The COVID-19 pandemic forced community health centers to reach patients by video and phone for the first time last year as stay-at-home orders and other restrictions kept people away from the doctor’s office.

In-person visits have resumed, but telehealth appointments remain wildly popular, even among the less tech-savvy elderly, clinic directors say.

“This pandemic has changed how we deliver health care, and it’s going to change it permanently,” said Christopher Russell, the medical director at the West Hawaii Community Health Center on the Big Island. “Patients love the convenience of it, and it increases our access. Our no-show rate has gone down tremendously.”

The Hawaii Med-QUEST Division’s decision in April 2020 to allow health care providers to bill Medicaid for video and audio health appointments paved the way for clinics and hospitals to get creative in how they connect with patients.

Telehealth also became a necessity, as many clinics and hospitals had to temporarily close and limit visitors, and many people were fearful of entering the facilities even in instances when allowed.

Now, doctors consult with patients via Zoom, pharmacists virtually supervise patients as they check their own blood pressure and tobacco cessation counselors chat with smokers on the phone.

While the shift to telemedicine was a result of the pandemic, community health centers have seized the opportunity to permanently transform the way they do business by expanding outreach to remote areas and more marginalized communities.  However, they continue to face challenges due to unstable Wi-Fi connections, expensive data plans or limited tech understanding.

At the West Hawaii Community Health Center on the Big Island, four out of 10 behavioral health appointments were virtual in 2020. Another 10% of medical visits that didn’t require in-person consultation were conducted remotely, according to the health center.

Russell finds those figures astonishing considering the fact that West Hawaii had never conducted a virtual health appointment at all before the pandemic.

“More and more patients are not going to want to sit in a waiting room with a bunch of sick people waiting to be seen for 15 minutes at an appointment that took two hours to get to,” he said.

Video and phone conferencing offer many advantages, including helping doctors connect with patients in the most remote areas of Hawaii Island that don’t have access to public transportation. Patients who previously had to drive nearly 100 miles to reach a WHCHC campus may now consult a doctor from the comfort of their own home, Russell said.

Hawaii’s largest insurer, the Hawaii Medical Service Association has offered a virtual health appointment option for about a decade but saw the number of users skyrocket to 245,000 in 2020 — 36 times the number of telehealth users it had the previous year.

At Kaiser Permanente, about 80% of care was virtual during the height of the pandemic last year, according to spokeswoman Laura Lott. That rate settled to about 40% of all visits so far this year as more people resume traditional office visits, she said.

By Popular Demand

There has yet to be statewide data collected about who relies on telehealth, according to Christina Higa, co-director of the Pacific Basin Telehealth Resource Center at the University of Hawaii Manoa. That’s something the resource center hopes to collect in partnership with Hawaii hospitals in the months to come.

But the experiences of community health centers — which make it their mission to reach low income and rural patients and receive federal funds to do so — provide a glimpse into how video and phone conferencing has changed the game.

Chrissy Kuahine, the Waianae Coast Comprehensive Health Center’s director of electronic health records, surveyed telehealth patients this year about whether they were likely to continue using the option.

Well over 70% of respondents said yes.

“For those who can connect it’s obvious: you don’t have to leave your house,” Kuahine said. “For patients who have gone back to work and don’t have paid time off, this is a way for them to receive and get health care without having to take time off of work. They can meet while on their lunch break.”

As of May, 37% of appointments at Waianae Coast Comprehensive Health Center’s were conducted virtually.

West Hawaii Community Health Center on the Big Island found similar results in a survey of its own, which was conducted digitally in April. Most respondents were older than 46 and urged the center to continue offering telehealth options.

“I’ve been pleasantly surprised as a provider because I’ve seen a lot of my older patients by telehealth,” said Russell. “Once they figure it out, the way we have it set up is just as easy as using FaceTime, and they’re already using that to communicate with their families.”

Shaky Wi-Fi

The lack of reliable broadband service in many rural Hawaii communities makes it difficult for many families to make virtual appointments since they have to rely on spotty satellite connections or don’t have internet at all.

In his State of the State address in January, Gov. David Ige said the pandemic “highlighted the digital inequity in Hawaii” and announced plans for a federally funded pilot project to launch new state-managed Wi-Fi hubs in Puna and Kau on Hawaii island; Hana, Maui; Kapaa, Kauai; and Nanakuli, Waianae, Waimanalo and Kalihi on Oahu.

“We have some ways to go with the broadband issues,” Higa said in an email. “In time these investments might help to increase telehealth, but a lot of these systemic issues take time to overcome.”

Many patients at the Waianae Coast Comprehensive Health Center in West Oahu have to do appointments by telephone because they either lack internet service, have unstable connections or didn’t have a camera-enabled device, Kuahine said.

“What we found in the pandemic year is that telephone visits ended up being for many patients the only way they continue their care with their provider,” she said.

It’s also uncertain whether insurance companies will continue to cover telehealth appointments after the public health emergency is lifted.

“More and more patients are not going to want to sit in a waiting room with a bunch of sick people waiting to be seen for 15 minutes at an appointment that took two hours to get to.” — Christopher Russell of West Hawaii Community Health Center

Judy Mohr Peterson, the administrator for Hawaii’s Medicaid program Med-QUEST, said the reimbursement policy will expire when the state’s emergency proclamation is lifted.

However, the insurer is exploring other payment options to keep telephone and audio-only visit reimbursements with the Hawaii Primary Care Association, the umbrella organization of Hawaii’s community health centers.

Richard Bettini, president and CEO at Waianae Coast Comprehensive Health Center, said there’s also an ongoing discussion about what qualifies as an audio health visit.

In the meantime, health centers are developing other ways to stretch their virtual health outreach by investing in or expanding mobile clinics equipped with Wi-Fi hotspots to connect people with doctors on the spot.

Waimanalo Health Center, which serves a predominantly Native Hawaiian community, dispatched its staff to teach patients, especially kupuna, how to use the technology.

Video and phone-based health appointments currently account for about a fifth of all of Waimanalo Health Center’s visits, and the center’s executive director Mary Oneha has joined efforts to advocate for continued Medicaid reimbursement for health appointments conducted by phone.

“If we could do a map of where broadband services are and social vulnerability population indexes, they might match up,” she said. “In our mind, it is an equity issue.”