Lessons from the field: How rural clinics, FQHCs can use telehealth, eConsults during the COVID-19 emergency Insight Article Patient Access Patient Engagement Population Health Patient Care Technology Sign in to save Miku Sodhi MBBS (MD), MHA, PCMH-CCE, FACMPE Shasta Cascade Health Centers’ FQHC clinics are in federally designated health provider shortage areas and medically underserved areas of Northern California. Two of them are located near Interstate 5 — high-risk areas for COVID-19 due to travelers coming in and out of the state. As of April 6, 2020, SCHC has done 200 screenings over one weekend and tested more than 50 patients. This work started with a hotline for residents who have traveled recently or have been in contact with someone who has the new coronavirus, shows symptoms, is in an at-risk age range or has underlying conditions. This has made the process systematic and safe for medical providers, health workers and the community. The clinics initiate patient screening through teleconference or video visits with a physician or nurse. In some cases, patients have no risk for coronavirus, yet they can be diagnosed and treated if something else is affecting them. If testing is appropriate, residents are asked to drive up to the facility and a physician will swab them at their vehicle. Due to limited testing availability, the clinic only tests patients who have serious risk of contracting COVID-19. Results typically come back in three to five days. Despite limited resources and being in a rural area of the country, the clinic has intelligently and aggressively implemented technology in screenings, diagnoses, visits and treatment for COVID-19, which has helped prevent further spread. Health policy implications for telehealth amid COVID-19 Previously, incident-to direct supervision guidelines were defined as: the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. As part of the waivers and flexibilities issued by the Centers for Medicare & Medicaid Services (CMS), an interim rule changed guidelines for incident-to direct supervision for the duration of the declared public health emergency regarding the COVID-19 pandemic. Now, direct supervision can be provided using real-time interactive audio and video technology. As long as the nurse practitioner (NP), physician assistant (PA) or other nonphysician provider (NPP) treating the patient has access to a doctor through telemedicine, it would qualify as direct supervision, and claims can be submitted under the doctor’s tax ID and get paid the full fee schedule. Keep in mind, telehealth reimbursement from state Medicaid payers may have different guidelines. Practice leaders should make sure they understand any differences between federal policies and those at the state level to effectively use telehealth and eConsults. Preventing fiscal loss In California, physicians reported a 60% drop in visits as patients were told to stay home unless a clinic visit is absolutely necessary. Patient visits in family practice are seeing a drop of 40%, and therefore both telehealth and eConsults can help practices and providers prevent further financial losses, especially among practices relying heavily on fee for service that play a crucial role in keeping patients out of emergency rooms. While in-office visits have dropped, staff are busier than ever answering patient questions over the phone. This communication is especially vital for keeping patients with chronic conditions, such as diabetes and asthma, out of the emergency room, where they could be at higher risk of exposure to the new coronavirus. As the federal government helps expand the ability to be reimbursed for telehealth, those revenues help make make up for losses suffered as in-office patient visits have dropped significantly. Thinking ahead: Using telehealth to address mental health issues amid COVID-19 Another area for aggressive use of telehealth and eConsults during the COVID-19 pandemic is mental health services. Healthcare executives and medical practitioners should consider the many mental and psychosocial effects of COVID-19 and how their practices can play a part in addressing patients’ mental health needs. This is especially important for FQHCs and rural clinics, where most of the patients served are Medicare or Medicaid beneficiaries. These patients often are vulnerable, low-income or migrants, with high social, racial, economic and healthcare disparities. They often have cultural and language barriers, and many are jobless with high stress. Patients over 65 often are homebound. It is imperative to understand, measure and treat the elements of mental trauma, anxiety, stress, depression, fear and/or social disconnectedness to ensure these factors don’t exacerbate their other health issues. SCHC calls every patient over 65 on a routine basis and asks whether they have access to food, groceries, medications and if they feel safe and secure. If the answer is “no,” the clinic connects them with a clinical care team and resource center, and then connects them with mental health therapists for virtual telehealth counseling sessions to clinically alleviate their fear, anxiety, depression and/or social disconnectedness from being homebound. If therapy is required, SCHC goes beyond telehealth and performs eConsults, looping in the specialists. Telehealth and eConsults can play a strong role in responding to the COVID-19 pandemic. Practice leaders should think a step ahead about holistic care for vulnerable patients in emergency situations, which includes considering their mental health. ADDITIONAL RESOURCES: MGMA Online Seminar: Best Practices for Optimizing a Successful Telehealth Program — Understand action steps needed to enhance patient access, cycle time, workflows, staffing, coding, billing and revenue cycle to achieve best practices for your telehealth program.