How telehealth is boosting care access among NYC’s homeless population

Though telehealth has the potential to significantly expand healthcare access, social determinants of health (SDOH) challenges like housing insecurity can hinder this access, depriving already vulnerable populations of much-needed healthcare services. However, initiatives supported by healthcare provider organizations and state agencies can help overcome this barrier, enabling those facing housing insecurity to access healthcare through telehealth.

In the fall of 2020, NYC Health + Hospitals and the New York City Department of Social Services launched an effort to provide homeless shelter residents access to the health system’s Virtual ExpressCare service. The initiative has grown steadily since then, with more than 5,000 shelter residents using the Virtual ExpressCare platform from January 2023 to April 2024.

The Virtual ExpressCare service provides 24-hour access to healthcare for non-emergency physical, mental, and behavioral health conditions throughout the year. The service treats conditions such as fever, influenza, upper respiratory infections, anxiety, depression, and substance use disorders. Convenient and quick access to these services is especially essential for people facing housing insecurity.

“I think for any person experiencing homelessness, it is a time of difficulty,” said Erfan Karim, MPH, executive director of Virtual ExpressCare at NYC Health + Hospitals, in an interview with mHealthIntelligence. “There's just so much stress and so many things that go on with not knowing exactly where you are going to live and how you are going to support your family or yourself through it.”

Data from the NYC Department of Homeless Services shows that as of May 9, 2024, 86,858 individuals were in NYC homeless shelters, of which 32,744 were children. This population tends to forgo or delay care, resulting in an overutilization of emergency departments (EDs), Karim said. Some residents delay care to the point that they need to call 911 and also end up in EDs following an emergency medical services response.

NYC Health + Hospitals, the largest municipal health system in the United States, works closely with other state departments to extend clinical care to vulnerable New Yorkers through various efforts.

“And we had been thinking…how do we work with these [homeless] patients more? How do we get services to the shelters and bring it to the forefront, to the patient, so that they don't have to travel, or they don't call 911,” Karim said.

The idea of introducing Virtual ExpressCare within homeless shelters was born out of these conversations. The shelters use telephones, tablets, and computers to connect residents with NYC Health + Hospitals Virtual ExpressCare physicians. The technology is provided by the Department of Social Services and other agencies, which are responsible for all technical needs, including ensuring WiFi access and equipment cleaning. The health system is responsible for all healthcare needs, including enrolling uninsured patients in health plans and referring them to other social services as needed.

“From an implementation perspective, it's making sure all those things work together,” Karim said.

A critical aspect of the deployment process was getting shelter staff onboard. NYC Health + Hospitals worked with the Department of Social Services to create a team to conduct outreach with shelter leadership, train staff within the shelter system, and integrate Virtual ExpressCare into existing agency initiatives. Karim noted that the health system also uses feedback from shelter staff to enhance new deployments.

“It's going to be different in each region, in each location, and [we] bring some information and learning from one location to the next and to see what works and what doesn't work,” he said.

Shelter staff are also encouraged to use the service themselves. Working in a homeless shelter is a demanding job, and so the health system wanted the staff to use the service to address any stress or anxiety they might be experiencing.  

“We felt that once they utilized the service, they would then promote the service to others,” Karim said. “Our [net] promoter score, which is something we track, is very high. It's like a plus 80. So, whenever somebody uses a service, there's usually an ‘aha’ moment for them.”

Not only that, but staff may have preconceived notions about telehealth from ill-prepared rollouts during the pandemic that must be mitigated.  

“People have that scar tissue, in some ways, of, ‘Oh, I tried it last time, and it didn't work well, or it was complicated,’ so we need to overcome that as well,” Karim said. “So that's education, that's having these visits with the shelters and working with those staff members to understand that — no, it really is that easy.”

In addition to working with shelter staff to deploy the Virtual ExpressCare service, NYC Health + Hospitals worked to break down patient-facing barriers. One strategy was to enable telephone-based access to the service.

“That was the first thing we did to ensure that everyone had equitable access if they were not comfortable with technology and decrease that barrier,” Karim said.

Further, patients who are comfortable with computers and tablets are able to connect with a healthcare provider with the touch of a button. Once connected with the healthcare provider, they are asked to fill in their name, date of birth, and other pertinent information. Patients are always connected to a human being, and “that was intentional on our front to make it patient-centric,” Karim said.

To engage immigrants and people with limited English proficiency (LEP) experiencing homelessness, the Virtual ExpressCare service provides 200-plus language options.  

The service was initially launched in 25 shelters and is now available to residents of the city's 600-plus shelters. Of the 5,000 individuals in shelters who used Virtual ExpressCare between January 2023 and April 2024, 70 percent were Black and Latino. Additionally, nearly half were uninsured, and 5 percent were covered through NYC Care, a program that guarantees low-cost and no-cost services to New Yorkers who do not qualify for or cannot afford health insurance.

“From a sheer numbers perspective, we see a positive trend of individuals utilizing it,” Karim said. “Our satisfaction numbers indicate that they overwhelmingly like the support and the clinical care that they're receiving from us.”

Shelter residents can use the service as much as they like. If Virtual ExpressCare clinicians identify long-term needs, they work with the patient to connect them with community-based organizations, he added. The health system has partnerships with various organizations in NYC that can help with food and income insecurity, among other SDOH needs.  

Eventually, the health system will also measure whether access to the service affects connectivity to care and ED use rates among NYC’s homeless population.

Looking back at the process of developing Virtual ExpressCare and embedding it into homeless shelters, Karim highlighted the importance of building services based on what the patients want and need. While technology can be a critical facilitator in meeting patient needs, health systems must be wary of overcomplicating care access and delivery.

Instead, Karim believes they should focus on making patient-provider interactions the heart of the technology implementation and keeping the processes around that central interaction as simple as possible.

This philosophy guided NYC Health + Hospitals’ implementation of Virtual ExpressCare in homeless shelters. And though it is a tall order, with hundreds of thousands of people experiencing housing insecurity in the city, NYC Health + Hospitals is making vital inroads.

“It's the mindset [that] maybe we'll never reach 100 percent, but we're going to strive towards it, and try to get better each day, and try to reach one more person,” Karim said.