Adopting TelehealthOur Experience & Lessons Learned

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About One Community Health We’re a nonprofit Federally Qualified Health Center serving ~17,000 patients in the Columbia Gorge (Hood River, Wasco, Skamania and Klickitat) Our Mission is to advance health and social justice for all members of our community We started as a migrant health center in 1986 We employ ~200 staff and offer integrated care that includes medical, dental, behavioral, and preventative health services We have a special focus on at risk and vulnerable populations

Opened in 1986

1988: Began First Health Promotion Program

1991: New Location

1995: Dental Department Added

2004: Expand to The Dalles

2013: La Clinica becomes OCH & Expands

2015: Opens First SBHC in Our Region

2016: Integrated Behavioral Health

2020: Future of OCH

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Telehealth Timeline

February 28th – First positive COVID-19 case in Oregon (0% Virtual Visits) March 3rd – OCHIN activates virtual visit technology for OCH

March 5th – OCH project head and lead physician live demo virtual visits to providers

March 6th – OCH announces upcoming Virtual Visits to all staff

March 12th – OCH team creates cross-functional launch checklist, company-wide training and guides published on Intranet

March 13th – Virtual Visits micro-site created and published on OCH public web site

March 14th – Email sent to all patients announcing Virtual Visits are now available (out-of-pocket costs waived for 30 days)

March 16th – OCH issues press release announcing shift to Virtual Visits and shares with media

March 17th – OCH and OCHIN send bulk MyChart activation to all patients sent using WELL text platform to accelerate adoption

March 18th – All COVID related calls shifted from nurse triage to Virtual Visits with providers

March 19th – Governor issues executive order prohibiting in-person elective and non-urgent procedures to preserve PPE

March 24th – Patient wide communication announcing that vast majority of visits would be moved to virtual visits

March 26th –70% Virtual Visits (28% video) September 30th – 23% Virtual Visits (49% video)

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Patients & Providers Prefer Video

Source: Crossroads Group, National COVID-19 Telehealth Evaluation Patient Survey Results, August 2020

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Driving Patient Portal/App Adoption

Tactics• All staff focus on onboarding patients• Shared learnings/best practices• End-to-end training/ troubleshooting guides• Dedicated enrollment specialists• Interns hire to assist • Cross-channel campaigns• Bulk activation via text to all patients with mobile #• Filtered analytics to discover disparities

Provides HIPAA-secure launching pad for Virtual Visits Exposes patients to benefits of digital engagement

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Focus on Video

Tactics• Customized text reminders • Pre-visit patient “tech-check”• Alternatives for tech issues• Instant messaging for warm hand-offs• Outbound call team prioritizing

vulnerable/at-risk patients• Mandate virtual for certain visit types• Detailed process guides/FAQs/

knowledge repository• Ensure good ergonomics and supporting

technology (e.g., wireless earbuds for providers enabling efficient charting)

• Share learnings/tactics of successful staff

Enables continuity of care that would otherwise be deferred due to government orders, patient and staff safety considerations Provides critical patient support to help cope with stress, anxiety, other behavioral/mental health challenges

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Video Visit Tips from Christina

• Review the schedule every morning, ensure patients are activated for MyChart (else contact them)• Call patients 20 minutes before their appointment to help with any technical difficulties • Join the Zoom to confirm video is fully working (share your screen to show them how to do things) • Let patients know what to do if the connection drops• Tell the patient how long the doctor will be before putting them into the virtual waiting room• Once the provider arrives, confirm they can see each other then exit the meeting• If the patient prefers a phone-only visit let them know their provider prefers to see them on video• If the patient has technical challenges, see if they are with anyone who can help. Many times a tech

savvy relative can be very helpful.

“I let them know we have switched to virtual visits and their provider would like to see them on Zoom. Almost 98% of the time they do it because their provider wants to see them on video. Even if they are not fans of the idea. when they see the provider their face lights up with a smile so big! It is

just a connection that is so different compared to just speaking on the phone with someone.”

