Commonwealth Care Alliance is a healthcare services organization that offers health plans and care delivery programs designed for individuals with significant needs. With offerings in Massachusetts, Rhode Island, Michigan and California, it delivers comprehensive, integrated and person-centered care by coordinating the services of local staff, provider partners and community organizations.

CCA specializes in managing complex care for individuals dually eligible for Medicare and Medicaid, as well as those who narrowly miss the threshold for Medicaid. As a healthcare services organization, it delivers and coordinates whole-person care that integrates primary care, acute care, behavioral health, and long-term services and supports, while addressing the social factors that impact health.

Telemedicine has grown to become an important part of delivering on CCA's mission. And all healthcare provider organizations can learn from CCA's implementation.

Adrienne Mullen is senior director of virtual care at CCA. We interviewed her to discuss why telemedicine has become such a priority, evaluating potential barriers and providing targeted assistance, CCA's set of virtual care guidelines to help clinicians determine the best care options, and some success metrics of the telemedicine program.

Q. Why has telemedicine become a priority for the organization?

A. CCA prioritizes our virtual care programming because access to technology and connectivity is a social factor that impacts health. It enhances care coordination by allowing us to engage members where they are and then leverage our deep, specialized and multidisciplinary team to best meet their needs at that moment.

It also was instrumental in supporting access to care during the COVID-19 pandemic, creating new ways to support our members. For example, CCA reached 91% of our members and patients through virtual care by the end of 2020, allowing continuity of care for many individuals during a challenging and isolating time.

From March 2020 to December 2022, CCA conducted a total of 149,723 virtual care visits with 38,082 unique members. This number continues to grow as a direct result of our efforts to scale virtual care programming during the pandemic.

We also are focused on providing choice in mode of care and increasing value to ensure that members are getting the care they need in the best way possible. With the right support and resources, virtual care removes significant barriers to access for those who are homebound, have difficulties accessing transportation or childcare or otherwise face challenges attending appointments.

Overall, we find having the choice of virtual care enables members to better navigate the healthcare system, especially if they have urgent or less predictable needs.

CCA is a leader in chronic disease management, and we have seen significant success using virtual care in this space. For our members with diabetes, heart disease, rheumatic diseases, obesity, high blood pressure and other chronic diseases, virtual care is an excellent way to improve care plan adherence by providing flexibility.

Often, chronic disease management involves frequent communication between members and their providers, but that doesn’t always have to be done face to face. We’ve found that members prefer using virtual care for regular check-ins and routine symptom management appointments because it saves time and stress.

Q. In addition to providing the actual telehealth visits, you evaluate potential barriers and provide targeted assistance and choice in mode of care to best meet your members’ needs. Please talk about how all this works with the evaluation and assistance.

A. We conduct a virtual care readiness assessment for all new members to assess their digital health readiness, including device availability, WiFi connectivity and consent for digital engagement. If we identify a lack of a reliable device or connectivity, we then work one-on-one with the member to help them secure the necessary supports.

Currently, this involves connecting members to federally funded free phones or internet connectivity services.

Through our efforts to connect members with the necessary resources, we’ve seen a 10% increase in device and connectivity access from 2021 to 2022 (from roughly 60% to 70%). We expect this number to grow as we continue to scale our virtual care program in the coming years.

Once we’ve managed any needs, our member video visit support team is available with instructional videos, educational materials and troubleshooting guidance.

In 2022, the member video visit support team aided 2,898 members, either through a successful practice video visit, where our team would facilitate a call ahead of the member’s appointment to answer questions and ensure comfort and readiness, or to troubleshoot challenges in the moment if any arise.

Virtual interpreters also are available, which has been instrumental in ensuring equitable access to virtual care. CCA provided interpretation services during 1,602 video visits in 2022, representing 27 different languages, including Spanish, ASL, Vietnamese, Haitian Creole and Cape Verdean Creole.

On the provider side, we offer training and technical assistance to eliminate barriers at both ends of the virtual care interaction. We’ve found that this assistance increases providers’ confidence and utilization of virtual care.

Q. Commonwealth Care Alliance has created a set of virtual care guidelines to help clinicians determine the best care options for members. Please describe these guidelines and why they're important for virtual care.

A. As we began scaling our virtual care program, we quickly learned there is no broad consensus on when to recommend in-person care or virtual care. This uncertainty is an important barrier to expanding and optimizing the use of virtual care, especially for clinicians and patients who are the ones directly involved.

