Sustaining the Success of Telehealth

Facilitated virtual care is a method for overcoming one of the biggest barriers to telehealth: technology.

This article was originally published May 12, 2021 on PSQH by Matt Phillion

Telehealth is not a new concept—the industry has been considering it for many years. But a global pandemic has put telehealth at the forefront of patient care, and the industry is looking to the successes of early adopters for best practices, key takeaways, and lessons learned.

During the Health Experience Design 2021 conference, Dennis Mihale, MD, chief medical officer for Upward Health, discussed lessons learned not only as an early adopter of telehealth in general, but also by having that advance familiarity when COVID-19 forced healthcare organizations across the world to reconsider their approach to telehealth.

“To be truthful, we’ve been doing telehealth for nine years,” says Mihale. “For us, it was a little easier to switch over. One day we were doing telehealth, and the next day we were doing telehealth during COVID.”

That experience doesn’t mean his organization’s program is faster or better than anyone else’s; they simply had the benefit of being an early adopter. But the organization uses specific tactics for telehealth that do make a difference.

“We offer facilitated virtual care,” says Mihale. “That’s what’s different.”

Facilitated virtual care is a method for overcoming one of the biggest barriers to telehealth: technology. “When you’re talking about seniors, 38% don’t have the technology or skill set for telehealth, no matter what anyone tells you,” Mihale says. “But with a facilitator, you can bring someone into the home, and bring with them the technology to facilitate the visit.”

A facilitator can perform any number of tasks core to tracking the patient’s health: taking vitals, checking medications, looking at the environment the patient is in, or reviewing social determinants of health.

“But most importantly, they bring the technology, so the only thing the patient has to worry about is being a patient,” says Mihale. “The patient satisfaction with the ability to bring a clinical person into the home is phenomenal. Our patients love it, and surprisingly our doctors love it—they were a little afraid of it at first, but then they took to it.”

Bringing care to the patient

What kind of technology the facilitator brings with them will vary based on the organization and the patient population. They may bring glucometers for checking on diabetes, digital stethoscopes, or whatever works best to tailor the facilitator’s capacity to the practice’s and the patient’s needs.

“The idea is that the doctor is, in real time, hearing, listening, seeing, and evaluating the patient in their home,” says Mihale.

What are the benefits to this approach, aside from patients preferring it? First, Mihale notes, an organization can deliver care through a multidisciplinary team. This begins with the facilitator themselves, who may be a licensed practical nurse (LPN), an RN, a specialized RN, a nurse practitioner, or any other skill set that meets the needs of the role.

“Every patient is partnered with a care specialist. This is important, because they develop a relationship of safety and trust with the patient,” says Mihale. It’s similar to what happens within a practice or doctor’s office. Having someone on staff the patient looks to and trusts allows an organization to carry out the treatment plan and better diagnose, prescribe, and assess the patient.

“It’s everything that is necessary for a complete and comprehensive visit, including social determinants of health, behavioral health, and so on,” Mihale adds.

Beyond that personal relationship, there are other, more tangible benefits. Mihale notes that, pandemic or not, avoiding unnecessary ED visits is incredibly beneficial. “If a patient needs to be in the [ED], I want them there now,” he says. “But if they don’t need to be there, I prefer they stay home and let us treat them in their home.”

And it works: Following implementation of their facilitated care program, the organization saw a 40% reduction in ED visits.

Facilitated care also makes regular or follow-up visits more reliable for patients who might otherwise fall through the cracks. “It’s phenomenal for transitions of care,” says Mihale. “You’re able to resolve issues over the phone, perform quarterly assessments, even do visits with new providers.”

In addition, specialists who are seldom able to get out of the hospital, such as neonatologists, hospitalists, orthopedic surgeons, or endocrinologists, have access to patients they otherwise would not. “You’re bringing the doctor to the patient,” says Mihale.

The services patients and providers want

Facilitated virtual care isn’t just conference calls or checking vitals, Mihale notes. “If you can do it in an office, you can do it remotely through facilitated care,” he says. “There are even portable, on-demand systems you can bring out.”

