Free and Charitable Clinic Perspectives on the Implementation and Utilization of Telehealth Services During the COVID-19 Pandemic

Abstract

Background:

The onset of the COVID-19 pandemic challenged healthcare providers to adapt their models of care and leverage technology to continue to provide necessary care while reducing the likelihood of exposure. One setting that faced a unique set of challenges and opportunities was free and charitable clinics. In response to the emerging pandemic, The North Carolina Association for Free and Charitable Clinics (NCAFCC) offered their 66 member clinics access to a telehealth platform, free of charge.

Objective:

This paper explores the varied perspectives of leaders in the NCAFCC member clinics regarding the implementation of telehealth services to facilitate continuity of care for patients during the height of the pandemic.

Design:

This qualitative study is part of a broader research effort to understand and contextualize the experience of implementing and using telehealth services by North Carolina free and charitable clinics during and after the COVID-19 pandemic. The research team conducted 13 key informant interviews and employed thematic analysis and grounded theory to explore critical themes and construct a model based on the CFIR to describe the use of telehealth in free and charitable clinics.

Results:

Twelve clinic managers and executive directors from free and charitable clinics across the state participated in the key informant interviews providing their unique perspective on the experience of implementing telehealth services in a free and charitable clinic environment during the COVID-19 pandemic. When examined within the lens of the consolidated framework for implementation research (CFIR), 3 key themes emerged from the key informant interviews: mission driven patient centered care, resilience and resourcefulness, and immediate implementation.

Conclusions:

This study aligns with existing literature regarding telehealth implementation across other safety net provider settings and highlights the key implementation factors, organizational elements, provider perspectives, and patient needs that must collectively be considered when implementing new technologies, especially in a low-resource, high need healthcare setting. The study showcases the implementation climate, resourcefulness, and mission driven approach that allowed many NCAFCC clinics to respond to an emergent situation by adopting and implementing a telehealth platform in a period of 2 weeks or less.

Introduction

During the COVID-19 pandemic, healthcare providers and organizations were given the unique challenge and opportunity to adapt their approach to caring for their patients and leverage technology to continue to provide necessary care while reducing the likelihood of COVID-19 exposure. ¹ One specific healthcare setting that faced unique challenges and opportunities to implement telehealth services quickly and efficiently during the spread of SARS-COV-2 (COVID-19) virus was the free and charitable clinic environment. Free and Charitable Clinics provide services to the most underserved populations and generally have lower operating budgets, fewer total resources, and rely primarily on volunteers and philanthropy to coordinate and fund their operations.^2,3 In 2020, the North Carolina Association for Free and Charitable Clinics (NCAFCC) provided their 66 member clinics access to a video, audio, and text/secure messaging telehealth platform free of charge. ⁴ This paper summarizes the varied perspectives of leaders in the NCAFCC member clinics regarding the implementation of the provided telehealth system that was put in place to facilitate continuing to provide medical and behavioral services for patients in the outpatient setting during the height of the pandemic. On a broader scale, this paper also discusses the key themes, processes, and challenges specific to providing care in a free and charitable clinic setting.

The Free and Charitable Clinic Environment

Free and charitable clinics are private, non-profit organizations that provide health care services at little to no charge to economically challenged individuals (low income, uninsured, or underinsured) by licensed volunteer health professionals.^2,5 The National Association of Free and Charitable Clinics (NAFCC) was formed in 2001 to advocate for the issues and concerns of free and charitable clinics. ⁶ This sparked a domino effect in the creation and growth of free and charitable clinics, prompting the formation of various state and regional organizations all across the United States.

The North Carolina Association of Free and Charitable Clinics (NCAFCC) consists of 57 member clinics that provide medical or behavioral health services and 9 clinics that only provide other services such as prescription pharmaceutical support and social services referrals. Of the 57 clinics offering medical and behavioral health services, 44 are located in metropolitan areas, 11 are located in micropolitan areas, and 2 are located in rural areas. However, key informant interviews indicate that many of the clinics located in micropolitan and metropolitan areas serve a large portion of patients from the larger rural region as gathered from comments on issues with travel and issues with cell service in remote areas. According to the Health Resources and Services Administration (HRSA), 28 NCAFCC clinics are located in medically underserved areas (MUAs) with a shortage of primary care providers, and 49 clinics are located in mental/behavioral health underserved areas. ⁷ The average number of annual patient medical visits for these patients as measured in 2021 was 2,684. ⁶

