During the height of COVID-19, Cleveland Clinic South Pointe Hospital in suburban Cleveland expressed a need for endocrinology services. At that time, adding an endocrinologist on site was not feasible, so a virtually enabled care system was developed. This technology connected specialists from the main campus and regional hospitals to the South Pointe patients who needed them.
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Building bridges to healthcare access is a passion for Shirisha Avadhanula, MD, a physician in Cleveland Clinic’s Endocrinology, Diabetes and Metabolism Department. Dr. Avadhanula performs a large number of the outpatient telehealth visits for Endocrinology. She also serves as medical director for the health system’s inpatient virtual health program, overseeing development of programs across medical disciplines.
The work has shown her that inpatient and outpatient care are really two sides of the same coin, she says. Inpatient care can be an opportunity to introduce technology that will make an ongoing difference in patients’ lives.
“We’ve really been able to leverage inpatient programs to try to address access issues,” says Dr. Avadhanula. “One of the reasons I became interested in telehealth was that I saw that there was a potential opportunity to address certain health-equity issues.”
Healthcare inequities among historically disadvantaged groups show up as financial and insurance barriers, cultural biases, transportation challenges and more. There is no one solution for everything, but a smart phone and inpatient education can connect people who otherwise wouldn’t have had access to follow-up appointments, prescription refills and other care.
The inpatient telehealth program that had begun in September of 2021 uses the time that patients are already spending in the hospital to introduce virtual-visit technology and set up out-patient appointments. A social worker can work with qualifying patients to educate them about using virtual visits and obtain a free government-issues smart phone if they need it for appointments, managing diabetes or other health issues they may have.
Cleveland Clinic Mentor Hospital, now under construction and expected to open later in 2023, will be optimized for inpatient telehealth, says Dr. Avadhanula. Equipment attached to the patient’s television will allow for access to sub-specialists at the main campus or other regional hospitals within the system.
Remote inpatient visits has benefits for the patient, she adds.
“A virtual visit can be less disruptive for a patient, it can reduce physical traffic in and out of rooms, and it can be very convenient for the patient. A consultant can beam into a patient’s TV and talk to the patient when it’s convenient for them, even allowing family members to listen remotely or having other specialists join the call for improved multi-disciplinary care,” says Dr. Avadhanula. “Having an inpatient virtual platform allows us to explore new models in health care that optimize both that patient and provider experience.”
Using inpatient time and resources to set up the patient for follow-up provides health system access many have not had before. This is especially helpful in the management of chronic health conditions such as diabetes and its complications, which disproportionately affect low income populations, older adults and communities of color.
“Now they have a point of contact,” she says. “This programs allow for ease of entry into the medical system, a critical factor when talking about health care access. This will allow patients to have good, stable outpatient follow-up, which in turn means they are less likely to end up in the emergency room if they run out of medications. Follow-up care for chronic conditions is essential, and having consistent follow-up can reduce the likelihood of a patient being readmitted.”
Hospital readmission rates decline when patients have stable outpatient follow-up.
“By improving equitable access and allowing the patient to leave the hospital with an appointment already made — virtually or in person, it doesn’t matter — we support them in managing their health.”
Inpatient telehealth education can prove especially important for patients who are inexperienced with digital technology.
“It can be hard for some patients to even understand how to get into a virtual visit,” she says. “So we take the opportunity while they’re an inpatient to have a social worker walk them through how to use the digital platform. For some of our patients, this will be the first time they ever see a provider virtually. We can prepare them for an outpatient virtual visit.”
Continuity of care
Once they are discharged, virtual medical visits can be a game changer — especially for patients who can’t easily miss work or who experience barriers to transportation.
“I’ve had many patients who are not able to take time off work for medical appointments – and it’s an unrealistic expectation for them to take a half day off to see a doctor for 20 minutes,” says Dr. Avadhanula. “My patients will often do their doctor’s visits during a break at work.”
Within the Endocrinology Department, the inpatient program so far has enabled Endocrinology care to hundreds of patients. Of the patients we have seen in the hospital and referred to our outpatient program with our social worker, approximately 33% have attended the appointments. “Thirty-three percent sounds like very little, but this is a subset of patients we would never have reached before,” says Dr. Avadhanula. “So we are comparing that 33% to zero.”
The impact on endocrine and metabolic disease
Lack of access to healthcare is important across all medical disciplines, but it’s especially important for those with chronic conditions. “It affects our specialty quite a bit,” says Dr. Avadhanula. “Those who lack access are more likely to live in rural areas or low-income urban centers, and they’re more likely to suffer the consequences of chronic medical conditions that can lead to heart disease. Diabetes and obesity are major contributors to heart disease. So health inequities disproportionately affect many of the patients who could be helped by access to our care.”
Reasons for optimism
Dr. Avadhanula emphasizes that telehealth is only one tool among many that are needed to address inequities in health care, but she sees reasons for optimism.
“In the last couple of years, we have all become more exposed to shortcomings in healthcare,” she says. “We are making efforts to include critical topics like equitable access, equitable distribution of care, and cultural competencies in our medical school, residency and fellowship curriculums. We’ve been teaching our trainees to be more complete in the care that we deliver.”
Having a background of access and equity in all programs changes the scope, she adds.
“It changes the lens,” says Dr. Avadhanula. “Rather than developing programs for a community, you’re developing programs with a community.