Back in the old days, when COVID-19 was truly novel in the U.S.—i.e., March—the increasing number of cases and uncertainty about how bad the pandemic might get set off a mad scramble among many health care providers to move to telemedicine. The question was: How can health care centers quickly make the shift without losing patients, and while still providing quality care?
For one HIV clinic in Nebraska, shifting to telemedicine required a quick adoption of a three-step plan. This plan and its success was the topic of a presentation at the IDWeek 2020 virtual conference earlier this fall by Nada Fadul, M.D., and Nichole Regan, M.S.N., APRN-NP, associate professors at the University of Nebraska Medical Center (UNMC).
“We wanted to keep patients close, even if not physically,” Regan told TheBodyPro. UNMC “is not just a clinic; for many patients, it’s a second home. Some of our patients are homeless and tend to show up randomly, not knowing what services they need.”
The UNMC HIV Clinic, which started in 1985, is a comprehensive HIV care facility delivering care to about half of the more than 2,000 people living with HIV (PLWH) in Nebraska. But it’s small enough, Fadul and Regan said, that many patients have become friends with the staff. Because a pandemic-based shutdown hadn’t happened before, there was trepidation about moving so many patients to telemedicine. But they had no choice: the physical space just wasn’t big enough to accommodate everyone with social distancing.
The priority of the UNMC team was to keep their patients linked to care and ensure no significant dip in viral suppression, even if a significant number of patients couldn’t come in to the clinic. (Before the COVID-19 crisis, 80% of clinic patients were linked to care, 67% were in care, and 61% were virally suppressed.)
A Multifaceted, Evolving Plan to Retain Patients Living With HIV
The clinic’s first step was to develop a plan to transform delivery of care, which took about two weeks. The process began when the first COVID-19 case in the state was announced; UNMC HIV Clinic team started work on the plan and devised tools to support their patients, both medically and socially. They mobilized staff and resources to see how they could use telemedicine “visits” for routine and non-urgent care.
While some clinics in the U.S. had added telemedicine to their services before COVID-19, the UNMC HIV Clinic had not, so they were starting from zero.
Another barrier: Not all of the clinic’s patients were primed for virtual visits. For one thing, nearly half of didn’t have access to the clinic’s MyChart portal, and some didn’t have devices with video chatting capability—or even smartphones.
So, the clinic created a plan B: telephone evaluations, rather than telemedicine, whenever they were necessary.
By mid-March, many clinic patients were already calling to cancel appointments due to COVID-19 fears. Within a few days, front desk staff was trained to switch these patients to phone visits.
The next issue was deciding who was a candidate for phone consultations, given that each clinic provider had different processes and criteria for determining who was a good candidate for telemedicine. UNMC settled on one standard: Telephone visits would be provided to established patients, which they defined as those who had visited the clinic within past nine months, had an undetectable viral load, and had a stable CD4 count.
For new patients, if their labs were stable, they had an evaluation from their previous provider in the past six months, and they could request refills from previous provider, new in-person appointments were scheduled for Summer 2020. New patients who were not transferring would get a COVID-19 screening; if it was positive, they’d be given instruction on self-isolation and monitoring symptoms. If it was negative, staff would schedule a new patient appointment at the clinic.
To keep track of the data and efficiently document visits in real time, a Smart Phase template was developed, containing all relevant criteria for telehealth billing and coding, and incorporating COVID-19 education language.
Adjusting on the Fly in an Unprecedented Time
Once their initial plan was enacted, the UNMC HIV Clinic team moved to their second step: active refinement. This included monitoring patient outcomes to see whether they were able to maintain their previous levels of care; dealing with issues the clinic team initially encountered in its quick conversion to telemedicine; and preparing for an eventual re-opening of on-site care as spring turned to summer.
Staff gathered data on patients who were lost to follow up, adding a prompt for a provider to note when further outreach and lab visits should be scheduled.
From mid-March to mid-April, the number of patients who were “seen” remotely ramped up quickly, reaching 50% of all patients. When new COVID-19 cases leveled off over the summer, the clinic was able to bring more patients back to the facility for lab work and physicals; by the end of August, only 6% were receiving care via telemedicine.
Assessing Patient Outcomes During the Initial COVID-19 Wave
Fadul and Regan found that, even though roughly half of all patients receiving only telemedicine service for several months, viral suppression rates among patients who were engaged in care dipped only slightly: from 92% to 90% by the end of August.
However, the number of patients lost to follow-up began to increase throughout the summer. By late August, there were more than 60 people lost to follow-up, and medical frequency—that is, clinic patients who had an appointment within the past year—declined from 69% in February to 55% in August.
That said, maintenance of viral suppression was considered a big win for the clinic, and even the drop in follow-up was not as great as the clinic staff had feared.
“In March I was worried about our patients, but we found that they were very receptive” to telemedicine, Fadul said. “In fact, we had a lot of patients coming out of the woodwork—patients we hadn’t seen in some time—who were worried about COVID-19 and wanted to take their health more seriously.”
A Key to Success: Constant Adaptation
Regan encouraged other HIV clinics and community clinics to remain available and flexible when moving to telemedicine. “We had to be proactive, and it took greater effort to stay in touch” with patients, she said. She noted that, thanks to the relatively small size of the HIV patient load in the greater Omaha area, case managers in most cases were able to utilize social media and word of mouth to reach patients who did not have stable housing.
The UNMC HIV Clinic was far from the only clinic to explore the use of telemedicine as the COVID-19 pandemic first took hold in the U.S.: A recent CDC report showed a 154% increase in telehealth and telemedicine visits during the last week of March 2020 compared to a year earlier. The trend toward telemedicine could continue even after the COVID-19 crisis has abated.
As for the UNMC HIV Clinic, as the IDWeek conference concluded at the end of October, Fadul and Regan said they were preparing to resume their telemedicine model, with COVID-19 cases in Nebraska beginning to surge again.