Telehealth and technology enabled tools represent an opportunity to address disparities in access to care and treatment in populations that live in rural communities, lack transportation, have unstable housing arrangements, and/or are homebound. ⁷ The populations served by free and charitable clinics are at higher risk of these access to care disparities and represent a population where telehealth may reduce barriers and increase access to services. For example, many of the North Carolina free and charitable clinics are either in a rural location or serve patients that reside in rural areas. Informants reported that patients residing in rural areas may have to travel up to an hour or more in order to participate in a face to face encounter with their healthcare provider. The North Carolina free and charitable clinic patient population living in rural areas faces several barriers to care including geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to healthcare specialists and subspecialists, and fewer job opportunities. The value of telehealth as a potential solution to infectious disease and transportation concerns and as alternative to face to face visits has been demonstrated in multiple research studies.^{8 -10} Specifically, telehealth has been demonstrated as a viable strategy for providing continuity of care in the outpatient setting. ⁹

Methods

This exploratory, qualitative study is part of a broader research effort to describe the telehealth implementation and utilization experience in the ambulatory free and charitable clinic setting and gain insights into the lessons learned during the past 3 years. This study represents the results of 13 key informant interviews conducted in Spring 2023 to gain additional context around cited changes and barriers in telehealth usage. Clinics providing medical, dental, social, medication management, and linkage services were invited to participate in the survey, and those who participated in the survey were further invited to participate as a key informant. Therefore, participant inclusion criteria also included completion of the initial survey and submission of contact information to participate in key informant interviews.

In the initial survey, a total of 39 clinic managers completed the initial telehealth perspectives survey providing their thoughts on the implementation and use of telehealth during the height of the COVID-19 pandemic. ¹¹ Of the 39 respondents, 32 provided complete responses representing the experience within clinic sites providing medical services, as opposed to only dental, behavioral, or other linkage services. Key informant interviews were then conducted with clinic leaders, including executive directors, clinic directors, and clinic managers who were directly involved with the adoption decision or process of implementing and optimizing telehealth services for their organization. The key informant interviews were conducted to gather richer, more contextualized information on the main themes and trends generated from the initial survey. The Consolidated Framework for Implementation Research (CFIR) was utilized as the framework for conducting these interviews and analyzing and interpreting discussions regarding the implementation of telehealth services. The CFIR serves as a model and organized approach for understanding factors associated with the implementation and use of technology. Specifically, this model provides a comprehensive overview of constructs that are associated with effective implementation and “provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories.” ¹² The CFIR has been utilized as a framework for multiple implementation science related studies and provides clear constructs to guide data collection, measurement, coding, analysis, and reporting within the field of implementation research. ¹³

Of the 20 clinic managers who initially expressed interest in participating in key informant interviews, ultimately 12 clinic leaders, each representing a different clinic organization, participated in 60 minute online key informant interviews conducted by the research team using the Zoom platform. This included 10 leaders from various clinics, including executive directors, clinic managers, and telehealth champions, using telehealth, as well as 2 who did not adopt a telehealth platform or rapidly de-adopted its use. One of the clinic leaders interviewed was also a nurse practitioner who both coordinated clinic work and provided services via telehealth. A member of the NCAFCC leadership team was also interviewed to gather information regarding the telehealth solution provided and overall implementation climate.

The research team conducted the key informant interviews via Zoom using a predetermined interview guide created de novo by the research team and based on insights and key constructs from the Consolidated Framework for Implementation Research (CFIR) ¹⁴ and Rogers Model of Diffusion of Innovation ¹⁵ (Interview Guide Provided in Supplemental Appendix A) to gather in-depth information on telehealth implementation, incorporation of telehealth within clinical care delivery, and the perceived impact of the implementation on patient care, patient engagement, and clinical quality measures. Informant interviews were each approximately 1-h long, and participants were compensated with a $99 gift card funded through a grant from the Blue Cross North Carolina Institute for Health and Human Services at Appalachian State University. This research study was approved as Exempt through the Appalachian State University Institutional Review Board.

