By Paola Peynetti Velázquez, Cambridge Health Alliance
On 11 March 2020, concerned by the alarming levels of spread and the severity of the illness, the World Health Organization (WHO) declared Covid-19 a global pandemic. This blog post is part of a series to reflect on the past year of the COVID-19 pandemic.
The speed at which the scientific and healthcare communities developed collaborative, innovative solutions to protect the public’s health in response to the Covid-19 pandemic is stunning. At Cambridge Health Alliance (CHA), a public healthcare system north of Boston that provides essential services to over 140,000 patients, we quickly pivoted to continue caring for our patients. In March of 2020, the organization’s Incident Command Center asked all services to transition non-urgent visits to telehealth in a matter of days, with only existing resources, staff, and technologies. The psychiatry department leveraged performance improvement tools and methods to implement a comprehensive telehealth program within five days (figure 1).
There are three important lessons we share based on this experience:
1. Lean supports rapid diffusion of innovation in low-resource settings
Many factors contributed to the successful design and implementation of a standard workflow using available technologies. Lean is a methodology for improving flow, maximizing value, and minimizing waste in complex processes; it gained its popularity after World War II, when the automotive industry in Japan developed organized systems to minimize waste.
Lean, six sigma, IHI’s Model for Improvement, and other quality and process improvement methodologies follow similar logic and tools, and can be leveraged in healthcare and other sectors to improve efficiency, reduce cost, and maximize value. At CHA, we leveraged these tools to design a simple, standard workflow that minimized human error and prioritized high-value change ideas. By using an Impact-Effort matrix, for example, we identified, categorized, and prioritized change ideas to address gaps with available resources (Figure 2). Additionally, continuous improvement cycles and daily huddles during the roll-out facilitated the identification of new challenges and monitoring of continuous improvement ideas.
2. Telepsychiatry offers opportunities to redesign mental health services
At least in the short term, we found that telemedicine can facilitate continuity of care while ensuring patients, staff, and providers can remain safely at home. We observed comparable visit volumes and a 48% reduction of no-shows (Figure 3). Anecdotally, we learned that patients who often miss in-person appointments due to common barriers to care (lack of transportation, childcare, etc), found virtual visits more convenient and accessible. Similarly, we learned from providers that the ability to see the patient’s home and (when appropriate) family interactions, contributed to their understanding of the patient’s environment, which informed their treatment.
One year later, an important challenge we are facing is ensuring patient vitals and labs are gathered in a timely manner to monitor medication side effects – for example, for patients on antipsychotics. If patients do not leave their house because of safety concerns (they may have multiple comorbidities) or practical limitations (e.g. lack of childcare), it is our responsibility to care for them in new, innovative ways. These may include partnering with EMS or visiting nurse groups that can take care of patients where they are.
3. An equity-based approach is fundamental to mitigate risks of worsening health disparities
We were already aware of structural inequities and social determinants affecting the health of our communities. In the transition to virtual care, patients lacking adequate technology and digital literacy faced additional barriers to care. Many providers also lacked the necessary technology at home and/or the digital literacy to feel comfortable conducting a video visit. We worked with the information technology, interpreter, and marketing teams to develop interactive provider and staff education materials and simple patient education materials and timely reminders in our four main languages. However, we still found that some clinics relied on phone-only communication for conducting their visits and consistently used video technology for less than 10% of their televisits (Figure 4).
One year later, these gaps remain. Siloed efforts to measure this “digital divide”, address patient social determinants of health, and understand barriers to completing video visits (instead of visits by phone) through research projects have raised similar questions. The challenge moving forward will be to ensure coordination while determining the role of the healthcare system, payers, community agencies, and other stakeholders in supporting patients and providers in real time.
Quality Improvement methods can facilitate a nimble transformation to virtual care, and in keeping with the above areas, we propose the following strategies (Figure 5) to ensure quality while responding to the Covid-19 pandemic and response:
Figure 5: Recommendations for Successful Implementations of Telehealth Programs in Low-Resource Settings Area Recommendations
Note: this article is a reflection and summary of a paper published on July 17, 2020 in the New England Journal of Medicine´s Catalyst Journal on Innovations in Healthcare Delivery.