By Nina Sparling | KQED
In the midst of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services have expanded access to telemedicine appointments for their beneficiaries. Thanks to a new waiver, more elderly and low-income people can now receive care from practitioners virtually — and doctors and patients across California are taking advantage of this new leeway.
Gabriela Hernandez, who is 38 weeks pregnant, is one of those patients. Normally, she would go to LifeLong Medical Care in Berkeley every few weeks for a check-up with Kim Cardoso, her certified nurse-midwife. But for the past few weeks, their appointments have been over the phone.
LifeLong is one of more than 1,000 community health centers in California. Many of these centers have dramatically cut back services under the shelter-in-place order to slow the spread of the novel coronavirus.
LifeLong closed all but five of its 14 clinics for in-person visits. Providers still see patients in person for the most urgent cases, but the majority are now virtual.
Community health centers like LifeLong depend on partial reimbursements from the Medi-Cal program to provide low-cost or free services. Typically, doctors and nurses have to see their patients in person for the clinic to qualify for those funds — but the recent waiver changed that. Now providers like LifeLong get to care for their patients over the phone, and get reimbursed.
Patients and doctors alike are adapting quickly. Hernandez learned how to take her own blood pressure using a wrist cuff she bought at CVS. She reports the numbers back to Cardoso, who records them into a digital chart.
“I think it’s a little high,” Hernandez told Cardoso. “It’s at 150 over 106.”
“Oh, I don’t like that,” Cardoso said. She asked Hernandez how she’s been eating and if she’s been exercising. Hernandez said she’s been walking around the backyard every day to stay active.
She told Cardoso she dropped off samples she took at a nearby lab, which is the kind of thing a medical assistant would normally do at a clinic.
The learning curve has been steep for everyone at LifeLong, said Chief Medical Officer Michael Stacey.
The ability to provide telemedicine services has been an essential lifeline for clinics like LifeLong, said Carmela Castellano-Garcia, president and CEO of the California Primary Care Association, a group that lobbies on behalf of community health centers.
“We’ve completely shifted our model of care,” Stacey said.
When Bay Area counties began issuing shelter-in-place orders in mid-March, LifeLong had to provide secure digital access to medical charts for many of its 61,000 patients in a matter of days. The clinic had to make sure its doctors and nurses had access to appropriate technology to spend their days sitting in front of a computer, instead of going from exam room to exam room.
The rapid change has put LifeLong and other facilities under financial pressure. The clinic has seen about a 35% reduction in visits, even with the switch to telemedicine. The implications of that are troubling, according to LifeLong Deputy Director Lucinda Bazile.
So far, LifeLong has reduced hours or furloughed 100 of its employees.
“It’s really stressful,” she said. “This is the work that we all chose and we want to make sure that this population gets the care that we need.”
The clinic where Cardoso works was one of the sites to transition entirely to telemedicine. She has been adapting to new ways to provide that care, including finding the corners of her house with the best cellphone reception and explaining to patients that they might hear her dogs, chickens or kids in the background.
But she said that telemedicine isn’t a long-term or complete solution, particularly when it comes to the violence and depression screenings that are part of the routine care she provides. She can’t be certain that her patients are alone and able to speak freely when she asks them about interpersonal violence.
“Can they answer truthfully when I ask them if they’re safe?” Cardoso said.
Cardoso relies on visual cues and body language to read patients’ responses to sensitive questions about their mental health, something that’s more difficult to do over the phone.
Patients like Hernandez are relieved to have that support from a distance, even if it means a different kind of care.
“I really like it,” she said. “But I do miss going to the doctor and feeling the baby’s heartbeat.”
How to Get the Most Out of Your Virtual Visit
Here are some tips to help you know when to call your doctor and how to get the most out of your telemedicine appointment:
- If you don’t have a primary care provider already, now is a good time to find one. Community health clinics like LifeLong Medical Care are still doing patient intake over the phone.
- Prepare for your appointment. Make a list of what you want to talk about during the phone call or video visit to get the most out of it and help your doctors understand your needs. If you have a thermometer, scale or home blood pressure monitor, have it nearby in case your doctor asks you to use it.
- Track your symptoms as they occur — write them down in your phone or on a sheet of paper. Pay attention to when the symptoms occur, when they get worse and if anything seems to trigger them.
- Take pictures. If your symptoms include rashes, bites or moles, your doctor wants to see that. It can be helpful to circle the affected area with a pen.
- Emergencies are still emergencies, so if you’re experiencing chest pain, weakness in one side of the face or body or a sudden thunder-clap headache, call 911 to speak with a professional who can evaluate you over the phone. Be prepared to describe your symptoms in a few sentences.