The Early Days of the Pandemic – Starting the Pivot to Telehealth

The early days of the coronavirus pandemic (COVID-19) were daunting for patients and providers alike. In-person health care visits were curtailed, and health care providers had to quickly pivot to telehealth services to ensure access to care for patients. For under-resourced patient populations, including those patients relying on Federally Qualified Health Centers (FQHCs) for services, access to care is often burdened by barriers – such as a lack of transportation or insurance, as well as health provider shortages. However, as outlined in the COVID-19 Policy Playbook: Legal Recommendations for a Safer, More Equitable Future,  the shift to telehealth imposed new barriers to care, such as a lack of broadband/unreliable internet, required devices for telehealth services (smart phones, laptops, etc.), and digital illiteracy. Moreover, FQHCs lacked the technological infrastructure and resources necessary to provide care via telehealth to all patients. Across the country, patients and health centers struggled with transitioning from in-person to virtual care.

In tandem with these challenges, health care providers were grappling with evolving policies around telehealth reimbursement and the legal requirements for providing such services to sustain operating budgets and maintain the existence of health centers.

Pivoting to Telehealth in Massachusetts – the FQHC Story

In Massachusetts (MA), approximately one million people (nearly 1 in 8) rely on FQHCs each year to receive medical care. Serving as a vital resource for under-resourced populations, FQHCs ensure that all people, including low-income, non-English speaking, and people of color have access to care and the necessary resources to address their social needs. Given the coronavirus pandemic, Community Care Cooperative (C3), a MA-based, non-profit, Accountable Care Organization formed and owned by FQHCs, the Massachusetts League of Community Health Centers (League), and the State Primary Care Association, along with their member health centers, identified the need to create a robust telehealth infrastructure, so that patients could access care outside of the traditional clinic setting. These organizations formed the FQHC Telehealth Consortium (Consortium). Today, this statewide Consortium comprises 35 health centers that collectively serve more than 700,000 patients.

Challenges and Solutions to Providing Telehealth

Prior to the pandemic, the Consortium FQHCs had varying levels of telehealth experience – some health centers offered little to no telehealth and others had modest telehealth offerings, including the ability to provide video visits. However, at the onset of the pandemic, FQHCs quickly pivoted to offering both video and phone visits for patients. Through the Consortium, C3 and the League worked with FQHCs to mobilize a rapid telehealth response to pool both knowledge and financial resources and create a robust telehealth infrastructure.

Additionally, C3 and the League provided legal and policy expertise to Consortium FQHCs on reimbursement and integrated care. These organizations devoted resources to understanding Medicare and Medicaid requirements for providing telehealth services, as well as innovations in complying with Health Resources and Services Administration (HRSA) (the federal agency governing care provided by FQHCs) standards and ensuring reimbursement for such services. These resources were critical to FQHCs in providing care, ensuring sustainability, and meeting patient needs.

To identify operational, legal, and policy challenges to virtual care, in early 2020 the Consortium conducted assessments with member FQHCs, surveying their progress and barriers to achieving the Consortium’s Telehealth Maturity Model, a framework that demonstrates the capabilities for long-term sustainability of telehealth. These assessments quickly led to the Consortium supporting health centers in creating multi-disciplinary teams to address ongoing challenges. At the same time, the Consortium also developed various resources to support member FQHCs, including the Telehealth Playbook (described below), monthly meetings to share clinical workflows and best practices, a plan for reimbursement, and a framework to address digital health equity.

Moreover, the Consortium secured funding from both public and private sources, that:

• Enabled FQHCs to provide COVID-19 care remotely, and to monitor those testing positive at home to determine when hospital care was required.
• Built robust and sustainable technology-driven workflows to support medical, dental, behavioral, and social needs.
• Improved access to behavioral health services for adults and children.
• Piloted and extended the provision of smart phones, connectivity and connected devices to over 1,500 patients within nine months.
• Created a vital “learning community” to share best practices and promoted a team-based model of care that integrated telehealth and in-person care.
• Created a cohort of nine FQHCs to advance telehealth maturity, including a funded project manager, a clinical leader, and training/coaching on telehealth at each cohort site.
• Developed an online Telehealth Playbook of tools and resources based on the Consortium’s Telehealth Maturity Model, a how-to guide to support the adoption and sustainability of telehealth at health centers.
• Developed a Health Equity Model aligned with the domains of the Consortium’s Telehealth Maturity Model.

Key Drivers for Achieving Telehealth Maturity

Through its work with member FQHCs to move the Telehealth Maturity Model

forward, the Consortium was able to create its online  Telehealth Playbook, a national resource that documents best practices as well as provides access to tools that were used successfully in this effort. Designed as a practical resource for clinical leaders, telehealth program managers, providers, staff, and telehealth funders and investors, the Playbook includes frameworks, best practices, clinical pathways, workflows, job descriptions, and many other resources. The Playbook is organized around the five domains that drive the Consortium’s Telehealth Maturity Model. These domains and some associated key drivers of achieving telehealth maturity are outlined below with additional information available on each component within the Telehealth Playbook:

• Strategy and Leadership
  • Board of Directors engagement;
  • Creation of a designated Team: Executive Sponsor, Provider Champion, Support Staff;
  • Virtual care built into health center budgets;
  • Established measures of success; and
  • Maturity Model assessment, gap analysis, and improvement plan.

• Clinical Integration
  • Redesigned care team roles;
  • Scheduling guidelines and workflows for virtual visits;
  • Clinical pathways for virtual care and hybrid models; and
  • eConsults for specialty referrals.

• People
  • Provider and staff training on telehealth
  • Patient education on telehealth;
  • Strategies for digital equity;
  • Satisfaction/Engagement surveys: patients, staff, and providers; and
  • Provider and Staff Training.

• Technology and Tools
  • Telehealth platform, integrated with electronic health record (EHR) systems;
  • Accessibility to smart phones and data plans for patients; and
  • Remote patient monitoring.

• Reimbursement and Policy
  • Expanded reimbursement guidelines at state and federal levels; and
  • Advocacy for HRSA and other regulatory agencies to support sustainability.

More to Come

Telehealth became and continues to be a critical tool for ensuring access to care during the pandemic. The Consortium is sharing its past, present, and future endeavors via a three-part series with the Network for Public Health Law. In the next post, the Consortium will address current legal and operational obstacles at FQHCs, including continuing to receive reimbursement for telehealth visits, addressing staffing shortages, and building a strategy to use telehealth to achieve health equity. The Consortium also will share information on innovative pilot programs, such as the Telehealth Transformation Initiative, the Telehealth Navigator Initiative, which uses remote patient monitoring as a critical resource, and the Federal Communications Commission’s Connected Care Initiative. 

This post was written by Christina Severin, President & CEO, Community Care Cooperative and Michael Curry, Esq, President & CEO, Massachusetts League of Community Health Centers.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.