Article By: Aisling Carroll
A Family Struggles
“Dad, don’t cry,” pleaded Luca, a pained 16-year old on the phone. His dad was telling him about being out of work.
It wasn’t the first time his dad, Marco*, who suffers from mental illness and epilepsy, had called him in tears. The calls started when Luca was a boy, after his parents divorced.
“I just worry and worry and worry,” said his mom Elizabeth, 55, who overheard their conversation and had asked Marco not to make such calls. She said they made Luca “very nervous.”
While she tried to shield her son, Elizabeth also took care of Marco, who had been in eight car accidents and sometimes behaved erratically.
For several years, she had worked at Safeway as a bagger on Saturdays and Sundays, in addition to her Monday-Friday house cleaning work, to secure health benefits for her ex-husband. She regularly drove Marco to the doctor, begged him to take his medication, sorted out his housing.
Then Covid-19 took root and Elizabeth was struck by another hardship: she was struggling to make rent. Her house cleaning clients stopped calling in March and someone who rented a room in the San Mateo house she lived in moved out. She couldn’t fill it, and she turned to Samaritan House for financial assistance.
The stress started to affect Elizabeth’s health. Her vitiligo, a skin disease that causes loss of color, was growing larger behind her ear. She was having problems sleeping. And she was feeling alone.
“I felt like I was in a jail,” said Elizabeth.
“I just worry and worry and worry.”
Patients Clamor to Connect
In the past, when she had felt unwell, she had sometimes gone to the ER. This time, she talked to her primary care doctor at San Mateo Medical Center (SMMC) and asked to see a psychologist.
“I try to be strong for Luca because we don’t have family here. Nobody,” said Elizabeth, who moved to the United States from Peru 20 years ago and is undocumented. “I want to be happy for my son. He worries for me.”
Due to early shelter-in-place orders, Elizabeth didn’t see Dr. Daniele Levy, supervising mental health psychologist of SMMC’s Integrated Behavioral Health department, in person. Dr. Levy’s office asked if she’d prefer a phone or video call. Accustomed to daily video calls with her family in Peru, Elizabeth chose video.
Unfortunately, Dr. Levy has been seeing and hearing from a lot of people like Elizabeth, low-income, service industry workers of color whose communities are most imperiled by Covid-19 – physically, emotionally and financially.
“People are showing up with a lot more stress and anxiety. People are at risk of suicide. People are at risk of abusing substances again. People are at risk of isolating themselves,” Dr. Levy said. “The need has never been greater for mental health services.”
Although neither SMMC or most patients had used telehealth before Covid-19, there was an almost overnight transition to 95 percent of behavioral health visits occurring virtually.
Desperate to connect with their providers, often out of earshot, patients have been propping their phones up on car dashboards, bathroom faucets and stair railings. Many live in multigenerational households. Some patients share space with other families as well.
Still, finding a quiet, private area in and around crowded homes has proved easier for many patients than in-person visits. Far fewer have missed appointments – also known as “no shows” – which is opening capacity to more efficiently serve patients. At SMMC overall, due to fewer missed appointments and increased demand for services, clinic volumes shot up from an average of 700 visits a day during the pandemic to a daily average of 1,100.
“Our show rates improved by almost 30 percent,” said an astonished Dr. Levy about her clinic’s rates of patients that are able to make their scheduled appointments. Since offering patients phone and video visits, “we had the highest show rates ever for our therapy appointments when we first transitioned to telehealth.”
“The need has never been greater for mental health services.”
Dr. Levy discusses how critical telehealth has been for San Mateo Medical Center’s integrative behavioral health program.
Surprised Doctors
“Pandemic or no pandemic, telehealth is more convenient,” explained Dr. Levy, accounting for her behavioral health department’s record-setting numbers of patients who can make scheduled appointments. She cited the lack of childcare and the travel time to get to the hospital or clinic and be seen that can make attending in person so burdensome for many of her patients.
Dr. Rakhi Singh, supervising physician at SMMC’s Fair Oaks Health Center Adult Clinic added that another obstacle for her patients to attend in person is the lack of built-in sick leave at their jobs. Most suffer lost wages when they physically show up at the clinic.
