Article By: Aisling Carroll
A “co-conspirator” in Merced County
Merced County’s leading cause of death in 2020 was the coronavirus, tragically exemplifying just how hard many of the Central Valley’s rural, low-income and vulnerable residents have been hit by Covid-19. According to The Lancet, there is a “co-conspirator” in areas disproportionately impacted like Merced: diabetes.
This complex chronic illness has shown Merced that it’s not limited to causing heart attacks, strokes, amputations, blindness and premature death; diabetes can also crater a patient’s chances of surviving Covid-19. Ranked as one of the least healthy counties in California, Merced has been particularly vulnerable.
When patients have high blood sugar levels (i.e., “uncontrolled diabetes”) and contract Covid-19, they can experience an increase in existing inflammation and a suppressed immune response. This may explain why patients with diabetes and heart disease were 12 times as likely to die of Covid-19 as otherwise healthy people in the first half of 2020.
At Merced-based Livingston Community Health, an alarming 30 percent of the clinic’s largely Latinx patients who work in agricultural jobs have hypertension and nearly 20 percent have diabetes. This number is nearly double the already high number of California residents with diabetes.
But if these diabetic patients are provided with opportunities to more easily access care, better understand their disease, and receive support to monitor their symptoms and lower their blood sugar levels (e.g., counting carbs per serving), they might stave off a severe and life-threatening case of Covid-19, as well as irreversible damage to their organs and nerves.
At Merced-based Livingston Community Health, an alarming 30 percent of the clinic’s largely Latinx patients who work in agricultural jobs have hypertension and nearly 20 percent have diabetes.
“Telehealth is not just convenience”
To help stop the spiral of these underserved patients’ diabetes and heart disease, Dr. Katherine Kim, associate professor at the Betty Irene Moore School of Nursing and the School of Medicine at UC Davis and an ex-Silicon Valley technologist, has spent the last seven years intensely researching barriers and implementing solutions to provide greater access and a higher level of education and care in the Central Valley.
“So many things conspire against farmworkers with these diseases from getting what they need,” said Dr. Kim.
Take a Merced farmworker with diabetes and depression. He needs to see a host of clinicians at least once every three months for everything from A1C (i.e., blood glucose level) tests to mental health support to foot checks. But because of lost wages or a lack of transportation, he is unable to regularly attend these numerous appointments at a clinic or hospital.
In this common scenario, telehealth visits – either by phone or video – are the only way for him to access critical care, learn more about his conditions and have any questions answered.
“Telehealth is not just convenience,” said Dr. Kim.
But although virtual visits over a smartphone can overcome many of the more traditional barriers that patients face accessing in-person care, they can also raise new ones.
For example, video appointments can be impossible when a low-income patient doesn’t have reliable internet access, can’t afford to pay for the data costs associated with the video call, and/or struggles with how to use the technology. These reasons may help account for why the majority of Livingston’s telehealth visits during the pandemic were audio-only calls.
“So many things conspire against farmworkers with these diseases from getting what they need.”
– Dr. Kim
Longstanding partners: UC Davis Health and Livingston Community Health
When it comes to improving the health of underserved Central Valley agricultural workers, what types of training and tech infrastructure would support clinics as they deliver care? For nearly seven years, that’s the question Dr. Katherine Kim of UC Davis Health and Leslie Abasta-Cummings of Livingston Health Clinic have been tackling together. For both the health coaching program they implemented in 2015 and the ACTIVATE telehealth pilot rolling out in the second half of 2021, UC Davis brings the technical and research skills while Livingston provides access to the patients who are “the experts in their own lives,” according to Dr. Kim. She and Abasta-Cummings have been relying on these patient insights to help them ultimately create expanded access and expedited care in one of the least healthy parts of the state.
Ambitious UC-led project
In order to ensure at-risk patients in the Central Valley receive the access, resources and digital skills needed to virtually receive care for their tough-to-manage chronic illnesses, UC Davis Health and UC’s CITRIS and the Banatao Institute, along with other UC partners, received funding from an anonymous donor in 2020 to launch a bold new telehealth initiative.
Called ACTIVATE, the full-spectrum program is being driven by what patients ask for. It will first launch with Livingston Community Health in the summer of 2021 before rapidly expanding to other community health clinics in the Central Valley.
“The main challenge has been that when you get funding for technology, often it’s enough just to implement the technology,” said Dr. Kim, who is co-leading ACTIVATE. “It’s not enough to change how you deliver health care. It’s not enough to retrain staff. It’s not enough to give training to patients on how to use the technology.”
ACTIVATE’s two-year pilot, however, offers sufficient funding to bring clinical care, information and support to homes, farms, packing houses – and anywhere else underserved Central Valley residents are – via telehealth.
This will include the infrastructure for a patient to see their doctor over video, attend a health education class online, measure their own blood pressure from their kitchen table or get their oxygen levels taken at a mobile health van parked alongside the site where they work.
For example, to eliminate the known barriers for patients who want to meet with their doctors and care teams over video, ACTIVATE will provide them with UC-vetted smartphones, tablets, internet routers and subsidies for their data plans. It might also tap UC’s network of technology companies to install services such as WiFi hotspots.
“The main challenge has been that when you get funding for technology, often it’s enough just to implement the technology. It’s not enough to change how you deliver health care. It’s not enough to retrain staff. It’s not enough to give training to patients on how to use the technology.”
– Dr. Kim
Potentially lifesaving digital devices? “Almost none.”
But even when patients have everything they need to connect over video calls, doctors are often unable to collect some of the data that they normally would during an in-person office visit. Data in the form of vital signs and symptoms allows clinicians to assess a patient’s health and determine treatments. It also provides patients with a valuable yardstick.
