Abstract
Background:
As a harm reduction-focused primary care clinic for people who use drugs, the Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program faced multiple barriers due to the COVID-19 pandemic. We describe and evaluate how the telemedicine-driven adaptations REACH made allowed the program to engage its patients.
Methods:
REACH expanded its telemedicine capabilities by transitioning its in-person clinic and methods of connecting with referrals to telemedicine. The program provided patients with phones to increase access to needed technology.
Results:
Throughout 2020, patient visits continuously shifted from being entirely in-person, to entirely telemedicine, to a hybrid model. Clinic show rates averaged 71% with this hybrid model, compared with 57% pre-COVID-19. Phones were distributed to 88 patients, 77% of which engaged in at least one telemedicine visit.
Conclusions:
Telemedicine allowed REACH to provide uninterrupted care during the pandemic. The program is now refining its hybrid model of telemedicine and in-person care to more equitably serve all patients.
Introduction
The Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program is a primary care clinic for people who use drugs (PWUD) at Mount Sinai Hospital in New York City. Using a multidisciplinary team model, REACH provides harm reduction-focused primary care, medications for opioid and alcohol use disorder, and hepatitis C virus (HCV) testing and treatment. The program has >300 active patients (74% male, 37% Hispanic, 29% black, and 75% Medicaid insured). The clinical team is committed to harm reduction and trauma-informed approaches to patient care that acknowledge systemic racial injustice and provide respectful, compassionate, and equitable care for all patients.
REACH's in-person model of care faced multiple barriers due to the COVID-19 pandemic. In addition, patients were at an increased risk of overdose because of social isolation restrictions, increased stressors, and interruptions in care caused by many harm reduction programs having to reduce their services. 1 We describe and evaluate how the adaptations made by REACH in response to these barriers allowed the program to maintain engagement with and meet the needs of its patients.
Transition Timeline
On March 13, 2020, REACH's in-person clinic closed as COVID-19 cases rose exponentially in New York City. 2 In response to the public health emergency, the Centers for Medicare and Medicaid Services (CMS) lifted reimbursement restrictions on the use of telephone and videoconferencing telemedicine services. 3,4 Figure 1 provides a timeline of REACH's transition to telemedicine (telephone and video sessions) during the first half of 2020. Since mid-June 2020, the program remained at 50% in-person capacity and is currently offering a mix of telephone, video, and in-person visits.
Changes the REACH Program faced in response to the COVID-19 pandemic and the telemedicine-driven adaptations it made during the first half of 2020. REACH, Respectful and Equitable Access to Comprehensive Healthcare.
Approach
Expanding the Program's Telemedicine Capabilities
Virtual clinics
REACH provided no billable telemedicine services before COVID-19. A systematic review of telemedicine interventions for the treatment of substance use disorders found that telemedicine was an effective alternative to in-person care, especially when access to treatment is limited, as it increasingly became during the COVID-19 pandemic. 5 Beginning May 1, 2020, REACH implemented 3, 4-h long virtual clinic sessions a week, allowing medical providers to schedule either telephone or video visits with patients. Medical providers ordered laboratory work so that patients could complete blood work at a walk-in phlebotomy laboratory in the clinic lobby or at a laboratory near their home.
During pre-COVID-19 in-person clinics, REACH patients had access to a multidisciplinary team of doctors, nurse practitioners, nurses, mental health professionals, social workers, and patient navigators who provided care coordination during clinic. 6 To provide the same approach virtually, the REACH team met through Zoom™ during virtual clinic sessions so that staff could communicate with each other and be available to patients as needed. After their encounter with the patient, providers would return to the Zoom meeting to communicate the patients' needs and discuss next steps. The patient navigator then coordinated with other team members to call the patient to provide individual services.
Telemedicine for HCV treatment
The COVID-19 pandemic forced REACH to simplify its model of HCV care. When medical providers were redeployed to inpatient COVID-19 service in March 2020, REACH shifted toward a nurse-driven treatment-monitoring model. A nurse proactively contacted all patients receiving HCV treatment to ensure medication adherence and coordinate refills. Furthermore, the use of telemedicine allowed for reduced in-person visit and laboratory work schedules.
