Dr. Jason Cunningham, chief executive officer of West County Health Centers, and Dr. Grace Floutsis, chief medical officer of White Memorial Community Health Center, discuss why they made video visits a priority for their organizations, explain how they supported their teams in that journey, and share some practical advice.
Dr. Jason Cunningham, chief executive officer of West County Health Centers, and Dr. Grace Floutsis, chief medical officer of White Memorial Community Health Center, discuss why they made video visits a priority for their organizations, explain how they supported their teams in that journey, and share some practical advice.
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We're doing about a thousand video visits a month. And it's because it's largely driven by the fact that number one, behavioral health, it's just a no-brainer for the teens who are having such a hard time during this pandemic, especially here in Boyle Heights. We're just seeing a lot of grief and. All of the different things that go along with financial difficulties or families are facing
welcome to the health pilots podcast presented by the center for care innovations. This podcast is about strengthening the health and wellbeing of historically under invested communities. Every episode offers new ideas and practical advice that you can apply to it.
this episode is adapted from a recent webinar. Enjoy. Wanted to start with a discussion with two liters, because as we know with any big change in an organization and going to video is obviously a significant change. We know that leadership support is critical. And so we're very lucky to have. Two amazing leaders.
Talk about why they need video visits a priority for their organization, how they've supported their teams and the journey, and some practical advice for you for your organization. So, um, I want to introduce Dr. Jason Cunningham, who is the CEO of West County health center. And, um, Well, this doctor based lot since who's the chief medical officer at white Memorial health center.
Um, we're going to start with just a quick introduction from both of them to learn about their organizations, um, hear about their journey. So maybe I'll start with Jason. I was going to play a joke and pretend like I was un-muted and are muted and then talk and that kind of stuff as a panelist and the video.
So. We've gone from that as the reality.
I mean, the reality is we're still having difficulty with this and there's differences in how people can access it. Um, so, uh, I'm super excited about this topic personally. I'm a little bit of an ITD, um, and like this stuff. So we've been doing. Some sort of video visits for almost 10 years now and practicing different platforms.
And I think I've been somewhat unsuccessful at really doing any large-scale, um, rollout of this. It has almost entirely been based on reimbursement. We have independently pivoted very quickly to the virtual environment, almost entirely with a phone. Then we went with Ronnie clinic work. So then we went with, um, trying to have only one platform available, which decided not to go with the duck city or the FaceTime or some of those, um, in with already clinical works, um, platform.
Which was unsuccessful, to be honest with you, it worked, we had a lot of push and it just was too clunky. Our staff felt like they were spending a lot of time calling patients ahead of time, figuring out the technology and ultimately scrapped it and ult, and then went to zoom and zoom has been just a no brainer for us.
And so we've set it up where our clients all call into one zoom per clinic. So West County health centers, gravity and health center clinic. There's one zoom. Then we have breakout rooms for each room. So we have a breakout room for my peer team, and then I'll go Oh, into a breakout room one to see a patient, come back to my care team and go out to break a room too and see care patient.
Okay. And we get the team experience where the nurse can go in and the ma can go in and I can have that collegial experience. And then now we've got it where we have multiple care teams on that same zoom. So that concept of us being primary care. Which is really a collaborative team sport, and that's part of what we're in it for.
And we'd like to talk about these complicated, interesting patients. It was a real miss with the phone. And so, um, turning that zoom on and then getting past the, um, freak out factor of technology in front of a patient and all that kind of stuff, our numbers have done this. And so it really has been the right factors if you will, the BioMAT that makes it successful and then picking a solution that has worked.
And, um, so that would say that would be some discussions I did want Christo to really highlight when we're talking about PPS rates. Right now we have Medicare, which is twice the reimbursement for video. And in-person that it is for phone is a huge driver for us to get into videos. So that disparity of the phone and the video will change the dynamics.
So if we're talking about the. Equity discussion. It's going to create the system to make that happen. So if we want telephone to be really available, you're going to have to in some way, make that relatively apart. At least not a huge difference. And then the concept of it's okay for the state to make a decision.
