Veenu Aulakh, Senior Innovation Fellow, Center for Care Innovations
Facing the prospects of mass layoffs after the COVID lockdown this March, Neighborhood Health Center in Oregon came up with an ingenious solution to keep all its employees on the job. Besides reassigning dentists and others to temporary front desk roles, the safety net organization opened an onsite childcare center for the children of employees, with dental hygienists doubling as teachers’ aides. Once the crisis is over, the childcare center will close, but for now it is a lifeline. Neighborhood’s innovation was bold but not unusual: This country’s safety net health system has always been a place of innovation. The safety net includes community health centers and public hospitals that serve the 100 million patients who either have Medicaid or lack health insurance entirely (Kaiser Family Foundation 2017). With limited resources and patients with complex medical, social, and behavioral health needs, the safety net has long had to innovate out of necessity.
The Center for Care Innovations (CCI) supports the health care safety net. Our mission is to work for health equity and strengthen the health and well-being of low-income, underinvested communities across the United States. Our programs are designed to aid people unable to access quality care due to lack of insurance, immigration status, systemic racism, geographic isolation, language and cultural barriers, hopelessness, and more. Our main partners include public hospitals, community health centers, Indian health centers, state and county health departments, substance treatment programs, and social service nonprofits.
Among the examples of innovation CCI has seen in its programs that support safety net providers:
- When the small town of Guerneville, California, was flooded by the Russian River in February 2019, homeless encampments near the river were the first to be destroyed. However, safety net workers from the West County Health Center used a geomapping tool the health center had helped develop to locate and aid their homeless patients (CCI 2019).
- Asian Health Services workers in Oakland were concerned that only 5 percent of their patients with abnormal behavioral health screens ever made it to an appointment. As part of CCI’s Catalyst Innovation program, which builds human-centered design skills in safety net health care systems, the health center co-designed handouts, workflows and other tools to explain the benefits of treatment. This resulted in 35 percent of patients who were more willing to use behavioral health services. (CCI 2018).
Telehealth Innovation Spurred by the Pandemic
Ironically, with the pandemic, many of the restraints that kept innovation from occurring and sustaining have been lifted, which has led to an explosion of innovation in telehealth and virtual care.
This includes the restrictions on reimbursement for telehealth and virtual care, in concert with a temporary rule change from the Centers for Medicare and Medicaid (CMS) this spring, allowing reimbursement for patient phone and video visits. Such changes are crucial at a time when many primary care clinics are shutting their doors or in danger of folding due to the huge loss of income from in-person visits.
Thanks to this new flexibility in virtual care, many safety net organizations were able to pivot quickly to telehealth, including many CCI partners and unaffiliated health systems like the NYC Health+Hospitals, the largest safety-net system in the country. Before the pandemic, the NYC health system served one million patients a year but billed fewer than 500 telehealth visits a month. But as the coronavirus roared through the city in March 2020, the entire system was converted to virtual care platforms, doing nearly 83,000 “billable televisits” in one month, along with more than 30,000 behavioral health visits over telephone and video (Health Affairs 2020)
In many ways, safety net organizations are better equipped to innovate during the pandemic than private-pay clinics. Safety net clinics are accustomed to operating on a tight budget and avoiding unnecessary care; they are prone to sharing their innovations; and they “are more likely to invest in population health programs that pay long-term dividends across departments and care settings” (). To avoid exacerbating the disparities and racial and ethnic inequities that the pandemic has laid bare, systems need to work to overcome the “digital divide” and ensure that broadband and devices are available to low-income patients (NEJM).
A Hunger for Health Equity
There is a growing hunger for safety net organizations to implement innovations that reduce disparities in care. In southern California, Neighborhood Healthcare purchased an SUV, equipped with remote monitoring devices, and drove to high-risk patients’ homes for provider video visits with people unable to come into the office.
Other health centers have assigned community health workers to provide virtual outreach and support for patients needing extra assistance with technical issues. Many of the health centers have rolled out text messaging on a large scale to communicate with their patients. Still others have developed creative solutions for patients with little or no access to technology, including setting up computer kiosks, partnering with local businesses to share WiFi, and setting up neighborhood tent clinics to treat homeless patients.
One especially compelling innovation is IsoCare, a community health care worker organization that helps patients safely self-isolate or quarantine. Many low-income and migrant patients do not have the resources to stay at home while sick. In addition to providing food, supplies and rent if necessary, IsoCare helps them understand what patients can do to protect their families from getting COVID-19 or finds them a safe place to self-isolate, all of which are crucial to controlling household and community spread (CCI 2020).
Philanthropy can support innovation in the safety net in the following ways:
- Support associations and non-profits that are working to ensure that reimbursement for telehealth and virtual care does not end with the pandemic;
- Put resources into organizations working for housing, health equity, jobs, and patient engagement through digital literacy;
- Fund groups that support undocumented workers, who have been unfairly left out of federal relief efforts; and
- Support the health centers and public systems that care for black and brown communities hit hardest by COVID.
Safety net organizations continue to be a place where innovation thrives. However, unless we garner the resources to ensure everyone has access to high quality virtual care, we risk creating further inequities by widening the digital divide. Foundations are well-positioned to ensure the infrastructure, resources, and knowledge to support effective virtual care are available to ensure that our most vulnerable populations have access to this crucial care.
References
Hembree Diana. Case Study: Responding to Homelessness Using Geomapping. Center for Care Innovations. October 8, 2019.
Hembree Diana. Creating a Safety Net for Patients in Home Isolation. Center for Care Innovations. June 8, 2020.
Case Study: Developing Patient-Friendly Behavioral Services. Center for Care Innovations. April 25, 2018.
Lau Jean, et al. Staying Connected In The Covid-19 Pandemic: Telehealth At The Largest Safety-Net System in the United States. Health Affairs. June 11, 2020.
Mullangi Samvukta, et al. Shoring Up the U.S. Safety Net in the Era of Coronavirus Disease. JAMA Health Forum. June 15, 2020.
Paradise Julia, et al. Community Health Centers: Recent Growth and the Role of the ACA. Kaiser Family Foundation. January 18, 2017.
Nouri Sara, Khoong Elaine, Lyles Courtney, and Karlinger Leah. Addressing Equity in Telemedicine for Chronic Disease Management during the COVID-19 Pandemic. New England Journal of Medicine/Catalyst. May 4, 2020.