“Can they come in on their lunch hour?” said Dr. Singh. “Probably not. It’s hard to drive and come and be seen and be guaranteed to come back.” And many rely on sometimes unreliable public transportation, which can eat into more of their day and pay.
But just because time-strapped patients struggle with these obstacles does not mean they don’t want care. For several years, Dr. Singh and one of her patients, who has uncontrolled diabetes, had been trying to set up an appointment with a nutritionist when the patient said, “What if the nutritionist calls me during my lunch break?” Shortly afterwards, they connected this way. “That would never have happened before,” said Dr. Singh.
More and more patients are requesting such phone and video visits so “they can really quickly get back to work,” said Dr. Singh. And SMMC is now caring for a larger swath of patients.
The majority of the patients at Dr. Singh’s Fair Oaks Clinic choose phone visits, which surprised her. Dr. Singh thought people would want video, especially since most of her patients seem to have smartphones.
However, the cost of data plans and intermittent access to Wi-Fi are often barriers to video visits. Dr. Singh also believes that some patients aren’t comfortable with them overall. “They’re shy about video in their home,” said Dr. Singh.
For those who don’t have a home, a phone visit can also make more sense. Dr. Levy treated a patient over the phone who was homeless and dealing with ongoing depression.
“I’ve always bought into video therapy, but I was not a believer in phone therapy before this (the pandemic) started,” said Dr. Levy.
“How am I actually going to get through to you if I can’t see you? If I can’t see the nonverbals? As a therapist, I move my arms a lot, trying to explain this and that,” explained Dr. Levy.
After several phone sessions with the patient, Dr. Levy felt uncertain. “I was never quite sure if I was being helpful to her.”
A few months later, the patient came to see her in person and asked, “can we continue these therapy sessions because I really miss talking to you.”
“I was somewhat surprised and quite touched,” said Dr. Levy. “But in six months, after doing half my caseload over the telephone, I’ve been pleasantly surprised, and the data does corroborate what I’m seeing, that yes, you can build strong, therapeutic alliances with people you’ve never seen. Emotional support is emotional support, no matter what format it takes.”
“Pandemic or no pandemic, telehealth is more convenient.”
Dr. Singh, a family medicine practitioner who works closely with Dr. Levy to screen patients for depression in primary care, describes how telehealth has allowed their system to delivery care in a way that meets patients’ needs.
“God blessed me with my doctor”
Elizabeth and Dr. Levy also established an alliance during the early days of the pandemic, but via video visits. Elizabeth found them “very easy,” and she liked seeing Dr. Levy face-to-face on her phone.
She saw Dr. Levy several times for the stress and depression that came with looking out for her mentally ill ex-husband Marco, feeling isolated as a single mom raising her teenage son Luca and worrying about making rent.
After meeting with Dr. Levy, Elizabeth has changed her relationship with Marco, and herself.
“I am not imprisoned anymore because I don’t help my son’s dad too much, just a little,” said Elizabeth. “I need to do more for me, too.”
She has been completing the visualization exercises that Dr. Levy emailed her. “My homework,” Elizabeth said with a laugh. And she works out in her bedroom every morning for 10-15 minutes, which she didn’t do before seeing Dr. Levy.
Her son often comes to watch her.
“Luca is so happy for me,” she said. Sometimes in the afternoon, despite her ongoing financial stress, they dance salsa together.
She’s also reached out to a new group of people.
In her appointments with Dr. Levy, they discussed Elizabeth joining a meetup.com group. Dr. Levy suggested she could help others learn Spanish, placing her in the confidence-building position of being an expert and connecting with others.
Elizabeth, who was nervous at first, enjoys it so much that she’s now in two groups.
“They say ‘Oh Elizabeth’s here!’ Everyone wants to talk to me. They make me feel happy,” she explained. “They say, ‘Thank you, Elizabeth, for helping us.’”
Likewise, Elizabeth said she is “very grateful” for the meetups and video visits with Dr. Levy.
“God blessed me with my doctor,” said Elizabeth. “She supported me during a difficult time. She is my angel.”
