Peer Reviewed

Review Article

Clinician-Led Telehealth Follow-Up Communications: A Potential Solution for Primary Care

AUTHORS:
Meagan Soltwisch, DNP, APRN, FNP-C • Ethany Howden, DNP, APRN, FNP-C

AFFILIATION:
Louise Herrington School of Nursing, Baylor University

CITATION:
Soltwisch M, Howden E. Clinician-led telehealth follow-up communications: a potential solution for primary care. Consultant. Published online May 25, 2022. doi:10.25270/con.2022.04.00001

Received May 21, 2021. Accepted June 23, 2021.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Meagan Soltwisch, DNP, APRN, FNP-C, Baylor University, Louise Herrington School of Nursing, 333 North Washington Street, Dallas, TX, 75246 (Meagan_Soltwisch@baylor.edu)


 

Abstract

The rapid acceleration of the adoption of telehealth services during the COVID-19 pandemic has increased the number of needed follow-up communications to discuss diagnostic results, to assess or reassess patients’ symptoms, and to refill prescriptions. These communications are frequently delegated to nonclinical office staff in the primary care setting, which can be challenging for patients with low health literacy or digital literacy. Current evidence suggests that using health care providers for follow-up visits is an opportunity to improve patient experience while improving the quality of care provided. However, integrating these telehealth services can be disruptive to a clinician’s schedule. This article provides an overview of a clinical protocol that designates a single health care provider in the clinic for all telehealth follow-up communications as a possible solution to this work-flow challenge.

Introduction

The rapid acceleration of the adoption of telehealth services during the COVID-19 pandemic has led to a renewed focus on best practices when implementing telehealth services, including how to best follow up with patients. The term “telehealth” refers to a wide array of services, which can be synchronous or asynchronous in nature. Synchronous delivery modalities are conducted in digital settings such as real-time audio-visual interfaces, telephone calls, and remote patient monitoring where the patient can interact with the clinician.1 Asynchronous modalities, such as via email, can be conducted at the clinician’s leisure, before or after a synchronous visit.1 One possible use of synchronous audio-visual interfaces and telephone communication is health care provider–led follow-up appointments. Follow-up services in the primary care setting traditionally have encompassed both in-person follow-up with clinicians and telephone follow-up with nonclinical staff communicating laboratory and/or imaging results. Clinician-led telehealth follow-up appointments combine both services to provide an alternative for in-person follow-up visits and follow-up telephone calls from nonclinician staff.2 This change to practice can potentially improve patient satisfaction and overall health outcomes.

Patient Satisfaction

Transitioning from face-to-face follow-up appointments and nonclinical office personnel delivering telephone follow-up to a clinician-led follow-up model—where the health care provider delivers all clinical follow-up services via telehealth—can raise concerns about patient satisfaction. However, multiple studies across practice settings have demonstrated that clinician-led telehealth follow-up appointments have high patient satisfaction ratings greater than or equal to that of in-person visits.3,4 This preference for clinician-led telehealth is not limited to replacing in-person visits. In fact, a recent study found that patients prefer receiving results from the clinician who ordered the tests.5 The same study revealed that most practices could improve their communication services in several areas, despite being a core activity in primary care offices.5 Patients reported frustration from the lack of communication with providers and nonclinical staff. This produces the need for improved processes.

Although some evidence shows that moving to a clinician-led telehealth follow-up model can improve patient satisfaction, it may be challenging to schedule appointments with the primary clinician in a timely manner. The proposed solution to this workflow challenge is to have the patient follow up with a designated alternate clinician in the practice. The World Health Organization acknowledges that there are multiple considerations for implementing new digital health interventions within an organization.6 One aspect of guidance for implementing digital health interventions is considering provider experience and knowledge of digital health delivery.6 This includes the needs of providers who are less knowledgeable of the new technologies. The proposed model of using a designated provider who is experienced in delivering telehealth in a clinic is a novel approach to effective staff utilization that is consistent with this guidance. This model allows the clinic to use a provider with experiential and educational qualifications in providing telehealth services while improving workflow within the clinic. This provides improvement of existing structures to progress access to laboratory appointments, improved management of patient care and advocacy, and a distinct protocol for communication.5

Additionally, providing patient education via the provider in a predictable flow allows for questions to be answered and prescriptions sent to pharmacies.