Other Medical Assistants

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Use Case - Comprehensive Geriatric Home Visit 76-year-old recovering from stroke Son able to video her performing activities of daily living, provider able to assess progress Provider able to assess safety setup of home Video simplified medication review, organization of her medications and streamlined refills Patient felt less isolated and supported knowing she could see her doctor, family reassured

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Use Case – “Tele-to-Tent” Enables rapid virtual screening of patients for symptoms and severity while preserving personal protective equipment (PPE) Allows provider to order COVID testing and any additional physical checks (e.g., listening to lungs) - “Tele-to-Tent” Facilitates follow up care with patients recovering at home Allows providers not able to see potential COVID-19 in-person to actively support patients

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Use Case – Behavioral Health Patients struggling with social isolation, kids at home while juggling working from home, COVID-related anxiety, difficulty sleeping Warm hand-offs from primary care to behavioral health consultant (BHC) using instant messaging (e.g., Epic chat) Video creates connection with patient, BHC able to read body language, increased empathy Use of technology carries over for patient to connect with others (e.g., Zooming with friends) to reduce social isolation

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Telehealth Coding/Billing Tips from Brett

During COVID-19 PHE, RHCs and FQHCs can furnish any telehealth service that is approved as a Medicare telehealth service under the Physician Fee Schedule (PFS), including CPT codes 99441, 99442, and 99443 (audio-only telephone evaluation and management (E/M) services). RHCs and FQHCs can use HCPCS code G2025 if at least 5 minutes of telephone E/M service is performed by a qualified health care professional to an established patient, parent, or guardian. These services cannot be billed if they originate from a related E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment. They must also be patient initiated.

Insurer Place of Service Modifiers Notes

OR Health Plan -DMAP

02 – Telehealth Services (physical and behavioral health)

• CR – Catastrophe/Disaster – for Covid-19 assessment, prevention, identification, diagnosis or treatment

• GT - Interactive audio and video telecommunications• 95 – Synchronous telemedicine for behavioral health via

audio and video (no modifier for phone-only)

• In person, Virtual, and phone visits are all reimbursed the same• Phone-only codes 99441-99443 & 98966-98968 are wrap eligible• 99441-99443 - for providers who can provide E&M services• 98966-98968 – for other providers, including non-physician

behavioral health providers

Regence BCBS 11 – Office Visit • 95 – all claims

Aetna 02 – Telemedicine

Cigna 11 – Office Visit • 95 – for all non-face-to-face E&M• CS – if Covid-19 related and patient cost sharing waived

• Only use Standard Face-to-Face E&M codes (99212-99215, 99201-99205) DO NOT USE 99441-99443

Moda 02 – Telemedicine • CR – on all COVID related visits

Providence 02 – Telemedicine

United Healthcare 11 – Office Visit • 95 – for all non-face-to-face E&M • Only use Standard Face to Face E&M codes (99212-99215, 99201-99205 – DO NOT USE 99441-99443

Medicare (FQHC) 02 – Telemedicine • 95 – optional• CS – if Covid-19 related and patient cost sharing waived

• HCPC Code G2025 used to bill for Telehealth services

Uninsured • The federal government is reimbursing health care providers for testing and treating uninsured individuals for COVID-19 — including related services provided via telehealth, generally at Medicare rates. https://coviduninsuredclaim.linkhealth.com/ for more information.

• Providers will verify and attest that the patient does not have individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse them for COVID-19 testing, treatment for COVID-19, and/or COVID-19 vaccine administration for that patient

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Ongoing Benefits of Virtual Visits

Key Benefits

Eliminates transportation barriers/costs

Provides physician a window into home environment

Patient time/money savings and convenience

Opportunity for new group engagement models/programs

Reduces no shows/waste

Allows medically vulnerable providers to continue to practice

Reduces risk of health care-associated infections (HCAIs)

Conserves PPE and other consumable resources

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Challenges & Mitigation

Challenge MitigationPatient tech literacy, multiple app installs (e.g., MyChart, Zoom), difficulty initiating online appointment

Clear patient instructions/install guidesDedicated team for tech escalationLeverage tech-savvy family membersPre-visit tech check/digital rooming

Timing – getting connection established can cut into patient care time

Appointment text reminders to prepare technology Pre-visit tech check/digital roomingAlternative connection options

Low Bandwidth (e.g., rural patients) Alternative connection optionsPatient assistance for high speed Internet

Environment Quiet spaceErgonomics

Interstate licensing State and federal policies/waiversCoding/Billing (state, federal, payor inconsistency) Quick guides/sheets

QUESTIONS

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