But at the federal government, it's CMS, doesn't allow for the patient to be at home alone as the initiating site. And we can't get our full payments. So it doesn't matter if a fee for service does it at the federal has to allow for it. CMS has to. And then if you do a fee for service, And we can't get a rap payment because it is a fee for service, but it's not counted as a real visit.
And it gets taken out at the end of the year when we do our wrap payments. So those nuances of PPS versus fee for service will drive the FQHC towards an outcome just because of the way it's set up. So those Andy Patterson at CPCA or others would be, if you haven't already talked to them, really important to work with, uh, the outcome and what we want to set up.
Thanks, Jason. Yeah, we've been talking to a number of the PCA's across the country and also with NAC. So I think that's a really important distinction. So grace, let's see if we can hear you. And if you could just introduce yourself and white Memorial. So I'm grace flutes as an actually I am the COO of white Memorial community health center, which is a local like in Boyle Heights.
Um, Los Angeles. And also the COO as of December 1st of 2020, which of course coincided with a pandemic hitting three months later. So at white Memorial community health center, we have about 16,000 patients. We're a small to moderate size look alike. And the vast majority of our patients are pediatric.
Although we're growing an adult practice pretty rapidly through the pandemic throughout this time. The move was instantaneous almost. We couldn't bring a bunch of children into a waiting room. We're a Petri dish on a normal day. And so we switched pretty seriously to telephonic visits almost immediately on March 15.
And as we started to understand our Hilo option or our applicant or UCW option, we quickly geared towards video visits. And I think for pediatricians, it was a no brainer talking to a child over the phone, just isn't they need to see the kid. And we still see a disparity in the adult versus pediatric providers almost entirely want video visits.
And so two thirds of our telehealth visits or more now are video visits. We're doing about a thousand video visits a month. And it's because it's largely driven by the fact that number one, behavioral health, it's just a no-brainer for the teens who are having such a hard time during this. Pandemic, especially here in Boyle Heights, we're just seeing a lot of, you know, grief and all of the different things that go along with being quarantined and financial difficulties or families are facing.
And so they're really able to. Up with us to video visits, they liked that. And then also we find that episodic pediatric care is really, really good on video visits. For most things are a few things. We really need to see them in person, but we can handle a lot of stuff that we make people wait in our waiting room for before and chronic disease management is the other area where we really see a future for video visits.
We're back to most of our visits being in person, we do a lot of, um, preventative health for children and really went back to it as soon as we put in June, but we're still doing a, probably a third of our visits are tele-health and of those, the vast majority are our video. And I think in terms of leadership, I think what our previous, our first speaker said was really my first take on the video visits.
We're here to stay and telephonic visits. We were going to have to fight for in one way or another. And so it made sense to invest in video visits as soon as possible so that we can show their value. So building on that, I mean, it sounds like you both are definitely strengthened video visit Kool-Aid and are leaders that believe in it and have made space.
I mean, I wonder if you have any thoughts about things you've been able to do to help bring your providers along in the journey staff. There's probably some people who weren't really comfortable. Like what as leaders have you been able to do to help a couple of things? One, we had to make sure the system works.
And we need to be honest about it. So if there was a lot of headache and heartache with the amount of work. Then asking our staff to do that. You'd have to have a very compelling reason for it. So either we weren't gonna get paid at all. If we didn't do video, that would be a driver or, or something like that.
Um, but that wasn't the case. There was another option. So it naturally brought us towards telephone. And that's why we went back and forth. We had to really push people to say, we should try and practice this out. And we finally give up to say, The system we were using just wasn't working well, now we have the zoom piece and then we felt comfortable if we practice the living daylights out of it.
And we had all sorts of workflows, we felt like it was a good product. And then for me, I wanted to say, well, now we have to move over that direction. So when we had them. Okay, you can try this. Even if we got practice, when a call center is on the line and now we've got seven or eight months worth of telephone in there, like you want to try zoom, maybe not.
