Changes in In-Person, Audio-Only, and Video Visits in California’s Federally Qualified Health Centers, 2019-2022

Uscher‐Pines, Lori; McCullough, Colleen; Sousa, Jessica L.; Lee, Sarita D; Ober, Allison J.; Camacho, Diana Vanessa Geraldo; Kapinos, Kandice A.

doi:10.1001/jama.2023.1307

Cited by 12 publications

(8 citation statements)

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“…Although TBOT has demonstrated the potential to extend treatment access to underserved areas, our findings that early UDS completion varied across demographic subgroups suggests that further study of UDS in remote care settings is warranted. As telehealth-based care has expanded in recent years, there have been concerns that the “digital divide” (ie, unequal access to digital technology and Wi-Fi that disproportionately affects marginalized populations) could exacerbate existing disparities related to health care access . It is thus important for TBOT platforms to consider the complex interplay between clinical suitability for remote care and socioeconomic and digital barriers, aiming to address the latter while not compromising on the former.…”

Section: Discussionmentioning

confidence: 99%

“…There has been a seminal shift in the National Drug Control Strategy and White House prerogatives for responding to the opioid crisis, notably expanding harm reduction services and removing the Drug Enforcement Administration’s X-waiver requirement for buprenorphine prescribers as of January 2023. In the context of ongoing policy debates over responding to the opioid crisis and allowances for telehealth modalities, removing barriers to buprenorphine access via low-threshold or “minimally invasive” care settings, aligned with improving equity, has become central . Largely due to COVID-19 regulatory reforms, the rapid expansion of telehealth for mental health and addiction treatment has bypassed long-standing requirements for initial in-person visits before prescribing controlled substances .…”

Section: Discussionmentioning

confidence: 99%

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Urine Drug Screening in a Telehealth Setting for the Treatment of Opioid Use Disorder

Williams,

Rowe,

Gallagher

et al. 2023

JAMA Health Forum

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ImportanceAmid rapid and widespread adoption of telehealth-based opioid treatment (TBOT), there is an urgent need for rigorous studies exploring the feasibility and characteristics of urine drug screening (UDS).ObjectiveTo investigate administration patterns and results of UDS to assess feasibility of UDS and patient outcomes in a TBOT setting.DesignThis observational cohort study was conducted between January 1, 2021, and December 6, 2022, and included patients with opioid use disorder treated in Ophelia, a TBOT treatment platform in 14 states. Data analysis was performed from January to March 2023.Main Outcomes and MeasuresNumber and percentage of patients with UDS within 30, 90, and 180 days of intake, grouped by adherence to clinical protocols. Associations were assessed between baseline characteristics and UDS completion and opioid positivity in first 30 days using χ2 tests. Baseline and 180-day follow-up UDS results were compared using McNemar tests.ResultsAmong 3395 patients (mean [SD] age, 38.2 [9.3] years, mostly male [54.1%], non-Hispanic White [81.5%], urban-residing [80.3%], and cash-pay at intake [74.0%]), 2782 (83.3%) completed a UDS within 30 days (90.0% among protocol-adherent patients, 67.0% among protocol-nonadherent patients). A total of 2750 of 2817 (97.6%) patients retained more than 90 days completed 1 or more UDS, as did 2307 of 2314 (99.7%) patients retained more than 180 days. Younger patients, patients of a racial and ethnic minority group, those living in urban areas, and cash-pay patients were less likely to complete a UDS in the first 30 days. Buprenorphine positivity increased (from 96.9% to 98.4%, P = .004) and opioid positivity declined (from 7.9% to 3.3%, P &lt; .001) over time.Conclusions and RelevanceIn this cohort study of patients with opioid use disorder receiving buprenorphine in a remote care environment, UDS was highly feasible, though early UDS completion rates varied across demographic subgroups. The prevalence of unexpected UDS results was low and declined over time in treatment.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Urine Drug Screening in a Telehealth Setting for the Treatment of Opioid Use Disorder

Williams,

Rowe,

Gallagher

et al. 2023

JAMA Health Forum

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“…Close attention to these distinct periods is needed because while telehealth visits substituted in-person care during the shelter-in-place period, both telehealth visits and in-person visits were available during the hybrid period. Moreover, given the wide variation across health systems in providing video or telephone-only telehealth visits, inclusion of safety-net settings, which often provide more telephone visits, in telehealth evaluations is particularly pressing . Safety-net systems serve a disproportionate share of disadvantaged patients who face barriers to digital health uptake.…”

Section: Introductionmentioning

confidence: 99%

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Nouri,

Lyles,

Sherwin

et al. 2023

JAMA Netw Open

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ImportanceTelehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient–clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions.ObjectiveTo evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics.Design, Setting, and ParticipantsThis retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed.ExposureTelehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021).Main Outcomes and MeasuresThe main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES).ResultsOf 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P &lt; .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03).Conclusions and RelevanceIn this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

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“…18–20 While telehealth visits represented 0% of all specialty behavioral health visits in California's Federally Qualified Health Centers (FQHCs) prior to the pandemic, in the summer of 2022, 62% of visits were delivered via telehealth. 21 To date, we know very little about how this dramatic and enduring change in behavioral health care delivery has impacted the availability of different types of visits, wait times, and general experiences of patients with LEP in accessing care. Further, although many patients with LEP prefer in-person care, 22 it is unclear whether they are offered a choice of visit modality.…”

Section: Introductionmentioning

confidence: 99%

Access challenges for patients with limited English proficiency: a secret-shopper study of in-person and telehealth behavioral health services in California safety-net clinics

Uscher-Pines,

Kapinos,

Rodriguez

et al. 2023

Health Affairs Scholar

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The recent growth of telehealth may be impacting access to care for patients, including those with limited English proficiency (LEP). Using a secret shopper design, simulated patients contacted 386 safety net clinics in California in both Spanish and English from February-March 2023. Callers stated that they were new patients seeking medication for depression, and they documented time to an appointment and available visit modalities (telehealth and in-person). Multinomial logistic regression models examined associations between clinic characteristics and available modalities. English-speaking callers were more likely to speak with a live scheduler and to obtain appointment information from a scheduler who could engage with them in their preferred language. Among Spanish-speaking callers who reached a live scheduler, 22% reached someone who did not engage (e.g., were hung up on) and as a result, could not obtain appointment information. The mean estimated time to a prescribing visit was 36 days and did not differ by language. 64% of clinics offered both telehealth and in-person visits, 14% only offered in-person visits, and 22% only offered telehealth visits. More attention and resources are needed to support patients with LEP at the point of scheduling and to ensure choice of visit modality for all patient populations.

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Changes in In-Person, Audio-Only, and Video Visits in California’s Federally Qualified Health Centers, 2019-2022

Abstract: This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

Cited by 12 publications

References 4 publications

Urine Drug Screening in a Telehealth Setting for the Treatment of Opioid Use Disorder

Urine Drug Screening in a Telehealth Setting for the Treatment of Opioid Use Disorder

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Access challenges for patients with limited English proficiency: a secret-shopper study of in-person and telehealth behavioral health services in California safety-net clinics

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