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When Social Determinants of Health Limit Virtual Care Access

Patient having access to virtual care.

Telehealth expands access to care. It’s practically a mantra at this point – the very real ability of remote communication technology to connect underserved populations to top-notch medical care. But what happens when certain populations can’t even get access to virtual care? We know that rural and underserved communities can benefit from strong virtual care programs, but those same communities may have digital connectivity barriers and social determinants of health (SDOH) that stop patients from accessing telemedicine.

Recently the FCC announced grant funding for expanded broadband access specifically for telehealth. This is great news for the many organizations trying to fill care gaps for these underserved patients. This includes a variety of nonprofit and public eligible providers like teaching hospitals and medical schools, community medical centers, local health departments or agencies, not-for-profit hospitals, rural health clinics, and skilled nursing facilities.

That funding can help them augment their in-person offerings with virtual care capabilities. But expanding broadband access isn’t always enough. Successful telehealth programs require three components:

  1. Consistent, reliable broadband service
  2. Patient access to a connective device such as a smartphone, tablet, or computer
  3. Technical literacy, such as knowing how to use devices and interact with electronic health record (EHR) portals and video interfaces

These three components are known as digital health readiness – and when it comes to underserved patients, much of their readiness is limited by social determinants of health.

Solving Virtual Care Access Means Tackling Digital Divide Barriers

Factors like race, gender, income, neighborhood, education, language, and incarceration history have influenced patient health. Now studies show they also correlate to someone’s likelihood of being able to participate in video visits or electronically request appointments or prescription refills. One study found that non-English proficiency was associated with a more than 50% decrease in the use of video or phone visits.

Consider that a patient on a limited income might not possess a smartphone or tablet for virtual visits. Privacy is another challenge for patients living in crowded households or dependent on public libraries for Internet access. When seeking treating for stigmatized conditions such as HIV or mental health issues, they may choose to forego virtual visits altogether rather than risk someone overhearing a discussion with their healthcare providers.

The availability of stable broadband or sufficient data speeds for video interactions is tied to social determinants. Home broadband use varies by age, race, income, and educational level with patients from ethnic minority or lower income groups more likely to rely on their phones for Internet service rather than broadband connectivity in the home.  The US Census Bureau 2016 data showed that 80% of white households had a desktop or laptop computer in 2016, while only 63% of Black and 67% of Hispanic households did.

In other words, any efforts to eliminate health inequities through virtual care must also address barriers to digital health access.

Connecting Patients in Need to Virtual Care

Consider Amy, 47, who has been diagnosed with mental health issues and chronic conditions. Unable to hold down steady employment and living off her disability check, she has not been able to upgrade her old flip phone to a smartphone model. Like many patients in her situation, she is covered by Medicaid and Medicare.

Amy receives care at a rural Federally Qualified Health Center (FQHC), built to provide whole person care for patients like herself. This center provides her primary care, dental services, pharmacy, and labs. Her appointments are coordinated so she can receive multiple services on one day, since she doesn’t own a car and transportation is a continual challenge. However, this FQHC suffers from the shortage of psychiatrists and other behavioral health providers so prevalent in rural areas – which means Amy’s mental health services are spotty at best. It’s been difficult for her to see one consistent provider or build trust with anyone she sees.

The FQHC changes that by launching a new telehealth program. The facility director realizes some of their patients in this underserved community aren’t technologically fluent, so her team hires educators and resource counselors to help patients feel confident using telemedicine. They also connect them to community supports designed to alleviate the negative impacts of SDOHs. Amy can now develop a consistent relationship with a psychiatrist and virtually see specialists for some of her other issues.

Like many underserved patients, Amy couldn’t transcend the barriers holding her back from digital health readiness on her own – but provider-to-provider telehealth helped her access virtual care anyhow.

7 Best Practices for Digital Health Readiness

To implement effective telehealth programs, here are a few recommendations that can bring connected care to those who need it most:

  1. Develop protocols to evaluate a patient’s digital readiness at clinical intake.
  2. Ensure instructive materials and virtual interfaces are accessible to patients with language barriers or hearing or vision impairments.
  3. Apply for broadband funding, as well as funding to offer smartphones, tablets, laptops, and headphones to patients.
  4. Hold community workshops to build technical literacy and answer questions about telehealth.
  5. Train staff to help patients use EHR portals and telemedicine devices.
  6. Create private locations for telehealth visits in clinical environments or at community-based sites.
  7. Track which patients are struggling with access, such as missing virtual appointments or relying on phone calls instead of video calls.

We can’t achieve full health equity until we bring all healthcare advances to all patients. For many patients, closing the bigger gaps in care means first closing smaller digital divisions. It’s easier to equip disadvantaged patients with telehealth tools and training than solve the social determinants of health impacting them – which is why provider-to-provider virtual programs can fast-track patients on the road to better outcomes.

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