Zoom interviews were recorded and audio transcriptions in the form of Web Video Text Tracks (WebVTT) files were captured and uploaded into MaxQDA qualitative analysis software. MaxQDA was utilized to clean and edit all transcripts and then code and analyze those edited transcriptions to determine common themes, elements, and attributions. This study employed thematic analysis and grounded theory to explore critical themes and construct a model (see Figure 2) based on the CFIR to explain and understand the use of telehealth in free and charitable clinics during the COVID-19 pandemic. The fundamental attitudes and themes regarding telehealth implementation and utilization were elicited using a qualitative descriptive technique. The research team utilized the key tenets of the CFIR as an initial framework for coding and interpreting interview transcripts within MaxQDA qualitative analysis software. Interviews were coded by a team of 4 researchers, working collaboratively to review for CFIR constructs, open code other relevant key themes, and verify agreement on the coded segments. The coded data was used to document key themes related to the CFIR model as well as creating open categories, axial codes, and finally selective codes based on higher level themes regarding the implementation and utilization of telehealth explored during the key informant interviews.

Figure 2.

Telehealth implementation in a free and charitable clinic setting: a model based on the CFIR constructs prevalent in key informant interviews.

A model for classifying key themes and selected comments, including barriers, facilitators, satisfiers, and dissatisfiers for telehealth utilization in this setting was created. While the axial and selective codes were created by grouping the themes discovered through open coding, application of the core constructs of the CFIR informed the creation of the coding schema and the finalized selective code categories. Initially, the researchers participated in key informant interview sessions and listened to recordings in order to understand the mood, context, and timing of comments with greater context. Two researchers then independently reviewed the interview transcripts and performed open coding assigning key themes as well as coding excerpts in alignment with the CFIR model constructs included in Supplemental Appendix B. Independent coding of the transcripts was followed by the research team review to initially capture accurate results prior to gaining group consensus and reduce the likelihood of researcher bias impacting the coded data as a whole. The researchers each identified common themes in responses across interviews and specific coded segments using inductive content analysis. The results of the initial coding were condensed into key themes using the constant comparative method. ¹⁶

Coded segments were then reviewed to determine the intercoder consistency (ICC) on the main themes and the general understanding and utilization of CFIR constructs for classifying and interpreting comments. Using a real-time polling system, 3 reviewers examined a sampling of 20 quotes from clinic leadership interviews and matched each of the quotes with the correct corresponding CFIR construct or theme confirmed by the team. The CFIR model constructs utilized for coding have been provided as supplemental material.

Results

Twelve clinic managers and executive directors from NCAFCC member clinics representing a variety of different organizations across the state of North Carolina participated in the key informant interviews providing their unique perspective on the experience of implementing telehealth services during the COVID-19 pandemic. The majority of clinic managers interviewed represented the primary care setting (87.5%); however, several sites reported offering some limited specialty care and/or behavioral health services. The majority of clinics (83%) whose leaders shared their perspectives on the realities, challenges, limitations, and benefits of telehealth implementation and providing care to disadvantaged populations during the COVID-19 pandemic were located in rural or micropolitan locations.

Clinic managers interviewed described a variety of different workflows and processes utilized to provide services via telehealth during the height of the pandemic. The telehealth platform provided by NCAFCC included video and audio visit functionality as well as secure text messaging and mass messaging capabilities. The system was accessible via computer or other small personal electronic devices, including tablets or cellphones, and could accommodate both patients and providers accessing the system remotely. Respondents reported a variety of locations where their providers delivered, and patients received, telehealth services. For some sites (33%), the patients were provided the opportunity to participate in telehealth services remotely from home or another location while healthcare providers were in the clinic location. In other clinics (25%), both patients and providers were remote with neither in the clinic. Lastly, several clinics (25%) permitted providers, who were often high risk or out of the area, to provide services remotely, while the patients would be in an exam room aided by technology and a medical assistant or other clinical support staff member. Lastly, 2 clinics (16%) did not complete the telehealth implementation process due to provider preference or inadequate resources.