Okay. That's fine. I'll put you on phone. When you're giving this staff patient choice, then it got into, it was we fell back to what we were all used to, and that little bit of a Hill that you're climbing with the technology barriers or the newness factor quickly moved people back. So we had to move towards.
This was the default and that therefore there are specific exclusions. Like my kid is, yeah, we only have one computer and they're on zoom or there wasn't connectivity, you had some appropriate and there was another option. So you could come to our clinic and go to a room, or you can sit in your car with an iPad that wasn't a legitimate option for people.
And we felt comfortable saying it's better care. It's better connection relationally. And we get reimbursed for it. We need to make this mandate. And that happened just recently for us. It drove kind of lift that lift of worry towards we're gonna, we're going to just have to do this, um, the negative. And so I think part of that is just a leadership decision.
Once you've tested it, you have to make that decision that you're moving forward on this. Yeah. I mean, I think I probably moved pretty quickly too. We're not going to get paid for Telephonics, so you'll have to do video. And that was telling us that we don't know how long this will last. We don't know how long, you know, powers that be in Washington will continue this.
So people were motivated for that reason. I think it is really important. I think we're still on the ECW option and it has improved significantly, but it is still very challenging. And so if all of our visits were video visits, that would be impossible. The fact that, you know, the end of the day is video visits and kind of problem solve them by then.
That helps a lot. And then the scripting for the front office, for the call center and for the MAs that conversation with the patients is really important. They need to know that this is really the option we're offering. What do I do if I can't do that? Well, we'll figure it out at the time of the visit.
If you can't get on this call, you have an email. We're going to send you this visit. You have a phone, we're going to text you this visit. And if you can't get on, then we're going to help you figure out another way to do the call. Which happens sometimes, you know, people just can't get on and then we'll do a telephonic.
We're starting to get some questions. I'm going to go to the questions. And then we just have about five more minutes. So one questions for Jason, I'm curious how you were able to train up your staff and what resources they needed to feel comfortable with the complexity of zoom. And did you need to invest in hardware to make it happen?
And if so, any tips in justifying that investment while the reimbursement questions are still so murky? I think two questions, the investment in the, um, in the infrastructure and investment in the intellectual and the emotional capital to do what I think are really important and they shouldn't be taken lightly.
I think the biggest risk for us is the freak-out factor. If I could. I always say that that's the coin freakout factor. This is a high freakout factor. There's. Technology, which is a freakout factor. There's newness. It's just big up factor. You're performing in front of somebody else. So you've got your credibility on the line.
If you can't figure things out, then it takes way. Are they going to believe me as a provider or whatever? There's lots of. Of risk there. And, uh, so we have a great team that's on the call now. So just to call them out, we have a dedicated team. I think this grant made a difference to be honest with you, that we had some money to offset some of that risk, but we have a dedicated team.
Who's doing the pilots, who's running with it. It's creating videos that, um, our big issue is that we train it, we test it and then we need to mentor it. So. Yeah, people who are shadowing people on the line, particularly for our concierge, where they have to bring in the patient in the waiting room and move them over to a room.
And that kind of setting up the zoom, all that kind of stuff. We needed somebody to literally help set them up, watch one, do one, teach one concept. Um, and we still have those laggers that need extra help. So that was the main thing is the lots of videos, lots of PowerPoints presentations, lots of training, and then mentoring.
And then for the investment, we already invested in all the Microsoft cams and that kind of stuff for our staff. Anyways, they're not that expensive if you put it together, but if you add it all up for all your staff is quite expensive. So some of the money that we got for our cares funding or some of the money for this would be a good example of kind of offset some of that one-time infrastructure costs.
We did spend some money on zoom licenses. So we chose that was an investment long-term, but we can make it up with the differential, just with our Medicare Medi-Cal, um, tele-health and Telephonics. Great. So, great. The question for you. Could you mention again which platform you're on and does that same platform serve all your visit types and specialties?