Beyond using telemedicine as a means to engage with established patients, the program utilized telemedicine to connect with new referrals for HCV treatment. REACH piloted a telemedicine-driven linkage to care strategy as part of an ongoing partnership with an inpatient substance use treatment program. Pre-COVID-19, program staff visited this program to engage with patients who were HCV RNA positive and provide HCV education and linkage to care services. Through the new strategy, REACH staff telephonically connected with new referrals for HCV treatment, providing information about HCV and the program and scheduling them for in-person appointments post-discharge.
REACH began offering telemedicine services to patients at a second inpatient substance use treatment program in October 2020. Referrals were identified based on their HCV RNA positive results during their program intake. Eligible individuals were scheduled for an initial video visit with a REACH provider to begin the HCV treatment workup process while still inpatient. In-person follow-up appointments were scheduled upon discharge.
Telemedicine for buprenorphine treatment
On March 31, 2020, the Drug Enforcement Administration made an exception to existing policies so that, during the public health emergency, authorized practitioners could prescribe buprenorphine to new patients through telephone or video visits without a prior in-person visit. 7,8 REACH was now able to initiate buprenorphine for new patients and continue engaging established patients through telemedicine. During COVID-19, the program received new buprenorphine referrals from the community and from established partnerships with the Mount Sinai Hospital inpatient units and emergency department. Regulatory changes allowed for increased responsiveness in scheduling these patients for intakes with REACH providers and/or the buprenorphine nurse care manager. 9
Increasing Patient Access to Telemedicine
In tandem with increasing program capacity for telemedicine, REACH worked to increase access to digital technology for its patient population. A 2015 survey of PWUD in Baltimore concluded that participants utilized information and communication technology less than the general U.S. population, with only 42% of participants being interested in receiving health information through phone or internet. 10 Many REACH patients did not have stable access to personal smart phones that can be used for telemedicine appointments. To address this access disparity, REACH obtained a crisis grant that allowed the program to provide iPhones with unlimited data plans to patients at no cost. REACH staff set up phones for patients, downloading the applications needed for REACH's video visits and REACH's support group. Beginning on May 15, 2020, patients could pick up the phones in the clinic lobby or have a phone shipped to a stable address. Referrals from the aforementioned inpatient substance use treatment programs were mailed phones if they did not expect to have phone service upon discharge.
From May 15 to July 21, 2020, medical student volunteers from the Icahn School of Medicine at Mount Sinai called patients who received an iPhone to assist them in setting up and logging into video visits with their providers. These medical students were also available during virtual clinic sessions to help patients who had technical difficulties at the time of their appointment. REACH staff also noticed that patients had trouble with basic smart phone navigation, highlighting low digital literacy beyond difficulty accessing video visits. To address these barriers, a medical student designed informational pamphlets on iPhone use. These pamphlets were distributed to all prospective patients who received phones. In addition, REACH hosted a Zoom webinar for patients on how to use iPhones.
Data Collection
All data presented are quality improvement metrics, which are routinely collected as part of REACH's clinical operations for the purpose of program evaluation and improvement. IRB approval was not requested given no research activities were conducted. The program tracks the number of appointments and appointment types conducted each month and calculates appointment attendance rates (the number of patients who attended a clinic session divided by the number of patients scheduled that clinic session) on a weekly basis. Using internal databases, REACH's outreach coordinator tracks newly referred patients' engagement with the program and program staff continuously monitor and record patients' HCV and buprenorphine treatment statuses to coordinate care.
Outcomes
Over the course of 2020, patient visits shifted from being entirely in-person, to entirely telemedicine, to a hybrid model of in-person and telemedicine (Fig. 2). Visit volume dipped dramatically in March and April but slowly returned to pre-COVID levels by May.
REACH's clinic appointments over the course of 2020.
Between January 1 and March 13, REACH's appointment attendance rate averaged 57%. Between May 1 and December 31, the appointment attendance rate increased to 71%.
Between March 14 and December 31, 2020, 33 patients started HCV treatment, 6 of whom had entirely telemedicine-based psychosocial and medical workups (18%). Of these, 20 have completed treatment and 2 are still pending end of treatment (67%). Of the 15 patients who completed treatment during this time and are due for sustained virological response evaluation, 10 have completed an HCV viral load test (67%). All 10 of these viral loads were undetectable, indicating cure of chronic HCV infection.