“Our patients are hungry for information,” said Leslie Abasta-Cummings, CEO of Livingston Community Health.
So are doctors who ask their chronically ill patients to regularly keep track of their blood pressure, blood sugar levels and heart rate. Patients don’t always have the tools to do so.
The good news: the technology to deliver on several of these patient and clinician unmet data needs exists. From wherever they are, patients can use devices like connected weight scales or digital blood pressure monitors to capture measurements themselves and gain instant insights into their health. They can then choose to share this data electronically with their clinicians in real-time.
For a patient with high blood pressure who currently only gets readings when she is able to physically meet with her doctor, a digital cuff means she can be made aware of her levels and monitored remotely between office visits. This allows her care team to catch any out-of-range spikes and immediately intervene to prevent a stroke or heart attack.
And for the Merced farmworker with diabetes, a continuous digital glucometer, in place of his standard one, would not require him to repeatedly prick his finger for a blood sample, pick up a pen, write down the readings and be burdened with providing them to his care team – hours, days and sometimes weeks after they were taken.
Instead, a sensor on the patient’s skin would continuously monitor his blood sugars so he could discover what food or activity was causing what reaction. Because the digital device would be connected to the clinic, unlike his standard glucometer, these numbers would be instantly shared with his care team. This would avert any high-cost acute episodes and save the patient valuable time and hassle while increasing his understanding of the multifaceted disease.
Yet despite years of studies and clinical trials demonstrating the effectiveness of remote patient monitoring (e.g., fewer trips to the ER) and research on its cost savings and high patient satisfaction, “almost none” of the current telehealth services for vulnerable populations consist of these devices, said UC Davis’ Dr. Kim.
To help turn this glaring inequity around, ACTIVATE will equip patients with the evidence-based, easy-to-use devices that they request, and the internet connectivity and data subsidies that enable them to connect to providers.
“Our patients are hungry for information.”
– Leslie Abasta-Cummings
High-touch support with coaches at the ready
Of course, patients won’t use these telehealth tools and services unless they are comfortable doing so.
ACTIVATE will build on the steadfast support and health education Livingston’s coaches already provide patients between doctors’ appointments, whether by phone, text or in person.
“We take for granted that our patients, just because they have the diagnosis, that they know everything about their health, and they don’t know,” said Rosa Pavey, a bilingual and licensed vocational nurse and health coach at Livingston. She is a graduate of the UC Davis Medical Assistant Health Coaching Program, which lays the groundwork for ACTIVATE and was developed in 2015 by Dr. Kim and the UC Davis Betty Irene Moore School of Nursing in partnership with Livingston.
Through ACTIVATE, Livingston’s medical assistants, coaches, clinicians and trusted promotores/community health workers will receive training to walk patients through how to use the technology. UC educators and researchers will also provide the clinic’s care teams with digital skills-building materials proven to be popular and effective with patients (e.g., animated videos).
“We take for granted that our patients, just because they have the diagnosis, that they know everything about their health, and they don’t know.”
– Rosa Pavey
Learnings from a patient-led design process
How do Livingston’s patients want to manage their health on a daily basis? And what devices and telehealth services do they specifically want?
So far, Livingston’s patients have said they like talking and texting with their care teams. Pavey’s phone attests to this feedback: it rings and pings with patients eager for her knowledge and support.
“Health care often says, ‘This is what you need, rather than asking the patient what they need,’” said Abasta-Cummings, who shares Dr. Kim’s design thinking approach. “We asked our patients first,” she added.
ACTIVATE’s co-design process consisted of multiple meetings of a group of Spanish-speaking Livingston patients, medical assistants, promotores/community health workers and other members of the community. Part of the collaborative process included digging into how the co-designers would want to receive care, their preferred way of communicating and what telehealth might be helpful.
The co-design team, which met over Zoom during the pandemic, also test drove some of the technology, such as digital blood pressure monitors. This allowed Dr. Kim and her colleagues to build a richer and more accurate understanding of telehealth’s pitfalls and possibilities for ACTIVATE’s target population. An interpreter translated for some of the researchers.
One of the issues important to the co-designers was how to understand the data displayed by the devices. They wanted to answer the “am-I-getting-better?” question for themselves.
“A lot of people make the assumption that patients can’t understand their data or they don’t want to be confused by it,” said UC Davis’ Dr. Kim. However, patients told her, “We want you to help us understand what the data means so we can be more in control of it for ourselves.”
The UC technologists who make up ACTIVATE will also oversee seamlessly integrating patient data back into the clinic’s EHR system and advising on any needed platform changes.
“Health care often says, ‘This is what you need, rather than asking the patient what they need.’ We asked our patients first.”
– Leslie Abasta-Cummings
Upcoming roll out
The co-design process, which Dr. Kim calls ACTIVATE’s “secret sauce,” reflects a broader listen-first approach. Once the first group of Livingston patients starts using ACTIVATE’s telehealth services in the summer of 2021, the program will seek feedback from them at every turn.
This will drive a rapid and creative iteration process to boost adoption and usage.
The UC partners will also rigorously evaluate the program for achieving its goals, which range from how often patients are using the technology to health care outcomes. They will also suggest ways to improve before the telehealth services and training are rolled out to other Central Valley clinics.
Ultimately, ACTIVATE aims to build a gold standard telehealth template for clinics to serve at-risk populations across the state and country in a more effective and cost-efficient manner due to its patient-centered approach.
“When you give patients the space to say how they think health care can be fixed, it’s amazing what comes out,” said Dr. Kim.
This blog is part of a series funded by the California Health Care Foundation.