How FQHCs Are Combating the Digital Divide in Telehealth, Remote Monitoring

Though telehealth remains popular among providers and patients alike, not all populations benefit from the care modality equally. Organizations that provide care to these underserved communities are focusing on mitigating telehealth access challenges through various initiatives.

On the one hand, telehealth alleviated several burdens associated with seeking care, like traveling long distances. Still, telehealth use is linked to other care access issues, such as the digital divide.

These issues tend to be concentrated among low-income, rural, and non-White populations.

According to a RAND Corporation report released in March, audio-only telehealth visit volumes remained higher than video-based care at safety-net health clinics through the COVID-19 pandemic, especially for behavioral health services. Another study showed that patient sociodemographic factors influenced whether a video visit was successful or not, with racial minority status and older age linked to unsuccessful visits.

Boston-based researchers recently created the term digital redlining to describe the health inequities and structural racism that create barriers to technological access.

Federally qualified health centers (FQHCs) across the country are working to overcome these barriers to virtual care by hiring telehealth navigators and extending internet access.

HURDLES TO TELEHEALTH USE

Community Care Cooperative (C3), a nonprofit accountable care organization governed by FQHCs in Massachusetts, has seen firsthand the many barriers their patient populations face when attempting to access virtual care.

"One is broadband access — not everybody has broadband access," said Jenny Azzara, senior director of performance improvement and organizational development at C3, in a phone interview. "The second is having a device. While many people may have a phone, not everyone has a phone with a data plan that could access telehealth visits or a phone that's a smartphone for video visits…And then the other barrier is just digital literacy."

C3 includes 18 FQHCs across Massachusetts, many of which have multiple locations. They serve historically under-resourced communities with higher percentages of Black, Indigenous, and People of Color and low-income populations.

"And really, each one has their own personality, so it's so hard to describe," Azzara said. "Some health centers have mostly non-English-speaking patients, and some health centers have mostly English-speaking patients. So, we have robust data to be able to understand [each] health center's communities and provide support to them in a really focused way."

C3 implemented telehealth at the beginning of the COVID-19 pandemic, partnering with the Massachusetts League of Community Health Centers to form a telehealth consortium to support all FQHCs in the state.

Initially, virtual care access challenges centered on technology support and ensuring vulnerable populations had access to the devices they needed for telehealth. But as the pandemic evolved, telehealth needs did well, with C3 developing a long-term strategy to integrate virtual care sustainably. It was in this second phase that C3 came up against the hurdles noted above: broadband access, phones with adequate data plans, and digital literacy.

Heritage Health, an FQHC in Idaho, faced similar issues as it expanded virtual care during the pandemic.

The organization cares for about 25,000 patients, offering an array of services, including primary and behavioral healthcare, said Allisha Rutherford, vice president of strategy at Heritage Health, in a phone interview. It also serves homeless patients through a street medicine program.

Heritage Health also implemented remote patient monitoring for their high-risk blood pressure patients in the past year, Rutherford added.

Incorporating telehealth and remote patient monitoring involved overcoming not only device access and broadband hurdles but also staffing challenges.

"We've had a staffing shortage, so that's been extremely challenging from a provider and support staff [standpoint] that contributed to access barriers," Rutherford said.

OVERCOMING THE HURDLES

One of the ways in which C3 has combatted patient access barriers to virtual care is by employing telehealth navigators, according to Azzara.

These navigators help patients address access challenges in various ways, including referring them to the Federal Broadband Program for internet connectivity support and helping them understand their phone carrier's low-cost options.

For example, Brockton Neighborhood Health Center, an FQHC that is a part of C3, used a Gordon and Betty Moore Foundation grant to implement RPM services for high-risk Black hypertension patients, Azzara said. The center hired navigators to engage these patients in their care and assess their health-related social needs, such as food, nutrition, and housing.

"This is a strategy that's about telehealth, but it's [also] about equity and addressing a condition with a community that has historically had higher rates of cardiac events," she said.

C3 plans to expand telehealth patient navigator roles to other health centers and have them focus on the specific needs of the populations they serve. For instance, another FQHC, North Shore Community Health, is using data on telehealth utilization across race, ethnicity, and language to determine their patient navigator's responsibilities.

"They see an inequity in terms of the rate of telehealth utilization between their English-speaking patients and their Spanish-speaking patients," Azzara said. "So, their patient navigator is going to be focused on this disparity and how to close the gap."

Similarly, Heritage Health has worked to increase its slate of community health workers and patient experience navigators, said Rutherford.

Heritage Health has offered competitive bonuses to address staffing issues, including retention and hiring bonuses. It has also worked to optimize provider schedules and provides the ability to work remotely.

Further, the FQHC is developing an initiative known as Heritage University, which will have different learning tracks to help grow staff within the organization and recruit others, Rutherford said.

In addition to bolstering staff, Heritage Health is working to close the digital divide by setting up 'telehealth' rooms in its facilities.

"Our patients could come to our clinics and actually have a telehealth visit with another provider from another location, whether it be one of our clinics or a specialty that's not in the area," Rutherford said.

Patients can also bring their own devices to Heritage Health centers and connect to their WiFi.

"So, we're allowing them to connect through our means with[in] our location on their devices to get that connection," Rutherford added.

The virtual care work at FQHCs across the country is ongoing. Though the regulatory flexibilities supporting telehealth have yet to be made permanent, those operating FQHCs expect it to remain a vital tool for care delivery. But to unlock its full potential, these centers will have to continue to identify and remove hurdles to access.

"Our goal from the beginning was to make sure that the adoption of telehealth for the pandemic became a sustainable, integrated care modality that complements in-person care. We're still working at that," Azzara said. "It's about provider and staff ongoing training, upgrading the telehealth platforms and technology to make sure they're user-friendly for everybody, and…it's about addressing the digital access needs."

Editor's note: This article previously included a reference to Codman Square Health Center, which is not a part of C3. The reference has been removed as of 6/17.