Rapid Tech Deployment to Reach Vulnerable Residents: A Q&A with the Washington State Health Care Authority

By Sarah Klein and Martha Hostetter

The Washington State Health Care Authority oversees care for 2.5 million Medicaid beneficiaries and public employees. As the state’s largest health care purchaser, the Authority has set the pace in shifting to telehealth to enable primary care and behavioral health care providers to reach vulnerable residents. It has also helped create a mobile app that frontline staff—working in tents, parking lots, and other places—can use to easily track and triage suspected cases of COVID-19. We spoke with Sue Birch, RN, director of the Health Care Authority, and Christopher Chen, MD, medical director for the Medicaid program.

How are things in Washington this week?

Chen: Yesterday’s reports seemed to indicate that the number of positive cases is stabilizing; I’m hoping that holds true. Hospitals are not overflowing at this time, though they are still preparing for a potential surge and struggling with personal protective equipment supplies. As a state, we were on the earlier side of school closings and other social distancing measures and I’m hoping the benefits of those measures will come to fruition.

What steps has the Health Care Authority taken to ensure Medicaid beneficiaries have access to telehealth services during the pandemic?

Birch: We had a pretty progressive telehealth stance in our state before the pandemic; in Medicaid, we had flexibility for home-based telehealth services, and also supported other services like teledentistry and store-and-forward teledermatology. But now we are doing even more and providers are getting creative. We’re getting calls from hospitals that were having personal protective equipment (PPE) shortages asking for help in setting up webcams in patients’ rooms so they can do virtual visits from nursing stations instead of using PPE every time they had to go in. We’re also expanding e-consults to ensure primary care physicians have access to specialists’ guidance.

What changes has the state made in terms of billing for telehealth services? Do these apply to the commercial population as well?

Chen: We already had parity in terms of in-person and telehealth visits in the Medicaid program. That was extended to commercial insurers by the state legislature recently. In addition, as a lot of other states have done, we’ve opened up codes for phone visits; clarified our policy around virtual physical therapy, occupational therapy, and speech therapy; and  are continuing to watch out for other ways we should expand access to telehealth. On our now twice-weekly calls with the managed care companies, we’ve asked them to make telehealth benefits visible to members. That constant communication with the plans helps.

In the last few weeks, you’ve distributed hundreds of HIPAA-compliant Zoom accounts and laptops to primary care, specialist, and behavioral health providers. What’s been hardest about this shift to virtual?

Birch: It’s a big shift for the small behavioral health providers and substance use disorder treatment facilities, and some of the smaller primary care providers. Many have minimal or no support staff and hadn’t done much in the way of telehealth before. So far, we’ve invited over 1,200 providers to join Zoom, and brought about 700 people through the onboarding process. I liken it to teaching your granny to be comfortable using the iPad—it would be easier if we could do in person, and not during a crisis.

Chen: We’re also offering technical assistance and resources to help providers get up to speed on best practices for telehealth, like how to confirm patient and provider identity,  make sure the service is appropriate for telehealth, and how to use a good virtual bedside manner.

Are you worried about Medicaid beneficiaries who may not have internet access?

Birch: Yes–even for some talking on the phone is a challenge because people may have limited minutes. The big telecom giants waived limits on phone minutes, but a lot of our folks in rural and frontier areas have small telecom providers, and they haven’t been able to get them on the phone to ask for help. As an alternative we’ve been encouraging grocery stores and Walmarts to make their wifi more user-friendly for people who may need to sit in parking lots to access care, for example. What I’ve learned is you need to become really good friends with the IT director and utility commissioner; we’ve had to take a crash course in some of these communication challenges.

We heard you partnered with the electronic health record giant EPIC and OCHIN–a health care innovation nonprofit–to create an app in six days to help providers test and triage patients who present with fevers, coughs, or other COVID-like symptoms.

Chen: Yes. Eighty percent of our hospitals use Epic. The app will help providers easily collect information in non-traditional settings, like in a tent where people are triaging patients or a parking lot where they come for testing. It can be installed on personal devices and used by someone without specialized training; Epic actually tested the interface among their culinary and landscaping staff. Users can go through a checklist to see if someone  should receive a COVID-19 test. After that, they fill in basic demographic information that either creates or links to an existing Epic CareEverywhere record. An Epic-based app then allows capture of vitals, symptoms, and other documentation.

How might this app help with tracking of COVID-19?

Chen: We see this as a link between public health—in terms of its surveillance and tracking functions—and the traditional health care delivery system. We hope it will prove useful once more tests become available. It could for example connect with the Department of Health, or the CDC to help them track cases or identify hot spots in real time.

Birch: The whole notion of how you track and record health encounters for a population that doesn’t typically hit the health care system is critically important, so you can get better epidemiological data over time. The tool is going to be useful for isolation and quarantine tents that are coming, to track health among the homeless and other people who can’t shelter at home. States should be looking at how to enroll these people. They should also ensure payers are using codes that allow for phone rather than video visits in case that’s the only option.