When examined within the lens of the consolidated framework for implementation research (CFIR), the manner in which interview participants described the different processes utilized to provide services via telehealth highlighted the key elements of the inner setting culture and each showcased a high degree of deliverer centeredness (provider centered motivation) and recipient centeredness (patient centered care) in addition to a prominent theme of equality centeredness. Comments such as “of course we still have patients coming in that needed to be seen, but we had at risk providers. So it was limited on what we could do, so the at-risk providers strictly stuck to telehealth” showcased a commitment to provider safety. While comments such as “We never shut down, because we couldn’t step away and leave the most vulnerable populations on their own. You know we had an obligation,” illustrated the commitment of free and charitable clinics to providing services throughout the pandemic.

Following the completion of the key informant interviews and the initial coding and analysis of the perspectives and information shared, the research team identified several key themes. While some of these themes align well with the initial context and aims of the project as well as the CFIR model utilized for a large portion of the initial coding, additional unanticipated themes outside of the model were identified. Specifically, the persistent challenges facing free and charitable clinics and the unique ingenuity, resiliency, and resourcefulness of these organizations were meaningful themes throughout the interviews. At times these themes and comments regarding each organization’s mission and operations overshadowed the discussion regarding specific telehealth implementation processes and the use of telehealth and technology within the clinics. Figure 1 below contains a summary of key themes across coding levels.

Figure 1.

Summary of primary themes identified from open, axial, and selective coding of key informant interviews.

Figure 1 illustrates 3 core themes, also known as selective codes, resulting from the key informant interviews. These themes are the key constructs that were most pervasive during the guided conversations and were present in all 12 clinic leader interviews and the interview with the NCAFCC leadership. Specifically, the final themes present in the interviews describing successful telehealth adoption and implementation included (1) mission driven patient centered care, (2) resilience and resourcefulness as key traits of the implementation and service delivery, and (3) immediate implementation at the onset of the pandemic.

Comments such as “And you know we don’t charge for anything, so we don’t have to get money for it. So we just do what is most efficient for us and the patient,” and “We will never provide lesser quality care just because somebody’s poor. So if the rest of the medical world was pivoting for people who were insured or had means, then we were going to pivot. We were not going to be left behind,” illustrate the mission driven attitude fueling the immediate implementation of telehealth services.

The research team utilized the thematic analysis conducted and themes described in Figure 1 to develop a broader extended model of key factors specific to telehealth implementation and use in the free charitable clinic setting. While the many factors explored across the CFIR are difficult to encapsulate in a single summary, Figure 2 below provides a visual representation of this model based on the larger set of themes most prevalent in the key informant interviews that correspond to constructs from the CFIR including key environmental and organizational influences.

Supplemental Appendix C provides a selected segment of selected comments that represent the major themes captured above in Figures 1 and 2. These comments capture the informed semi-structured nature of the key informant interviews while also highlighting the resourcefulness, barriers, norms, and challenges present in the free and charitable clinic environment.

Discussion

Key themes both related and unrelated to telehealth utilization were uncovered during the key informant interview sessions. These themes illustrated the unique environment, operational challenges, and mission driven approach of these organizations. One such theme, mission driven patient care, was clear in multiple statements revealing that free and charitable clinics appeared to be one of the few stable environments and supports for patients throughout the pandemic. This was expressed in tandem with the concept that many of their patients have limited access to social support, and that the clinics may be the only interaction that some patients had in days, weeks, or months. It was also independent of the type of services being offered (face to face or remote). With the onset of the COVID-19 pandemic, the free and charitable clinic is increasingly replacing the social and safety net roles that the community previously filled. These unfulfilled roles have the potential to create downstream costs and strain across the healthcare system affecting everything from acuity of conditions due to delays in care ¹⁷ to hospital lengths of stay and readmissions. ¹⁸ This speaks to the importance of the free and charitable clinic model in addressing social determinants of health and warrants further research on the economic impacts of the free and charitable clinic model on the healthcare system.

