Perspectives from leadership and frontline staff on telehealth transitions in the Los Angeles safety net during the COVID-19 pandemic and beyond

Abstract

ObjectivesThe start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a “digital divide” that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits.MethodsThis qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes.ResultsTwenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels.ConclusionsPatient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.

Free and Charitable Clinic Perspectives on the Implementation and Utilization of Telehealth Services During the COVID-19 Pandemic

“…11 This study aligns with the findings of several other recent studies that address the mission driven nature and culture elements common when implementing and utilizing telehealth services in other healthcare safety net provider environments, including community clinics, federally qualified healthcare centers (FQHCs), and community hospitals. [21][22][23] This study adds to the existing literature by incorporating the perspective of a different group of safety net providers and expands upon the research team's previous work by adding context and nuance to the quantitative results, providing a fuller story. Future research should further investigate the acceptability and potential sustainability of telehealth services in a free and charitable clinic environment and incorporate the patient and healthcare provider perspective.…”

Optimizing Telehealth Services

“…Yet, despite studies examining telehealth implementation from the perspective of health centers and clinicians, less is known from the patient's perspective. [8][9][10] Studies that have been conducted suggest several explanations including challenges accessing language-concordant care, 8 a lack of understanding of how to access telehealth services, and a preference for in-person care. 9 A better understanding of CHC patient experiences, however, can guide postpandemic expansion of telehealth services.…”

“…Qualitative and mixed-methods studies have sought to explain these disparities. Yet, despite studies examining telehealth implementation from the perspective of health centers and clinicians, less is known from the patient’s perspective 8–10 . Studies that have been conducted suggest several explanations including challenges accessing language-concordant care, 8 a lack of understanding of how to access telehealth services, and a preference for in-person care 9 .…”