, so VIM volunteers would have had to suspend operations during COVID-19 if they had not gone live with Epic when they did.

“In mid-March 2020, it became quite apparent that VIM was going to need to pause in-person visits to the Bend clinic,” said Jennifer Fuller, RN, clinic nurse manager at Volunteers in Medicine’s Clinic of the Cascades. “The COVID-19 pandemic had reached a level that the highest-risk community members were being asked to shelter at home.”

The Bend clinic ran a report on its volunteer pool and quickly discovered that it had only a handful of active volunteer nurses and providers under the age of 65, the age determined to be at highest risk of COVID-19 death. VIM knew it needed to protect its volunteers from COVID-19 exposure, so temporarily closing its doors was essential.

“On March 17, 2020, the Bend clinic held one final in-person clinic and then asked all of our more than 200 volunteers to shelter in place,” Fuller said. “This crucial decision was the safest decision we could make for our volunteer pool. However, we now were left with a clinical staff of three: one doctor, one nurse and one referral coordinator to meet the medical needs of 1,200 patients in the midst of a worldwide pandemic.”

"In accomplishing the vital ongoing patient care, VIM also accomplished the goal of ongoing community-member volunteerism, two passions that VIM holds strongly."

Jennifer Fuller, RN, Volunteers in Medicine’s Clinic of the Cascades

It is important for VIM to serve two purposes in the community, Fuller explained: Meet the medical needs of the low-income working community members and provide a valuable and lively place for community members to volunteer. With this temporary, unexpected closure, VIM staff knew they needed to find a way to continue to meet both goals.

PROPOSAL

Prior to the COVID-19 pandemic, Bend clinic staff occasionally had been using their new ability to remote into their Epic EHR from home. After the decision to temporarily close to in-person patient visits on March 17, staff knew the ability to remote access the EHR was going to be key.

“The clinical staff began actively calling patients who had previously been scheduled for chronic conditions [and] managing their care over the telephone,” Fuller recalled. “We also were fielding incoming calls from patients experiencing acute medical needs. We quickly found that the clinical staff of three could not efficiently and safely meet the needs of what upwards of 60 clinical volunteers used to accomplish.”

Additionally, VIM has a vibrant mental health program, she added. VIM staff knew continuing to support their patients’ mental health needs would be crucial during this highly stressful time. The question arose, “How does a counselor maintain connection with a patient without having a face-to-face interaction?”

VIM staff decided to implement work from home with their clinical volunteers.

“We had the idea of building a strong nurse triage work-from-home pool using the remote access to our EHR and considered the idea of video conferencing for our mental health appointments,” Fuller said. “This would alleviate the problem of limited access to care for our patients, while at the same time provide a meaningful volunteer opportunity to at least some of our clinical volunteers.”

MARKETPLACE

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MEETING THE CHALLENGE

The newly implemented work-from-home process evolved over several months. Being an Epic Community Connect partner with St. Charles Health System, the Bend clinic already had remote access capability to the EHR.

“Our volunteer coordinator worked with five of our volunteer registered nurses and two of our volunteer providers to access Epic through the Citrix platform from home,” Fuller explained. “This involved loaning home-use laptops and installing Citrix if the volunteer was using their home computer. Then the volunteers could securely access Epic through St Charles’ Gateway website.”

Doctors and nurses now were fully equipped to see the Epic Telephone Triage List of calls to return, see the provider appointment schedule, call patients and document the call, all from the safety of their home environment.

“For the first several months, the nurses and providers were using their own cell phones and blocking their phone numbers,” Fuller noted. “This would result in several unreachable patient calls, as some patients would understandably ignore a call from a blocked number.”

About three months in, VIM was able to upgrade its phone system to InfoStructure. With InfoStructure technology the nurses were able to use a mobile app called SNAPmobile. When a call was placed, the VIM phone number would show on the patient’s caller ID. This greatly increased the success of reaching the patient on the first attempt.

The other technology that the Bend clinic had quickly been becoming familiar with was video conferencing. VIM made the decision to use Zoom technology to provide “face-to-face” interaction for its mental health appointments. “This was met with great success,” Fuller said.

RESULTS

Implementing remote access to Epic, call access via InfoStructure’s SNAPMobile and video conferencing through Zoom has allowed VIM to continue to meet the needs of its patients on a daily basis, Fuller said, spring-boarding the suddenly closed clinic to “virtually open” in a matter of a couple of weeks.

“In accomplishing the vital ongoing patient care, VIM also accomplished the goal of ongoing community member volunteerism,” she added, “two passions that VIM holds strongly.”

ADVICE FOR OTHERS

“My first thought is, ‘Go for it,’“ Fuller advised. “As long as your process is HIPAA-compliant, the technology is there. Don’t be afraid to use reliable, HIPAA-compliant technology to allow medical workers to work from home.”

That said, never in a million years did VIM consider what it would do if suddenly the clinic lost the ability to have every one of its more than 200 volunteers come in to volunteer, she added.

“My advice? Have a plan drafted and have systems in place,” she said. “If your current systems cannot support working from home, look into available technology now. Being prepared and comfortable with our available technology allowed us to quickly flex to meet both the needs of our patients and our valuable workforce.”

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