New Model Builds Virtual Communities of Care

With a $100,000 grant from Archstone Foundation, LA Net Community Health Resource Network (LA Net) will partner with Florence Western Medical Clinic and Partners in Care Foundation to implement and evaluate a new health care delivery model that remotely connects low-income, vulnerable older adults to primary care providers and community health workers.

The Virtual Communities of Care model grew out of discussions between Lyndee Knox, PhD, CEO of LA Net, and her colleague, America Bracho, MD, when they saw the distress caused by primary care being “benched” as the pandemic unfolded this year. The new model provides a necessary and rapid response to the COVID-19 pandemic by connecting vulnerable patients with their primary care providers. It also incorporates community health workers to address important social determinants of health, which the Centers for Disease Control and Prevention defines as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” These include food insecurity, housing insecurity, and loneliness, among others.

Kevin Thomas, MD, a primary care provider at Florence Western Medical Clinic, is no stranger to understanding the importance of social factors in influencing health. Before the pandemic, his practice addressed these basic needs by providing a food bank and a clothing bank. With the onset of COVID-19, Thomas noticed his patients having even greater difficulty meeting their basic needs.

He found that family members who previously subsidized older relatives’ food and finances are no longer able to support them due to unemployment; older patients are experiencing anxiety and depression for the first times in their lives; and grandparents raising grandchildren have the added stress of grandchildren being home from school, which requires greater time, attention, and resources from the grandparent. The heightened fear around the pandemic further affects older adults whose social isolation and loneliness exacerbate their health issues and prevent them from being able to access care.

‘The Reality of Things’

What distinguishes Virtual Communities of Care from other primary care providers’ telehealth services? LA Net connects primary care providers from Florence Western Medical Clinic with community health workers from Partners in Care, who work in South Los Angeles, where Thomas’ patients live. This allows for peer-to-peer exchanges that “create trust and provide knowledge that people from the community have about the reality of things,” according to Dr. Knox. The project will seek to establish a true community of care by having primary care providers and community health workers work together, rather than separately and in parallel.

The virtual connection is provided by PatientToc, a multi-lingual patient engagement platform previously developed by LA Net that enables people with low literacy and limited English proficiency to complete assessments that are read aloud to them. This improves efficiency of visits by giving health care providers necessary information about the patients’ social determinants of health in advance.

The PatientToc survey, previously completed on tablets in a doctor’s office, will be available on smartphones via a web-based platform for Virtual Communities of Care participants. The survey will be sent by the patient’s primary care provider, as older adults will likely respond to a trusted health care professional, rather than an unfamiliar health care provider.

The PatientToc system then sends real-time notifications to the primary care provider and community health worker, alerting them of patients with urgent social health issues so they can mobilize the support patients need, such as providing connections to housing, food, or social support.

‘More confidence, and a better sense of control over their lives’

The implementation and evaluation project aims to remove barriers to care by providing a virtual care community that is accessible to older adults with minimal effort and minimal risk. The Virtual Communities of Care model facilitates social engagement and access to services that do not require them to leave their home or spend money on computers and internet.

It’s true that some barriers to care have been removed by the nature of the pandemic. For example, a patient who cannot afford transportation or does not have a family member who can miss work to take them to a doctor’s appointment can now access care virtually without leaving their home.

However, other new barriers have been put in place, including unfamiliarity with how to access virtual care. As Thomas explains, lower-income patients who have more time than money could spend more time getting to affordable health care providers before the pandemic. Now that going to health care providers is often not an option, virtual communication, which is less familiar to low-income patients, is becoming mainstream.

The project will establish a virtual method of communication that can be easily adopted by low-income older adults, can expand their access to specialists, and will likely remain a primary method of communication, Thomas says. Through the project, health care providers will teach low-income older adults how Virtual Communities of Care can improve their care. “They will walk away with more confidence, and a better sense of control over their lives,” he says.

Scaling Up

Archstone Foundation’s funding will support outreach to 2,250 low-income, predominately African American and Latinx older adult patients from Florence Western Medical Clinic. Once participants complete PatientToc surveys, those who need resources to address their social determinants of health will be enrolled in a three-month intervention in which they are navigated to necessary services and social supports.

During the three-month demonstration phase, it is estimated that about 200 to 300 older adults will be engaged with a community health worker and connected to support services. An evaluation of the intervention will assess how many older adults the program reaches, how effective the program is in reducing the burden of social determinants of health and loneliness, how much the program costs, and how satisfied patients are with the intervention.

Findings from the evaluation will be disseminated to healthcare providers via a written report distributed to local health plans, public health departments and departments of aging, and via a webinar, with the goal of scaling up the program and sharing the Virtual Communities of Care model with other providers.