Another particularly relevant element of this first theme was the rigorous standards upheld by the NCAFCC member clinics. The clinics have various models of reimbursement, funding, and reporting, but due to the nature of their funding, free and charitable clinics have to provide excellent quality of care and meticulous documentation of this quality. While public perception might indicate that these clinics provide minimal care at any standard, ¹⁹ the interviews indicate that they are not just bound but motivated to provide the highest possible standard of care for the disadvantaged populations that they serve. All (100%) of the interviews had underlying themes of the member clinics striving to meet and exceed the needs and wants of their patient populations. This is borne out with evidence from the literature not only indicating excellent quality of care in free and charitable clinics, but also commending the NCAFCC for their success in this realm. ²⁰

The implementation climate and readiness of clinics to act with resiliency and resourcefulness to immediately implement telehealth systems was also made clear in the interviews. While these themes were coded across multiple CFIR constructs, the relative priority of telehealth implementation and the specific workflow elements discussed across clinics illustrated the readiness of clinic leadership to fully commit to the implementation process and move forward with telehealth adoption quickly. In reaction to the challenges of implementing telehealth services during the pandemic, many clinic managers had the opportunity to have a positive reappraisal of their experience during the interviews. Comments such as “In hindsight it was good. You know it’s easier to just get thrown into the fire, and everybody was so helpful,” and “Now I don’t know what we would have done without telehealth being stood up very quickly. That’s one of the positives that I see coming out of the pandemic,” showcase the resourcefulness of these organizations and the teaming and engagement that occurred during the implementation process.

The 2 clinics that did not fully implement and sustain telehealth services experienced barriers to implementing telehealth services based on their locations. One clinic was located adjacent to a shelter for unhoused individuals and the provision of telehealth services would not meet their populations’ on-site needs. The second clinic shared that their location was within a health department and without their own computers and clinic space their access to suitable technology and resources was greatly limited at the onset of the pandemic.

This study builds on the research team’s previous efforts to address gaps in the literature regarding the free and charitable clinic experience with telehealth. Our previous study illustrated several motivating factors for implementing telehealth during the COVID-19 pandemic including the desire to provide needed services, increase patient convenience, increase patient access, and to some extent increase provide efficiency and see a larger number of patients. ¹¹

This study aligns with the findings of several other recent studies that address the mission driven nature and culture elements common when implementing and utilizing telehealth services in other healthcare safety net provider environments, including community clinics, federally qualified healthcare centers (FQHCs), and community hospitals.^{21 -23} This study adds to the existing literature by incorporating the perspective of a different group of safety net providers and expands upon the research team’s previous work by adding context and nuance to the quantitative results, providing a fuller story. Future research should further investigate the acceptability and potential sustainability of telehealth services in a free and charitable clinic environment and incorporate the patient and healthcare provider perspective. Further studies should be conducted to identify the barriers and facilitators of telehealth utilization for all populations. However, further research is critical to inform the design, configuration, and implementation of systems and programming to meet the needs of underserved populations. Further exploring and addressing the barriers and facilitators present for this patient population is crucial to designing, configuring, and implementing systems and programming to meet patient needs.

This study included several limitations common to qualitative studies exploring perspectives provided via key informant interviews. As with many qualitative studies, this study utilized a small sample size and therefore the results may not be generalizable to all free and charitable clinics. While the initial survey distributed included a response rate of 48% (n = 32 of 66 clinics), 12 clinic leaders and 1 association representative participated in the key informant interviews which met the frequently referenced minimum sample threshold of 12 interviews discussed in the literature.^{24 -26} The likelihood of self-report and social desirability bias is high given the lack of anonymity present when being interviewed via Zoom. Furthermore, the special circumstances created by the COVID-19 pandemic resulted in a rare implementation climate for free and charitable clinics that may not be generalizable to future timeframes or other settings. Another key limitation is the potential for response bias. With only 12 out of 66 available clinic sites choosing to participate in the interview process, the study may not reflect the perspectives of those who did not feel telehealth was a priority or did not have the time to engage in the research study. However, the research team did achieve theoretical saturation through the interviewing of the clinic leaders and NCAFCC staff members, with key themes present being recurrent and pervasive across all interviews.

Conclusion

This study highlights the key implementation factors, organizational elements, provider perspectives, and patient needs that must collectively be considered when implementing new technologies in a low-resource, high-need healthcare setting. The study also showcases the implementation climate, resourcefulness, and mission driven approach that allowed 10 out of 12 NCAFCC clinics to adopt and implement a telehealth solution, each with a planning and training period of 2 weeks or less. The results from this study may be used to inform practitioners, providers, and policymakers in implementing systems, developing policy, and appropriating funding to address the opportunity for telehealth to expand access for patients seeking care through free and charitable clinics and other safety net providers.