We knew that it was important to set parameters and expectations to ensure all members get the care they need in the correct setting. Dr. Dan Henderson, senior medical director of instED and virtual care at CCA, has helped us consider and develop guidance.

When considering how to create guidelines, we were dealing with the intersection of accessibility, comfort, comprehensiveness, cost and safety. Our view at CCA is that members should get the format of care they prefer, all else equal, and assuming their choice is reasonably safe.

When members are unsure or ambivalent, we think a virtual-first approach – with some guardrails – can be a right one, for a few reasons:

• Virtual visits are usually much more available and accessible. Without the need for transportation, it can be easier for patients and providers to come together on short notice or when the timing is ideal. Keep in mind, we do many home-based visits, so this isn’t just about getting patients rides to the office, but at times there can be more opportunities with scheduling via virtual visits.
• Virtual visits are more readily available than in-person visits. When clinicians’ schedules can be pooled, or when virtual care can be done during downtime or no-show time, wait times for visits fall dramatically. This matters not only for urgent care issues, but also when a patient is motivated and wants to secure a visit quickly.
• In-person visits can be more comprehensive than virtual visits, but that doesn’t always impact the quality of care. Most chronic conditions only require occasional hands-on care. When improving treatment is the goal, seeing patients more frequently often can be more powerful than seeing them more comprehensively.
• Virtual care should not be withheld because it might not succeed. Approaches that err on the side of “bringing patients in” aim to avoid “wasted” or “failed” visits. We believe that CCA members' preferences are the most important factor in choosing the site of care, even if some visits end up requiring in-person care later. Supported by guidelines and care team members that protect members from unsafe uses of telehealth, we think this approach maintains the customer focus that has long been a part of our history and mission.

With this focus on convenience, access and member choice, we need to ensure some protections against visits that are likely to be dangerous or otherwise low value. To screen these out, our clinicians assess the presence of certain red-flag issues that disqualify a visit from being appropriate when conducted virtually. These include things like:

• Any symptom that is severe.
• Any time a member thinks immediate medical attention is required.
• Any symptom that is both new/unfamiliar and at least moderately severe.
• Certain symptoms suggestive of heart problems, especially chest pain, shortness of breath, palpitations (lasting more than a few minutes), leg swelling, lightheadedness (except when familiar or typical for the individual).
• Certain symptoms suggestive of brain and nervous system problems, especially face, arm or leg weakness, speech change, vision loss, balance problems (when new or unfamiliar), or passing out.
• Severe headache.
• Severe abdominal pain.

Conversely, we consider concerns like well-managed chronic conditions, continued care for behavioral health issues and low-risk health conditions such as rashes, allergies, family planning and smoking cessation to be high-value use cases for virtual care.

All of the above is within a culture of erring on the side of caution when clinicians have concerns about virtual care, and being empowered to make decisions along with our members that best serve their needs and preferences.

Q. What are a couple of success metrics of your telemedicine program? Please detail these metrics and talk about how you achieved them.

A. Through our virtual care program, we define success in several ways. First, we have looked to increase access to virtual care for our members and ensure that we are delivering high-quality services. We continuously track the number of members we serve through virtual care, the number of resulting virtual care visits and how many of those are repeat members year over year.

In 2022, we served 25,166 unique members through virtual care ranging from 21 to 105 years of age, totaling 46,886 visits. Seventy-seven percent of those were repeat users since 2021.

Through a responsive care survey, 93% of our members found our offerings to be helpful or very helpful in their overall care. We continue to use this data and feedback from our members and providers to improve our services.

We also are tracking access to technology as a success measure for our virtual care program, due to the impact that technology can have on an individual’s overall health and wellbeing, as well as their ability to navigate the world around them.

As such, from 2021 to 2022, we saw a 5% and 9% increase in internet access among our CCA Senior Care Options and CCA One Care members, respectively. We also found members accessed our member video visit support team twice as frequently in 2022, compared to 2021, indicating more individuals are seeking the resources they need.

In the future, we hope to support even more members through obtaining access to technology and internet service to further grow our virtual care program.

As I mentioned earlier, the confidence of our providers in their ability to offer a positive virtual care experience is another element of our success. We trained 50% more providers on CCA’s virtual care platform in 2022 than we did in the previous year and hope to continue this trend as we bring our care model to more people across the country.