During this same period, REACH received 47 referrals for HCV linkage to care from inpatient substance use treatment programs. Four of these patients had initial in-person appointments at REACH after their discharge and five of these patients had initial telemedicine appointments while inpatient. Six of these patients continue to engage with the program and three have started HCV treatment.
Also between March 14 and December 31, 2020, 32 patients were initiated on buprenorphine, 18 by phone or video (56%). Of the 32 new patients, 64% are actively engaged in medical care with REACH as of December 31, 2020.
Phone Distribution
REACH provided smart phones to 88 unique patients. Overall, 68 of these patients have engaged in at least one telemedicine visit (77%). Of the 11 patients who received the phones while inpatient at a substance use treatment partner, only 1 went on to have a telemedicine visit (9%). Of the other 77 patients who received phones, 67 had a telemedicine visit (87%).
Discussion
The REACH program's adaptation to COVID-19 required rapid and ongoing changes in program structure, staff roles and responsibilities, and expectations of patient engagement in response to new hospital policies and federal health regulatory changes. Some of the programmatic adaptations were only possible due to CMS regulatory changes, whereas other program innovations could have been implemented pre-COVID-19 but had not been considered. As a result, REACH's response to the crisis will result in permanent changes in operations that move the program away from its previous in-person-only approach. Patients now have more choices in how they receive medical care: in-person, by telephone, or by video. These decisions are guided by the provider's clinical assessment but also take into account patient preference and ability to access digital technology. However, the future of these changes are unclear as some CMS regulatory changes may be reversed once the public health emergency ends.
Introducing telemedicine allowed REACH to engage with newly referred patients and provide uninterrupted HCV care during the pandemic. However, many referred patients missed their initial appointments and many established patients were lost to follow-up before completing treatment. Although telehealth-driven treatment simplification allowed us to virtually connect with and provide HCV treatment to patients, it also created barriers to making strong connections with patients, which may have affected attendance and adherence rates.
The REACH Program had more success maintaining engagement with patients who were in care with REACH pre-COVID-19 than it did in engaging new patients from inpatient substance use treatment programs. This latter group of patients, the vast majority of whom were unstably housed, faced multiple barriers to successful linkage to care during the COVID-19 pandemic, which required more intervention than provision of a phone to ensure their engagement. In response to this need, REACH has implemented new strategies to provide structured assessment of these barriers and to offer needed psychosocial interventions during the inpatient stay.
Similar successes and failures were observed in the program's clinical transition to telemedicine. As shown by the increase in clinic show rates during the pandemic, telemedicine services have allowed REACH to exceed existing levels of engagement. However, although telemedicine can eliminate barriers, it can also create new ones and perpetuate health inequities. We observed this specifically with iPhone distribution. Providing patients with iPhones and telephonic guidance about accessing video visits allowed a subset of patients—77% of those who received phones—to engage in telemedicine appointments. However, another subset still was unable to access telemedicine services despite this support. Patients faced technological barriers that REACH had overlooked during the initial design of the project, namely, unfamiliarity with general smart phone technology. Because we had underestimated these barriers, we did not execute the project in a way that fully addressed them and, therefore, perpetuated existing health disparities in our patient population. Because of social distancing requirements, REACH was unable to provide in-person training to patients who received phones. REACH patients have self-reported to staff that in-person training opportunities would have made them feel more comfortable utilizing telemedicine and that having in-person guidance from friends and family has been the most helpful learning tool.
Conclusions
Utilizing telemedicine during the COVID-19 pandemic has allowed the REACH Program to provide uninterrupted care to PWUD, maintain engagement with established patients, and refine strategies to connect with newly referred patients. We are working to improve our existing hybrid model of in-person and virtual care to ensure equitable access for our entire patient population. Ultimately, we aim to provide medically indicated care that is guided by patient preference and addresses disparities in access to technology.
Footnotes
Authors' Contributions
All authors fit the criteria for authorship as defined by the International Committee of Medical Journal Editors.
Disclosure Statement
No competing financial interests exist.
Funding Information
This research was supported by the New York State Department of Health AIDS Institute (Grant Nos. DOH01-C31257GG-3450000 and DOH01-C34805GG-3450000), The Robin Hood Foundation (Grant No. n/a), The New York City Council (Grant No. FY21 05888), Public Health Solutions (Grant No. Contract No. 17-BUP-294), and The Fund for Public Health (Grant No. Contract No. 83855).