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Clinical Integration

Updated June 16, 2021

Maturity Model

The Maturity Model provides high-level guidance for advancing telehealth capabilities. It’s the “what” we hope to achieve. This is the model for Clinical Integration; view the full Maturity Model.

Sustainability Curve 1:
Covid-19 Response
Sustainability Curve 2:
CARE INTEGRATION
Sustainability Curve 3:
EXPANSION & SUSTAINABILITY
COVID and non-COVID workflows; telehealth substitutes for some in-person visits to health centerIntegrated into delivery of care across all health center disciplines and for all patientsOn-site and virtual specialty care integration; optimization of community-based care with remote monitoring, in-home testing, and portal use

Drivers of Success

The Drivers of Success represent “how” to improve performance. These are the drivers for Clinical Integration; view the full Driver Diagram.

  1. Redesigned care team roles
  2. Scheduling guidelines and workflows for virtual visits
  3. Clinical pathways for virtual care and hybrid models
  4. eConsults for specialty referrals

Redesigned Care Team Roles

Health centers have depths of experience with care delivery transformation through the adoption of the patient-centered medical home, including implementing care teams, integrating behavioral health care, and developing care models for patients with complex medical conditions.

Similar to the medical home transformation, health centers are now updating and adjusting team-based care workflows and roles with the growth of telehealth. Some functions may stay the same but have new workflows. Virtual and hybrid models of care offer new opportunities for shared visits and for synchronous and asynchronous consultations. Long-term sustainability of telehealth will require the integration of all members of the primary care team into hybrid and virtual care delivery.

Examples of new functions, workflows, and opportunities

Care team Membernew functions, workflows, and opportunities
Community Health Worker• Provide patient education and support for telehealth visit, including technology assistance
• Virtually accompany patients to telehealth visits
• Conduct virtual chronic disease check-ins
• Understand community technology needs and gaps
Medical Assistant• Provide patient education and support for telehealth visit, including technology assistance
• Reach out to patients with chronic diseases and care gaps who have not been seen
• Room patients virtually
Primary Care Provider• Lead the virtual huddle
• Utilize eConsults as needed for specialist consults
• Conduct more shared visits

The following resources include sample job descriptions that incorporate new and expanded job functions related to telehealth:

  • Resource

    Job description: Telehealth Program Coordinator

    Sample job description for navigator to provide support patients for their virtual medical visits.

    PDF
  • Resource

    Job description: RN Telehealth Coordinator

    Sample job description for RN telehealth coordinator.

    Visit website
  • Resource

    Job description: Telemedicine Navigator

    Sample job description for navigator to provide technical assistance to patients on how to navigate telemedicine platform for their virtual medical visits

    PDF
  • Resource

    Job description samples

    Sample telehealth job descriptions for medical director, site coordinators, instructors, clinic managers, technical support from the CA Telehealth Resource Center

    Visit website

Scheduling Guidelines & Workflows

Patient preferences and clinical guidelines should be considered when scheduling patients for in-person or virtual visits. Telehealth is more suitable when a patient already has a relationship with the provider. Telehealth is recommended for behavioral and mental health, virtual urgent care, and follow-up for chronic conditions such as diabetes and hypertension.

In certain instances, virtual visits may not be appropriate. These may include:

  • Annual check-ups
  • Instances where exam, lab tests, and images are known as critical
  • Patients with multiple complex problems involving highly nuanced care
  • Highly sensitive matters, such as a new cancer diagnosis
  • Medical procedures
  • Behavioral crisis intervention

Health centers and other providers will need to develop specific scheduling workflows and guidelines that incorporate the use of telehealth.

Scheduling Guidelines and workflow checklist
Phone triage of urgent/sick visits guidelines
List of appropriate appointments for virtual visits by department
Script for staff to define and explain to patients how to prepare for virtual visits
Scheduling rules in EHR (length of appointment, appointment notes)
Process for ordering labs or imaging in advance of telehealth visit
Process for integrating interpreter services into virtual visits
  • Resource

    Appointment Type and Visit Duration Guide, Southcentral Foundation

    Scheduling guideline to help determine whether an in-person or telehealth visit should be scheduled from the Southcentral Foundation

    PDF
  • Partner Resource

    Scheduling a Patient for an In-Person vs. Telehealth Appointment, Fenway Health

    Criteria to schedule patient for in-person or telehealth visit from Fenway Health

    PDF
  • Resource

    Video Visit Screening & Script, LACDHS

    A sample script that can be used to explain video visits and screen patients for digital access from the Los Angeles County Department of Health Services

    PDF

Clinical Pathways

The COVID-19 pandemic required health centers and other providers to rapidly pivot to offering telehealth services. Beyond the pandemic, the opportunity for hybrid models of care have emerged. Hybrid models of care offer a clinically appropriate, patient-centered balance of virtual and in-person encounters.

