VTDigger is posting regular updates on the coronavirus in Vermont on this page. You can also subscribe here for regular email updates on the coronavirus. If you have any questions, thoughts or updates on how Vermont is responding to COVID-19, contact us at coronavirus@vtdigger.org
Northeast Kingdom Human Services’ coronavirus crisis team met Monday morning at the agency’s Derby office. Sort of.
Members each called in from different rooms, part of a 40-person skeleton crew out of the 200 or so employees usually there. And the regional health care provider is asking patients to do the same: Most of its services have gone remote.
“We have tapped into any and all technology that might be available in order to be able to provide as many services in our communities as we had before,” said Tomasz Jankowski, the organization’s president.
Health care providers nationally have begun transitioning toward digital and phone services as the coronavirus pandemic escalates and people look to distance themselves from others. The methods are usually grouped under the terms telehealth or telemedicine.
“Almost all of our face-to-face services are now being provided via telehealth,” said Dan Hall, director of outpatient services for the Howard Center in Burlington, the largest social services organization in Vermont. “It’s really the primary mechanism for delivering services now.”
‘A tectonic plate shift’
Before the pandemic hit the United States, the Howard Center only had a pilot program in place for telehealth, Hall said.
Change came quickly last week. “Within five business days, we had transitioned an organization of our size to remote work,” Hall said. “It was pretty miraculous.”
The pilot program had been with Zoom — the much-written-about phone and video conference client — so the Howard Center finalized an agreement with the company, Hall said. About 600 employees have registered for that service, and most patients have been talking to staff through it or via text.
“I think there might have been some concern that it wouldn’t feel as authentic,” he said. “But from the conversations I’ve had with my staff, for the most part clients have responded very well and have been very open to the idea.”
That’s partly because it limits contact, he said, and because communicating remotely is easier for some folks, eliminating obstacles like transportation.
Telehealth efforts have become more accessible with loosening regulations.
Vermont senators on Tuesday passed several bills aimed at addressing the coronavirus outbreak. One of them, H.742, aims to expand access to telemedicine by temporarily making sure more remote services are reimbursable by insurance. President Donald Trump last week moved to do the same for Medicare recipients.
“What can qualify as a reimbursable telehealth service has gone from … face-to-face video telehealth to just about any mechanism where you can contact a client,” Hall said.
Some federal health privacy requirements have been relaxed, too, to make telehealth easier.
“That is like a tectonic plate shift,” said Jankowski.
Connectivity can be challenging
Jankowski said his organization began planning for a transition to remote work two or three weeks ago. Employees were given laptops and remote-access devices, and the agency bought Zoom licenses. Soon, some workers will get tablet computers too.
“We are very aggressive here in the Northeast Kingdom, understanding that we are also challenged by the technological barriers that are imposed on us,” Jankowski said.
The region’s three counties are the most underserved in the state for high-speed internet, according to state data from just before the new year. That could be a complicating factor for the pivot to telehealth in underserved areas, as with remote learning and other work.
Jankowski said his organization has run into minimal problems with connectivity so far; only one provider in the agency doesn’t have adequate home internet, and she uses devices at one of its two facilities instead.
For Hall, in Chittenden County, the challenge is less an internet issue. He said a “sizable portion” of Howard Center clients either don’t have a phone or have a restrictive minutes or data plan.
The center is considering setting up kiosks where clients can use provided devices, he said, and it may also buy disposable cell phones for some.
Remote communication creates challenges, too. Play therapy for children doesn’t translate well, Hall said. Some counselors are looking at using online games.
“I think during this time, because it is such a unique situation, our primary goal is to really make sure we keep in contact with our clients and make sure we don’t lose anyone,” he said. “When you think of traditional therapy services, that probably wouldn’t be enough, but I think the main goal is, we just want to keep in contact with everybody.”
Some services can’t turn remote, though, either because of care need or regulations. Hall named methadone treatment as one. And Jankowski said his organization’s group homes, which right now house around 30 vulnerable people, are still staffed by about 175 employees.
‘Shapes better communication’
Ken Major, a clinical psychologist who works with veterans and practiced for years in Vermont, has been working via telehealth for the last seven years.
“Over and over again, (studies) have found that these modalities are not inferior” to traditional ways of working with clients, he said.
Telehealth is of particular benefit to rural or otherwise remote people, he said.
“You just decrease no-shows and cancellations, as well as increase broader access for particularly needy … populations.”
Most clients in his experience tolerate — or benefit from — telehealth methods, but he highlighted several ways patients and providers may have to adjust.
“Some of the difficulties that arise with treating younger patients is that they might respond to this too casually,” he said, explaining the need to be appropriately clothed, not eat and be in a private place.
“It can be so casual that you really have to socialize them into thinking about this just like an office visit,” he said.
Some older folks can get overwhelmed with the technology, he said, especially if a connection lags.
And providers, particularly those working in substance recovery, have to be even more cognizant than usual. Hygiene cues — smells, for instance, that indicate someone isn’t sober — are an important aspect of treatment lost in the switch to telehealth.
“You have to be really thoughtful and vigilant,” he said. “There’s a lot of agility and flexibility, but also it means you have to be that more conscientious about the boundaries and limitations.”
For patients experiencing addiction-related or thought disorders, or who are at risk to self-harm, telehealth becomes a significant obstacle to treatment.
“You have a lot less that you can control, and your information is somewhat more limited, and some of those risks go up,” Major said, adding that in those cases, providers should try to meet in-person before moving to remote services.
But some patients may actually benefit from telehealth, he said. In-person couple’s therapy can result in a lot of conflict — talking over one another — but the remote medium, especially if the patients are in separate places, can force people to listen more actively and take turns.
“It really almost invisibly shapes better communication,” he said.
And patients who have experienced trauma may feel more comfortable with the greater sense of control that telehealth allows — they’re in their own space and can leave the situation at the push of a button.
He hopes people’s experience moving through this crisis establishes telehealth as a more viable option in the future. And Jankowski agrees.
“Perhaps we have held back,” he said, “because we did not know any better.”