 

Despite these potential advantages, designating a single clinician for telehealth follow-up communications may result in a lack of continuity of care, because an adjunctive clinician may be less familiar with the patient’s situation. However, the evidence provides objective data that the patient’s perspective, understanding, and perception of their imaging, disease process, and overall health are improved with clinician-provided follow-up communication; the evidence also suggests that patients who receive results via telephone are most concerned with privacy, responsiveness and interactive feedback, and timeliness.5,6 A well-planned protocol can address these needs for consistency and timely individualized care while improving patient health outcomes.

Improving Health Outcomes

A key goal for primary care providers is to empower patients in self-care through addressing client self-efficacy and health literacy. Self-efficacy is defined as one’s belief in the ability to succeed in specific situations and accomplish tasks.7 Self-efficacy serves a defining role in how one approaches challenges in their health status and sets goals for achieving optimal health. Evidence has shown increased self-efficacy in chronic conditions including diabetes mellitus, heart disease and arthritis as a result of lifestyle interventions.7 In particular, telehealth has been shown to improve patient self-efficacy in chronic conditions with improvement in health behaviors and an increase in health status.8 This may be due to improved access to care via telehealth for populations with barriers to traditional health care, such as transportation, scheduling, and mobility limitations.9

While telehealth services may improve health self-efficacy through improved access to care, health literacy and digital literacy are threats to this access and, therefore, should be a consideration when implementing telehealth services. The term “health literacy” is defined as “the capacity to seek, understand, and act on health information.”10 There is an assumption that low health literacy translates to poor communication between patient and clinician and, therefore, incomplete health care use.11 The challenge in addressing health literacy is to effectively provide patient education during the appointment, whether the appointment is in person or via telehealth. However, the appointment occurring in the digital environment of a telehealth visit presents additional challenges to providing patient education and, thereby, addressing health literacy.

Digital literacy is a unique barrier to health literacy during telehealth visits. Digital literacy is one’s ability to thrive in a digital technology setting.12 This includes access to technology as well as using technology that is vital in participating in a telehealth appointment, such as a mobile device or computer.13 Although racial and ethnic minorities are disproportionally affected by digital and health literacy, there is evidence of these marginalized populations having a positive attitude toward the adoption of telehealth services.9,13 Therefore, the increased access that telehealth services provide can address health literacy, as long as barriers related to digital literacy are addressed as part of the implementation of telehealth services.

Using Best Practices to Inform a Telehealth Protocol

The protocol presented was developed by the authors of this article to address the needs of a local clinic. This protocol proposes designating a single clinician in the practice to provide all telehealth follow-up appointments as part of a comprehensive telehealth implementation initiative. These telehealth appointments can be used to provide follow-up services for both in-person and telehealth appointments and can be delivered via synchronous audio-visual platforms when the patient has the necessary technology available or via telephone when phone communication is needed. This protocol was developed as a novel approach to implementing telehealth services in a primary care clinic to seamlessly integrate with existing provider workflows and use a clinician experienced in telehealth for the delivery of telehealth.

The protocol was also developed to align with telehealth best practices outlined by the US Health and Human Services (HHS) telehealth website.14 The proposed types of follow-up appointments are based on services that are already provided in the clinic by nonclinician staff, such as telephone follow-up about patient status after an acute visit, calling a client to report diagnostic results, and prescription refills (per existing clinic protocol) (Figure). These follow-up services can be integrated into the designated clinician’s telehealth service workload.

 

Figure. Protocol for Clinician-Delivered Telehealth Follow-up

 

Many telehealth services, including asynchronous services, are reimbursable by Medicare, Medicaid and/or private health insurance during the COVID-19 pandemic, but the clinician should be aware of the billing requirements for telehealth services.15,16 The technology requirements noted in the figure are intended to be nonpublic-facing applications, compliant with the Health Insurance Portability and Accountability Act (HIPAA) and in alignment with vendor recommendations outlined by HHS.17 The HHS telehealth website is a wonderful resource for telehealth implementation information. However, it is also important to note that laws related to providing telehealth services can vary from state to state. Therefore, clinicians should also be familiar with their state’s telehealth laws when developing clinic protocols.

