The University of Nebraska Medical Center/Nebraska Medicine (UNMC/NM) Specialty Care Center (SCC) is the largest provider of comprehensive HIV care—including primary and HIV-focused medical services as well as multiple support services—in Nebraska. In March 2020, at the onset of the COVID-19 pandemic, the clinic integrated telehealth into its care delivery model to continue serving patients beyond the clinic structure, and developed algorithms that allowed any team member to quickly identify a patient's eligibility for a telehealth visit. The algorithms include the date of the most recent office visit, stability of HIV disease, most recent viral load and CD4 count, and antiretroviral therapy (ART) refill histories as a proxy for medication adherence. Overall, viral suppression rates remained high for all patients regardless of visit type, indicating that telehealth is a successful alternative to in-person visits for providing HIV care.
During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV, with many clinics transitioning rapidly to alternative methods such as telehealth.1 In March 2020, SCC recognized the need to adjust its clinic operations to promote patient and staff safety during the pandemic. This adjustment, limiting in-person interactions, conflicted with the clinic’s usual approach to promoting retention in care and viral suppression, which relied on patients making frequent visits to the clinic not only for clinical care but also for ongoing medication adherence and case management support. Prior to March 2020, SCC did not offer telehealth services.
UNMC/NM’s electronic health record (EHR) is equipped with a secure patient communication portal. At the onset of the pandemic, UNMC/NM built out additional templates in the EHR to support telehealth scheduling, documentation of HIV care, and billing for telehealth visits.
To identify patients eligible for telehealth visits versus in-person visits, clinic champions developed simple algorithms for new and established patients. These algorithms incorporated factors—such as the date of the most recent office visit, most recent viral load and CD4 count, and ART refill histories as a proxy for medication adherence—to select patients with stable HIV to receive telehealth. The algorithms also provided direction for referrals to case management services, vaccinations, and laboratory visits.
Between April 1, and October 30, 2020, 1,167 total HIV care visits with a SCC provider occurred for established patients: 412 (35%) were telehealth visits and 755 (65%) were in-person visits. Based on a retrospective chart review, SCC found that while viral suppression was high in both groups at the end of October 2020, viral suppression rates were higher for patients with telehealth visits, indicating that telehealth is a successful option for HIV care, especially for patients determined to have historically stable HIV.
* statistically significant
Source: Fadul N, Regan N, Kaddoura L, Swindells S. A Midwestern academic HIV clinic operation during the COVID-19 pandemic: Implementation strategy and preliminary outcomes. J Int Assoc Provid AIDS Care. 2021;20:23259582211041423.
Telehealth infrastructure and policies. At the onset of the COVID-19 pandemic, UNMC/NM was rapidly developing policies and infrastructure to promote the transition to telehealth (two-way communication between patient and provider via either audio or video) for the large health system. UNMC/NM’s EHR already had secure patient communication tools and a portal with audio/visual capabilities in place.
Identification of barriers and facilitators. At the HIV clinic level, SCC identified several barriers that included patient lack of access to technology, staff unfamiliarity with telehealth documentation, and wide variations in providers’ criteria for patient eligibility for telehealth. As a result, SCC incorporated resolutions to these barriers that included using telephone (audio only) visits as the preferred telehealth modality, developing progress note templates in the EHR, and educating staff on how to change in-person visits to telehealth visits. Finally, SCC developed algorithms, as noted above, to identify patients eligible for telehealth and developed standard operating procedures for staff to follow before the visit, day of visit, and after. These included the progress note templates in the EHR (mentioned above) to incorporate elements necessary for HIV care, billing, and coding for telehealth visits.
Staff training. At implementation meetings, staff were provided with updated algorithms and a progress note template. HIV clinic staff participated in trainings on telehealth, rescheduling of patients, proper use of personal protective equipment, SARS-CoV-2 swab collection, and physical distancing and environmental modifications to safely accommodate patients in clinic who did not meet criteria for telehealth. Many providers and other clinic staff were not comfortable in the beginning; SCC provides ongoing staff training and tip sheets, as well as EHR support.
“We wish we had been utilizing telehealth prior to a pandemic! We would encourage other clinics to establish this before it is needed again in a public health emergency like March 2020. Patients are very capable of this. I think we made assumptions about low patient portal engagement but really, with some education and tech support, more patients have been able to utilize it.”
Now that EHR infrastructure and processes for telehealth visits are integrated within SCC, telehealth visits are still available for patients with stable HIV disease, although currently underutilized as most patients have returned to in-office visits. SCC provides ongoing training to staff on how to support patient access to the patient portal and video visit platform. They have also updated cameras and lighting sources in clinic for providers to conduct video visits.
- SCC had low patient enrollment in the secure patient portal required for video visits, which is why they initially focused on audio telehealth visits. As a result, a dedicated staff member now focuses on increasing patient enrollment in the portal, speaking to patients in the clinic and reaching out to others. They are also working with community partners to establish locations where patients can connect to telehealth when they do not have access to the internet at home.
- Patients often did not complete ordered labs before or after a telehealth visit. SCC established a system to provide a direct line of communication between each provider and a support staff to arrange the labs and other follow-up with patients. Additionally, there are efforts underway to identify community partners to assist patients with obtaining labs outside of the Omaha Metro area.
- Standard operating procedures for telehealth visits*
- Algorithm to determine eligible established patients for telehealth*
- Algorithm to determine eligible new patients for telehealth*
- National Ryan White Conference on HIV Care & Treatment (NRWC) 2022: Telemedicine Implementation at a Midwestern HIV Clinic During COVID-19: One Year Outcomes
*These standard operation procedures and algorithms were developed in 2020 during the early months of the COVID-19 pandemic. Updated standard operation procedures and algorithms are available upon request for non-urgent implementation. See contact below.
- Fadul N, Regan N, Kaddoura L, Swindells S. A Midwestern academic HIV clinic operation during the COVID-19 pandemic: Implementation strategy and preliminary outcomes. J Int Assoc Provid AIDS Care. 2021;20:23259582211041423. doi:10.1177/23259582211041423
- Labisi T, Regan N, Davis P, Fadul N. HIV care meets telehealth: A review of successes, disparities, and unresolved challenges. Curr HIV/AIDS Rep. 2022;19(5):446–453. doi:10.1007/s11904-022-00623-z