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May 2020

Spotlight: Telehealth Role in Managing Chronic Care During COVID-19

With: Dirk Steinert, MD, Medical Director, Specialty Care - Quality, Ascension Wisconsin

Dr. Dirk Steinert

While healthcare systems had a goal to increase virtual visits over the next few years, the use of telehealth rapidly escalated when COVID-19 halted in-person clinic visits.

“Suddenly, everybody across the country was scrambling to do virtual health care to continue caring for their patients during this unique time of social distancing,” said Dirk Steinert, MD, Medical Director, Specialty Care - Quality, Ascension Wisconsin.

The Centers for Disease Control (CDC) identified the highest risk patients for COVID-19 were those with chronic illnesses that require monitoring and ongoing care to avoid hospitalization. High on this list were patients with one of more of the following conditions: diabetes, hypertension, older than 65, liver disease, or lung disease. For example, only six percent of the patients treated for COVID-19 in one New York area health system had no chronic conditions. Hypertension, obesity and diabetes were common.

“When I looked at the projections for COVID-19 surges in hospitals, my first thought was we need to keep our chronically ill patients, who are at higher risk for the virus, out of the ER and hospital with active case management,” said Dr. Steinert.
To begin proactive outreach to patients most at risk, Ascension Wisconsin clinicians coordinated with the IT department to sort medical records to identify people who were at higher risk for hospitalization if they contracted COVID-19. Using the Charlson Comorbidity Index (CCI), which predicts 10-year survival in patients with multiple comorbidities, and certain diagnosis codes the technology team scored patients using the CCI and the clinical team then began to contact them based on their risk score.

The Ascension Wisconsin clinical team, led by Dr. Steinert, developed a workflow to contact high risk patients based on the date of their last clinic visit. Those who had not been seen recently were proactively contacted and encouraged to set up a virtual visit with their provider.

Clinicians could connect with patients on Ascension’s secure, confidential platform - Ascension Online Care, in addition to Zoom, Google Hangouts and FaceTime. Because many patients and clinicians were first-time telehealth users, it was critical to offer a variety of secure platforms to ease comfort levels.

Ascension Wisconsin also encouraged patients to use its online portals and OpenNotes to directly communicate with their clinicians. This empowered patients to better manage their healthcare needs.

“While telehealth may seem easy, not all patients and not all physicians are comfortable discussing health matters virtually,” said Dr. Steinert. “There is a learning curve for both patient and provider.”

To assist clinicians, Dr. Steinert and the Ascension Wisconsin team developed tools that would help guide them during a telehealth visit. This was especially important when asking questions related to depression, which is critically important when people are isolated due to in-home sheltering. Depression is also a factor in whether a patient can adhere to their care plan. Asking questions about their sleep habits, lifestyle, ability to exercise and whether they are interacting with others in meaningful ways can help the clinician determine how the patient is doing. Based on their responses, medications can be adjusted or changed. And with that, the physician also can ask if their patient can access medications by having home health or the pharmacy deliver them. In some cases, the physician might determine that a virtual visit with a behavioral health professional would be beneficial.

“If a patient has diabetes, we might ask if we could set up a visit with a diabetes educator,” Dr. Steinert said. “What’s nice about a virtual visit is we can ask to see how our patients live and better understand their social determinants of health. Sometimes our patients show us the inside of their refrigerator which helps understand their diet and whether or not they have access to nutritious foods. That is important, and for some patients, it is reassuring to have an ‘in-home’ experience. They really enjoy that interaction and as a physician, it means a lot to me, too, that they are willing to share details of their lives that can help me help them.”

COVID-19 has made clinicians rethink how they can use telehealth to interact with patients on a personal level to learn how their patients’ lives and identify socio-economic needs. A telehealth visit can also improve safety at home by helping the patient identify expired or unused medications that are in their medicine cabinet that should be disposed of, so they don’t accidentally take the wrong medication.

“Telehealth is not something most physicians do naturally. It requires guidance and practice to do it successfully. And not all patients like it, so we need to take that into account to determine how to do this well in the long term,” Dr. Steinert said.
According to the American Hospital Association, telehealth is changing how care is delivered in communities across the country. From emergency department care to remote patient monitoring for chronic care management and access to care from specialists, telehealth is changing the way healthcare is provided – both expanding patient access to routine and specialty care while improving patient satisfaction and outcomes. (American Hospital Association, AHA.org, 4/27/2020)

“This crisis will lead us to improved and expanded care possibilities which will aid our patients and communities into a safer healthcare dynamic,” said Dr. Stienert. “We have learned many lessons during this time and can use our findings to improve healthcare delivery. We want to encourage patients to feel supported and safe when they seek care and to not delay reaching out for help. As healthcare professionals, we are here for them and the community in this time of need, and in the future.”

The COVID-19 pandemic has accelerated and necessitated the use of virtual care in a matter of weeks. Over time, telehealth will make care more accessible and with that, have a measurable positive impact on population health.

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