Summary

When developing a protocol for telehealth implementation, an important consideration is the purpose of the telehealth services and how it will impact the practice. The discussed protocol was designed to add telehealth follow-up services to existing audio-visual synchronous telehealth appointment offerings. While adding these services allows the practice to offer telehealth throughout the continuum of care, it represents a change in the clinic workflow. The American Medical Association recommends considering workflow when implementing telehealth services in regard to clinician, staff, and patient experience.18 This protocol is intended to be a novel solution for practices identifying ways to implement varying types of telehealth and the resulting workflow challenges. However, workflow consideration is only one aspect of implementing telehealth services in practice and should be considered as one part of a broader telehealth implementation.

References

1. Best practice guides. US Department of Health and Human Services. Accessed July 10, 2021. https://telehealth.hhs.gov/providers/best-practice-guides/

2. Kyanko K, Hanley K, Zabar S, Joseph J, Bateman W, Schoenthaler A. Introducing primary care telephone visits: an urban safety-net community clinic experience. J Prim Care Community Health. 2018;9:2150132718792154. https://doi.org/10.1177/2150132718792154

3. Donelan K, Barreto EA, Sossong S, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care. 2019;25(1):40-44. https://www.ajmc.com/view/patient-and-clinician-experiences-with-telehealth-for-patient-followup-care

4. Ramaswamy A, Yu M, Drangsholt S, et al. Patient satisfaction with telemedicine during the COVID-19 pandemic: retrospective cohort study. J Med Internet Res. 2020;22(9):e20786. https://doi.org/10.2196/20786

5. Litchfield IJ, Bentham LM, Lilford RJ, McManus RJ, Greenfield SM. Patient perspectives on test result communication in primary care: a qualitative study. Br J Gen Pract. 2015;65(632):e133-e140. https://doi.org/10.3399/bjgp15x683929

6. WHO guideline Recommendations on Digital Interventions for Health System Strengthening. Geneva: World Health Organization; 2019. https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf?ua=1

7. Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017;30(1):112-113. https://doi.org/10.1080/08998280.2017.11929552

8. Jaglal SB, Haroun VA, Salbach NM, et al. Increasing access to chronic disease self-management programs in rural and remote communities using telehealth. Telemed J E Health. 2013;19(6):467-473. https://doi.org/10.1089/tmj.2012.0197

9. Coleman C. Health literacy and clear communication best practices for telemedicine. Health Lit Res Pract. 2020;4(4):e224-e229. https://doi.org/10.3928/24748307-20200924-01

10. Nutbeam D. The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072-2078. https://doi.org/10.1016/j.socscimed.2008.09.050

11. Wills J. Health literacy: new packaging for health education or radical movement? Int J Public Health. 2009;54(1):3-4. https://doi.org/10.1007/s00038-008-8141-7

12. Patient-centered care. In: Gogia S, ed. Fundamentals of Telemedicine and Telehealth. Academic Press; 2019.

13. Ghaddar S, Vatcheva KP, Alvarado SG, Mykyta L. Understanding the intention to use telehealth services in underserved hispanic border communities: cross-sectional study. J Med Internet Res. 2020;22(9):e21012. https://doi.org/10.2196/21012

14. Getting started with telehealth. US Department of Health and Human Services. Updated May 19, 2021. Accessed March 2, 2022. https://telehealth.hhs.gov/providers/getting-started/

15. Medicaid and Medicare billing for asynchronous telehealth. US Department of Health and Human Services. Updated October 8, 2021. Accessed March 2, 2022. https://telehealth.hhs.gov/providers/billing-and-reimbursement/medicaid-and-medicare-billing-for-asynchronous-telehealth/

16. Billing for telehealth during COVID-19. US Department of Health and Human Services. Accessed March 2, 2022. https://telehealth.hhs.gov/providers/billing-and-reimbursement/

17. Understanding telehealth technology options. US Department of Health and Human Services. Updated May 19, 2021. Accessed March 2, 2022. https://telehealth.hhs.gov/providers/getting-started/#understanding-telehealth-technology-options

18. Telehealth Implementation Playbook: Digital Health Implementation Playbook Series. American Medical Association. 2022. https://www.ama-assn.org/system/files/ama-telehealth-playbook.pdf