Yeah. So we're on ECW and ECW has, uh, an app, which is also its patient portal, but also has its video visit capability. And, um, and we're using that at first patients had to download the app, which was a real problem and was a barrier, but now they don't need to have the app. They just need an email or a phone that we can text the link to them.
So that piece works well. The connectivity issue, even in Boyle Heights is still a problem. Especially because some folks have phones that are, you know, still 3g, not, they're just not as web enabled. They don't have as great of bandwidth as we would like, but it's all part of the, the doctor can document and be talking to the patient on the same application.
It's very, um, and then the billing piece is very transparent. So for the purposes later of auditing and stuff, it's, it's very obvious if you're doing a video visit or not. Okay.
Okay. In your scheduling temp, what is your scheduling template for tele-health? How many visits are scheduled completed in a day? We found that telehealth visits back to back are harder than in-person visits back to that. And that's because. The pressure of patients waiting online for you is somehow different than the ability to multitask a patient multitask with several patients at the same time.
Maybe zoom solves that problem, but you kind of have to finish your episode and then go to your next patient. Whereas in real life, When I bought that and non-virtual life, you can be with a patient for five minutes, ask for some information, take care of some, you know, get some tests, results, and then be with another patient right at that time.
So we're giving a full 20 minutes and that's tight for each visit, which is for PD or pediatricians, that slope, they prefer to see patients. Yeah, our experience, we just basically it's the same. Uh, we don't have any change in the template. We just either say zoom or phone in the ours, the reason field. And it's just a matter of the office, the nurses in there and their call center just.
Making sure that it's a zoom or a phone. It doesn't change our visit. It could be a 20 minute visit or 40 minute visit. It's just zoom. And our big issue is we're prioritizing getting as many zoom visits as we can as a goal rather than as a phone. And it's really more of a change management than it is anything else.
As far as I was going to comment, Charles has come to question about the zoom licensing. We do have a, um, Health care licensed. So it is, it is licensed as a encrypted license and we use the waiting room. And so the patient has to line up and we have a concierge bringing each one individually, and then we put them directly into a breakout room so that the patients aren't.
By accident, interfacing with a HIPAA issue, works out really well. So you have one person who's a concierge and bringing you in and out and allows them for us to kind of go back and forth. So once we figured that out and the zoom was a no brainer because of the team connection and being able to work around kind of that kind of stuff.
And then future state being able to bring family members in being able to bring a pastor in or a cardiologist into those visits is something that we'd like to. Okay, I'm going to try and squeeze in like one more question. There's I may need to follow up because we have more questions than we have time today.
Question around how you triage patients, either a telehealth visit or an in-person visit. How are you all thinking about that? I know that's come up a lot. All our preventative care now is being done for children in person. At first, we were only doing under two years of age, but now we're just seeing kids who want to come in well childcare.
And then for the pediatric visits, everything else goes to a video visit. And then. The provider to make a decision at that time that they need to bring the patient back for further follow-up in person or follow-up video, um, transmission rates in Boyle Heights and out of control. Crazy. So we're assuming every patient comes in to be the purpose of the video visit is not so much to keep it's more for their safety than ours.
We're in full PPE with every visit. I think the question of what's the most valuable visit for the patient is a really important question that we'll need to work out over time. So I would say that our big issue is to say, I'd rather have it be a video, unless you have very specific exclusions. That's our work going on.
So you can't, we're not giving patients an option anymore. I think it's important, but what is better done in person? Versus a video, I think is a really important thing that I would love all of us to figure out. Is that better relationally? Is it better clinical care? Is it better for us to be seeing patients first and then do a video?
What things do we need to do in person? Can we bring in people more chronic disease. I had a, my last visit, um, yesterday this person brought her bunny rabbit and I was talking to her and her bunny rabbit for the whole time. And that was such a sweet visit. Right? So sometimes just having us be in a person's home is better than the patient being in the office and certainly having to sit and wait me for an hour.
So those kinds of discussions and things, I think we're going to all have to have. So one word about how you're feeling about the future of video.
I mean, I, I feel it's going to play a role in, especially in an area of behavioral health.