Analysis illustrates California safety net facilities’ experience implementing telehealth


Eli Kirshbaum


Telehealth use in California’s safety net hospitals increased from 4% before the pandemic to 55-75% post-pandemic, according to Natasha Arora, evaluation and learning associate at the California Health Care Foundation (CHCF)’s Center for Community Health and Evaluation.

Through its Connected Care Accelerator Innovation Learning Collaborative (CCA ILC), CHCF gathered clinical utilization data from 23 state safety net health centers between Feb. 2019 and Feb. 2021 to assess their experience with the shift to widespread telehealth use and to identify where they had success.


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Arora outlined four main findings from the collaborative at a webinar hosted by CHCF on Monday.

Telehealth replaced a large volume of care during COVID-19

Of the 55-75% of visits conducted via telehealth after the arrival of COVID, 94% of primary care visits and 89% of behavioral health visits were over the phone — compared to video visits. She noted that although a considerable amount of patients shifted to telehealth use during this time, overall patient volume remained relatively steady.

“One of the key things to notice here is that there is not a decrease in volume — volume maintained itself pretty stably throughout this period of time. Patients were still able to access care, and the vast majority of that care … [was from] phone visits.”

The total volume of behavioral health visits, however, increased between February and April of 2020, partly due to decreased no-show rates in the wake of the pandemic. There was slightly more utilization of video visits (compared to audio-only) in behavioral health than in primary care.

The rate of adoption of video visits varied and was supported by a few key implementation practices

Arora said facilities implemented video visits at differing rates, with certain facilities having more success than others — likely due to specific practices.

In order to adopt video visits, health centers faced a number of tasks including selecting a platform for video visits, onboarding patients, establishing new care team models, and determining how to connect language interpreters to these visits.

Health centers with high video utilization used platforms that provide easy access for patients, scheduled telehealth appointments as video by default, set targets for video utilization, and prioritized operational bandwidth to make the transition to video.

“…the health centers that were using some of [these] key practices … were conducting about 29% or more of their visits by video. So we really do see a huge amount of variation based on the resources that health centers were able to put into this, as well as the technology they were using and other aspects of their care model.”

Health centers developed unique telehealth models and incorporated needs of patients, staffing models, and tech infrastructure

Arora explained that each facility needed to address specific needs in their telehealth models, such as staffing.

They also needed to make technology related decisions, such as whether to implement short-term or long-term telehealth technology infrastructure. Some health centers, Arora said, took a short-term approach and adopted what was “doable in a short period of time,” while others implemented more sustainable technology infrastructure, taking into consideration both patient and provider needs.

There was variation among video platforms as well, with some being more accessible to patients than others. Facilities needed to decide when to use video versus phone visits (which depended on things like clinical criteria, provider or patient preference, and quotas for the use of different modalities).

Financial incentives also played a big role in the shift to telehealth, Arora said.

“Overall, the current policies in place around reimbursement really served as a catalyst for rapid change. Health centers knew they could get paid for using telehealth and needed to get paid, and so [they] were able to use both phone and video visits.”

Health plans offered incentives for providers to conduct a certain amount of video visits for their patients, which incentivized providers to conduct more visits via video.

Health centers implemented and continue to seek solutions to address digital barriers

In implementing increased telehealth use, facilities had to navigate digital barriers among their patients. This included needing to offer “hybrid visits” for certain patients, in which the patient could be in-person at the facility but also connect with a provider at another location.

“One thing that we heard from health center teams was really about the strength of their patients and the support provided to patients from family members and across generations in order to try new things and use technology that they weren’t always comfortable with.”

Other challenges included enabling the use of language interpretation in video visits, implementing remote patient monitoring, enrolling patients in patient portals, and providing hardware and Wi-Fi to patients who didn’t have them. In some cases, this involved setting up Wi-Fi in facility parking lots, Arora said.