“I need to do more for me, too.”
Below-the-knee Amputation Averted at Ventura County Medical Center
In terms of patients flocking to telehealth (and sometimes even favoring it), San Mateo Medical Center is no outlier. Some 350 miles south at Ventura County Medical Center, patient telehealth satisfaction provider ratings recently eclipsed their in-person ones.
This feedback mirrors a California Health Care Foundation-NORC statewide survey of California residents who had received health care since March 2019. The study found that 65 percent who had a doctor’s visit by video reported being more satisfied or just as satisfied with telehealth as they were with in-person appointments. Even more respondents – 72 percent – felt that way about having their provider visit by phone.
For one 85-year old diabetic patient who had a toe infection, a timely video visit was what made the difference between saving or losing his foot, and possibly his leg, to amputation.
He was due for an in-person visit with Dr. Stanley Patterson, family physician at Magnolia Family Medical Clinic and chief medical information officer for the Ventura County Health Care Agency, to inspect his toe infection in early April, at the first height of the pandemic.
Although Dr. Patterson favored a clinical examination at the clinic, what he calls “the gold standard,” he asked the patient if he would be open to a video or phone visit given the Covid-19 risk of coming in. The physician, who has a longstanding and warm relationship with the patient, encouraged a video visit so he could see his foot.
“We wanted him home and safe and to create the most valuable visit we could, given the technology,” he said. His clinic had never officially used telehealth until the month prior due to reimbursement, technology and workflow hurdles.
For the patient and his family, any technology questions were addressed in advance to increase their comfort level. As part of their standard process, Dr. Patterson’s clinic calls a patient a few days prior to the appointment to explain how the video visit will work, from clicking on the text link that starts the appointment to activating the camera.
One thing that aided the visit was that the patient lived with his extended Filipino family who served as “his own production team,” as Dr. Patterson affectionately referred to them.
The patient, who is bright-sided by nature, was dealing with insidious symptoms that can go unnoticed by diabetics until it’s too late for limb-saving procedures. He told Dr. Patterson during their video visit that his toe was getting better and looking better.
But when Dr. Patterson asked if the patient’s slipper could be removed, he was alarmed by what he saw. The toe looked angry, with swelling, redness, dead skin and a foreboding black cap at the tip consistent with signs of gangrene.
“He (the patient) had a perception that he was feeling better. However, the reality was the infection was concerning enough that it really needed immediate action.”
Dr. Patterson rushed to phone the podiatrist that day, forwarding photos that he had captured during the video visit.
He described the situation as “a witch’s brew.” The patient had heart disease, high blood pressure, kidney issues and had been living with diabetes for at least 20 years.
The day after the visit, the patient saw the podiatrist in person and completed an urgent vascular study and angiogram. These diagnostic tests, which revealed poor blood flow, resulted in the patient undergoing bypass surgery and vascular procedures – all within two weeks of the April video visit. His toe, which was “never getting better” due to the gangrene, was amputated in early May.
“Without the video visit, the patient would have likely progressed to worsening gangrene,” said a relieved Dr. Patterson about averting a dire delay due to telehealth. “He would have possibly lost his foot or even part of his leg to amputation. The patient was grateful that we were able to save his foot.”
A longtime champion of telehealth, Dr. Patterson believes “the technology is overdue” to benefit his low-income and medically underserved patients. He said they often face “challenges that are really hard to overcome” in order to attend in person. Sometimes the challenge is a changing shift schedule at work or a hitting-the-limit credit card with no wriggle room left for gas or a Lyft.
Phone and video visits “allow us to offer an option for those patients who would otherwise no show or cancel,” said Dr. Patterson. “Access is everything.”
Phone and video visits “allow us to offer an option for those patients who would otherwise no show or cancel,” said Dr. Patterson. “Access is everything.”
Dr. Stanley Patterson, a family medicine physician at Ventura County Health Care Agency, discusses the important role of telehealth, particularly for medically underserved patients.
This blog is part of a series funded by the California Health Care Foundation.
* Names have been changed for privacy purposes.