Facilitated care isn’t so different from traditional telehealth, he says, but the difference is that there is someone in the home. “They make the technology transparent,” says Mihale. “So the patient doesn’t have to worry. And they’re able to do a lot of other things in the home: looking at pills, checking on electric and water bills, checking out the refrigerator. They can check the entire situation, the whole person.”

And, of course, facilitated care and telehealth alleviate the other biggest barrier to in-person visits: transportation. “You solve social isolation,” says Mihale.

The openness creates and advocates for a relationship of safety and trust. Looking back on the benefits of this relationship, Mihale notes that with facilitated care, the organization saw a drop in ED visits, admissions, and readmissions.

“We find that when a patient leaves the hospital, two days later they often don’t remember everything they were told at discharge,” he says. “It’s very difficult sometimes to educate the family. But going to the home four or five days later, speaking with the patient, reminding them why they went to the hospital, making sure they understand their treatment plan… it all goes such a long way to helping patients feel comfortable and recover.”

Quality improvement

Mihale, who has worked in quality improvement for much of his career, says that facilitated care can markedly boost the success of quality improvement plans.

“When you can evaluate the patient’s environment, take vitals, make assessments, you can truly understand if a quality improvement program is delivering improvements,” says Mihale. “They can respond to deficiencies, take advantage of opportunities, work on self-care, improve engagement.”

And that face-to-face time can solve a problem patients may not even know they have: communication.

“Patients may not call you when they don’t understand something, but if they have a visit, they’ll open up,” he says. “And most importantly, you can respond to same-day or next-day needs of the patient. If you don’t have a policy of same-day or next-day visits in your office, you’re going to have more ED visits and more readmissions than you deserve.” Sometimes, Mihale says, the patient physically can’t get there the next day—so you have to go to them.

“You can deliver comprehensive care” through facilitated virtual care, he says. His organization leverages an interdisciplinary team to deliver that care: primary care physicians (PCP), behavioral health professionals, nurse practitioners, RNs, LPNs, nutritionists, social workers, and more. Telehealth simplifies communication between those team members.

“Try doing that in a conference room when those people don’t all work in the hospital,” he says. In contrast, with telehealth, “we can meet at one time. They’re in the meeting, notes are being taken, the follow-up is there.”

What the patients like about it

Patients enjoy improved access to care—and that access is responsive and timely. Rather than being told to come to the facility in two weeks for a problem they have now, they can receive more immediate care without the challenges of transportation and travel time. They also benefit from a lower cost of care without an on-site copay.

Facilitated care also helps patients in an unexpected way, Mihale says. “One thing I didn’t predict was it helping reduce health inequities,” he says. “We thought it would improve the health of the overall population, but not address health inequity.”

Many of these inequities are the result of social determinants of health. “If you have someone worried about food, legal problems, transportation—well, keeping an appointment at the clinic is difficult and may be number 10 on their list of concerns for the day,” says Mihale. “If you’re a single mom and your child is getting off the bus in a place you don’t want them to be alone, to heck with your appointment—you go to your child.”

The facilitators will help with problems that may not be immediately recognizable as health related: legal issues, housing, food security. But “until you solve those problems, they can’t think about self-care, and they’re not going to work toward bettering their health,” says Mihale.

In many ways, facilitated virtual care is a sort of surrogate PCP, he notes. “We’re bringing in observations and information to the PCP, who may not be one of us, and at the same time we know the treatment plan and are able to advocate for that PCP and their treatment plan,” says Mihale.

Upward’s patient population is in the highest 5% of risk and need utilization, and traditionally among the lowest in engagement. “We take on the toughest to manage and treat,” he says.

One lesson learned looking at the health of this population is that 5%–10% of patients with chronic disease may not have seen a doctor in 12–18 months. Lack of annual wellness visits and coordination of care make it very difficult to help these patients.

And with regard to chronic conditions, facilitated care helps enable remote patient monitoring for conditions such as heart disease, diabetes, asthma, or hypertension, which helps facilitators know when they “really have to get into the neighborhood and into the home,” Mihale says.