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Virtual Care
FEATURES
HOW TELEHEALTH IS BOOSTING CARE ACCESS AMONG NYC’S HOMELESS POPULATION
NYC HEALTH + HOSPITALS HAS DEPLOYED ITS VIRTUAL URGENT CARE SERVICE IN HOMELESS
SHELTERS CITYWIDE, ENABLING THOUSANDS TO ACCESS PHYSICAL AND BEHAVIORAL
HEALTHCARE.
Source: Getty Images
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May 14, 2024 - Though telehealth has the potential to significantly expand
healthcare access, social determinants of health (SDOH) challenges like housing
insecurity can hinder this access, depriving already vulnerable populations of
much-needed healthcare services. However, initiatives supported by healthcare
provider organizations and state agencies can help overcome this barrier,
enabling those facing housing insecurity to access healthcare through
telehealth.
In the fall of 2020, NYC Health + Hospitals and the New York City Department of
Social Services launched an effort to provide homeless shelter residents access
to the health system’s Virtual ExpressCare service. The initiative has grown
steadily since then, with more than 5,000 shelter residents using the Virtual
ExpressCare platform from January 2023 to April 2024.
The Virtual ExpressCare service provides 24-hour access to healthcare for
non-emergency physical, mental, and behavioral health conditions throughout the
year. The service treats conditions such as fever, influenza, upper respiratory
infections, anxiety, depression, and substance use disorders. Convenient and
quick access to these services is especially essential for people facing housing
insecurity.
“I think for any person experiencing homelessness, it is a time of difficulty,”
said Erfan Karim, MPH, executive director of Virtual ExpressCare at NYC Health +
Hospitals, in an interview with mHealthIntelligence. “There's just so much
stress and so many things that go on with not knowing exactly where you are
going to live and how you are going to support your family or yourself through
it.”
Data from the NYC Department of Homeless Services shows that as of May 9, 2024,
86,858 individuals were in NYC homeless shelters, of which 32,744 were children.
This population tends to forgo or delay care, resulting in an overutilization of
emergency departments (EDs), Karim said. Some residents delay care to the point
that they need to call 911 and also end up in EDs following an emergency medical
services response.
NYC Health + Hospitals, the largest municipal health system in the United
States, works closely with other state departments to extend clinical care to
vulnerable New Yorkers through various efforts.
“And we had been thinking…how do we work with these [homeless] patients more?
How do we get services to the shelters and bring it to the forefront, to the
patient, so that they don't have to travel, or they don't call 911,” Karim said.
The idea of introducing Virtual ExpressCare within homeless shelters was born
out of these conversations. The shelters use telephones, tablets, and computers
to connect residents with NYC Health + Hospitals Virtual ExpressCare physicians.
The technology is provided by the Department of Social Services and other
agencies, which are responsible for all technical needs, including ensuring WiFi
access and equipment cleaning. The health system is responsible for all
healthcare needs, including enrolling uninsured patients in health plans and
referring them to other social services as needed.
“From an implementation perspective, it's making sure all those things work
together,” Karim said.
A critical aspect of the deployment process was getting shelter staff onboard.
NYC Health + Hospitals worked with the Department of Social Services to create a
team to conduct outreach with shelter leadership, train staff within the shelter
system, and integrate Virtual ExpressCare into existing agency initiatives.
Karim noted that the health system also uses feedback from shelter staff to
enhance new deployments.
“It's going to be different in each region, in each location, and [we] bring
some information and learning from one location to the next and to see what
works and what doesn't work,” he said.
Shelter staff are also encouraged to use the service themselves. Working in a
homeless shelter is a demanding job, and so the health system wanted the staff
to use the service to address any stress or anxiety they might be experiencing.
“We felt that once they utilized the service, they would then promote the
service to others,” Karim said. “Our [net] promoter score, which is something we
track, is very high. It's like a plus 80. So, whenever somebody uses a service,
there's usually an ‘aha’ moment for them.”
Not only that, but staff may have preconceived notions about telehealth from
ill-prepared rollouts during the pandemic that must be mitigated.
“People have that scar tissue, in some ways, of, ‘Oh, I tried it last time, and
it didn't work well, or it was complicated,’ so we need to overcome that as
well,” Karim said. “So that's education, that's having these visits with the
shelters and working with those staff members to understand that — no, it really
is that easy.”
In addition to working with shelter staff to deploy the Virtual ExpressCare
service, NYC Health + Hospitals worked to break down patient-facing barriers.
One strategy was to enable telephone-based access to the service.
“That was the first thing we did to ensure that everyone had equitable access if
they were not comfortable with technology and decrease that barrier,” Karim
said.
Further, patients who are comfortable with computers and tablets are able to
connect with a healthcare provider with the touch of a button. Once connected
with the healthcare provider, they are asked to fill in their name, date of
birth, and other pertinent information. Patients are always connected to a human
being, and “that was intentional on our front to make it patient-centric,” Karim
said.
To engage immigrants and people with limited English proficiency (LEP)
experiencing homelessness, the Virtual ExpressCare service provides 200-plus
language options.
The service was initially launched in 25 shelters and is now available to
residents of the city's 600-plus shelters. Of the 5,000 individuals in shelters
who used Virtual ExpressCare between January 2023 and April 2024, 70 percent
were Black and Latino. Additionally, nearly half were uninsured, and 5 percent
were covered through NYC Care, a program that guarantees low-cost and no-cost
services to New Yorkers who do not qualify for or cannot afford health
insurance.
“From a sheer numbers perspective, we see a positive trend of individuals
utilizing it,” Karim said. “Our satisfaction numbers indicate that they
overwhelmingly like the support and the clinical care that they're receiving
from us.”
Shelter residents can use the service as much as they like. If Virtual
ExpressCare clinicians identify long-term needs, they work with the patient to
connect them with community-based organizations, he added. The health system has
partnerships with various organizations in NYC that can help with food and
income insecurity, among other SDOH needs.
Eventually, the health system will also measure whether access to the service
affects connectivity to care and ED use rates among NYC’s homeless population.
Looking back at the process of developing Virtual ExpressCare and embedding it
into homeless shelters, Karim highlighted the importance of building services
based on what the patients want and need. While technology can be a critical
facilitator in meeting patient needs, health systems must be wary of
overcomplicating care access and delivery.
Instead, Karim believes they should focus on making patient-provider
interactions the heart of the technology implementation and keeping the
processes around that central interaction as simple as possible.
This philosophy guided NYC Health + Hospitals’ implementation of Virtual
ExpressCare in homeless shelters. And though it is a tall order, with hundreds
of thousands of people experiencing housing insecurity in the city, NYC Health +
Hospitals is making vital inroads.
“It's the mindset [that] maybe we'll never reach 100 percent, but we're going to
strive towards it, and try to get better each day, and try to reach one more
person,” Karim said.
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