Virtual and hybrid models of care create opportunities for a variety of patient touchpoints over time.

Legend for Diagrams of Clinical Pathways for Virtual Care & Hybrid Models

The following clinical pathways visually demonstrate a year in the life of a patient. Beginning with an in-person visit, the remainder of the year can consist of a combination of touchpoints, including telemedicine visits, phone check-ins, and home-based monitoring.

  • Partner Resource

    Clinical Pathway: Asthma/COPD

    PDF
  • Partner Resource

    Clinical Pathway: Co-Morbidities of Diabetes 
and Hypertension

    PDF
  • Partner Resource

    Clinical Pathway: HIV PreP

    PDF
  • Partner Resource

    Clinical Pathway: CHF

    PDF
  • Partner Resource

    Clinical Pathway: Routine Health Maintenance (RHCM) – Adults

    PDF
  • Partner Resource

    Clinical Pathway: Well Child Exam

    PDF
  • Partner Resource

    Clinical Pathway: Depression, Anxiety or ADHD

    PDF

Integration of Telehealth Beyond Primary Care

With the Maturity Model focus on integrating telehealth throughout the health center (Curve 2) and into specialty care (Curve 3), some key areas for health center focus include:

  • Behavioral health – Specialty behavioral health services, integrated behavioral health, and substance use treatment
  • Oral health – Teledentistry
  • Specialty care within the health center
  • Specialty care via eConsults – Asynchronous provider to provider consultation

Opportunities & Best Practices in Behavioral Health Integration (BHI) via Telehealth

For virtual warm handoffs, leverage technology:

  • EMRs and Zoom have a ‘drop in’ feature for video visits where another provider can pop in
  • Chat tools like Microsoft Teams or even texting can facilitate quick 1:1 or group communication about patient needs
  • Placing patients into ‘waiting rooms’ where the next team member can gather them can prevent patient from getting lost to follow-up

And leverage people:

  • Schedule Integrated Behavioral Health staff to be available during certain hours for virtual warm hand-offs
  • Use a rotating on-call staff person or contracted partner agency

Consider that many of the practices used to develop in-person BHI are also critical for virtual care, such as:

  • Building the health center’s culture around integration, clinical pathways, and staff workflows
  • Establishing support for the behavioral health provider as a member of the care team

Opportunities & Challenges in Teledentistry

Teledentistry provides the opportunity to address trends in dental care such as disparities in access and declining dental visits. It can also create capacity and adaptability for staff shortages. In 2018, the American Dental Association created codes for both synchronous and asynchronous dental visits.

“With the addition of telehealth-connected teams that can reach people who do not traditionally receive regular dental care, we have the opportunity to fundamentally advance the ability to improve the oral health of the population, lower the cost for providing care, and lower the cost and consequences of neglect.”

DentaQuest Foundation White Paper

Opportunities

  • Triaging all emergency visits to determine who needs to be seen for a same day dental visit and making a medical appointment where needed
  • Leveraging the capabilities of dental hygienists for home and self-care
  • Integrating dental care into primary care and school-based health care via telehealth

Challenges

  • Need for patient education in the value of telehealth visits
  • Dental space is not always well designed for telehealth visits

eConsults for Specialty Referrals

The availability of provider to provider, non-urgent consultation is valuable when patients lack timely access to specialty visits. An eConsult is an electronic request, generally from a primary care provider (PCP) to a specialty provider, to review a patient’s chart and make recommendations for treatment and/or referral to in-person specialty visit. There are three main goals for eConsults:

  1. Increase timely access to specialists
  2. Give support to providers on difficult cases
  3. Decrease utilization of unnecessary visits

eConsults Service Workflow Options

Different eConsult vendors offer different types of communications. Some, such as ConferMED, offer asynchronous communication between primary care providers and specialists. Others, such as The MAVEN Project, offer the choice of either asynchronous or synchronous communication between primary care providers and specialists. High level workflows for each type of eConsult:

Asynchronous Communication

combined asynchronous/synchronous communication