At Catholic Charities Opportunity Center in downtown St. Paul, Senior Clinical Manager Stacie Joncas works with some of the people who’ve been hardest hit by the many crises that have befallen the Twin Cities over the last few months.
“These are people who are really having a rough time right now,” she said. “With the murder of George Floyd, the riots and COVID, what we’re finding is a huge increase in mental health and substance use problems among our client population.”
A day center for people experiencing homelessness and for members of other vulnerable communities, the Opportunity Center provides a safe place for people to spend time, eat a hot meal and get help with a variety of issues, including looking for a job, finding affordable housing and getting support for mental health and addiction concerns.
When COVID-19 hit Minnesota this spring, most health care providers made the shift to telehealth as a way to safely see their patients without risk of spreading the virus. While this approach works for people who are well connected through smartphones, computers and tablets, Joncas said a large number of her clients at the St. Paul Opportunity Center (and its sister program in Minneapolis) live on the edge of the virtual world, making accessing health care via telehealth nearly impossible.
At Catholic Charities Minneapolis, Joncas works with a group of 95 men at the nonprofit’s Exodus Residence. Many have regular appointments with mental and chemical health counselors. When the counselors shifted to seeing their patients online, Joncas said that many of the men missed their appointments.
Providers tried to make scheduling online visits easy, but that really didn’t make a difference for her clients, Joncas explained.
“When we’d say, ‘I see you missed your appointment. Let’s get another appointment set up on your phone,’ it usually didn’t work,” she said. “Many of these guys didn’t have phones to begin with. Or, if they did have a phone, their payments were erratic so their service was off and on. Or they had limited data and didn’t want to use it up.”
Lack of privacy an issue
And clients who did have a working smartphone weren’t all that keen on giving telehealth a try, Joncas said. Shelter living is famous for its lack of privacy, so virtually visiting with a health care provider in spaces already occupied by other people felt unappealing.
“It’s not like these gentlemen were saying, ‘Can you hook me up with telemedicine?’” Joncas said. “They were already in crisis and figuring that out was not at the top of their minds. Quickly it became clear that this was a barrier we needed to get over.”
Then a way to surmount this barrier arrived in the form of an email. The message, which came to Catholic Charities’ downtown Minneapolis office, was from M Health Fairview. It said that behavioral health staff at the health care system was working on ways to expand access to telehealth in disadvantaged communities.
The email said, Joncas recalled, “‘We’re aware that one of our behavioral health clinics is close to the Opportunity Center,’ and ‘We’re aware that we have not been able to see our mutual clients. We want to figure out what we can do to make sure these clients have access to their therapists.’”
The email went on to explain that M Health Fairview had already set up telehealth hubs — or private rooms outfitted with high-definition computers where patients could safely have remote visits with mental- and chemical-health counselors — at M Health Fairview St. Joseph’s Hospital just a few blocks away. Would Catholic Charities be interested in setting up a similar hub at the Opportunity Center?
“From there it was pretty easy,” Joncas said. The St. Paul Opportunity Center actually had a number of private consultation rooms that usually are used by case managers during client meetings. The rooms were too small for two people to practice social distancing, so they’d been standing empty for months.
Agreeing to set up a telemedicine hub at the Opportunity Center was a no-brainer, Joncas said: “We want to serve our clients well and we have these spaces. We thought it would be great if we put a computer in there and gave folks a way to see their doctors in private.”
Focus on health equity
The idea of creating telehealth hubs grew out of a realization that virtual medicine doesn’t work for everyone, said Rich Levine, M.D., medical director of outpatient services for M Health Fairview’s mental health and addiction service line. Levine, who is dual-boarded in psychiatry and family medicine, said that while moving providers online is a needed safety measure during a pandemic, the response left some of the most vulnerable patients shut out of care.
“It started when we began to figure out how to do telehealth visits during COVID and realized that not all people will have the space or the ability to use a phone or a tablet or a computer to do their visits,” Levine said. “We wanted to come up with a way to provide care for everyone.”
The people who lack the connectivity and privacy needed for successful telehealth visits are often members of communities that already struggle to get the health care they need, Levine said.
Those groups include low-income communities, recent immigrants, people experiencing homelessness and residents of isolated rural towns. “We tried to find a way to make sure that all those patients can get the care they need,” Levine said.
M Health Fairview’s first telehealth hubs are set up in urban areas with larger homeless populations. The people the hubs were designed for, Levine explained, “don’t have a phone or a computer or a safe place where they can visit virtually with a doctor.” Setting up a telehealth hub near a place where many patients regularly spend time — like the Opportunity Center — or normally see health care providers — like M Health Fairview St. Joseph’s Hospital — was a way to further increase accessibility.
Allison Holt, M.D., a physician and chief of M Health Fairview’s mental health and addiction service line, said that as much as the switch to virtual care was essential for protecting the health of care providers and patients, developing new ways for less-connected patients to continue to see their providers online was also essential for ensuring that all people had access to care.
“These hubs are our way of meeting our patients where they are and not forgetting about people who don’t have access to technology,” she said. “We’re not leaving them behind but we are welcoming them into our services by giving them a hub where they can sit and talk to our providers online. We are committed to increasing health equity.”
As the stresses of everyday life mount, there’s been an increased demand for mental and chemical health services. Levine said that among some of the state’s struggling communities the need is particularly acute. He hopes that the telehealth hubs will help at least some people get access to care that can help them weather the storm.
“We’ve always known this is an underserved population to begin with, and now with the extra stressors it is even more so,” he said. “With the civil unrest and what happened to George Floyd, it is important for people to be able to talk to a professional about difficult things.”
Beyond filling a gap that appeared in the wake of COVID closures, Holt said that the hubs are an acknowledgement of health care inequities that existed long before the current wave of crisis. Many communities already lacked care, or lacked recognition of their trauma and struggles to survive. The civil unrest that consumed the Twin Cities in June was an indicator of those larger inequities; turning an eye to that injustice and responding with new care options is a small step toward creating a more just community for all.
“It’s been a mental health crisis for a long time that we’ve probably ignored,” Holt said. “Now we are listening. It is important that we are listening. This program is a direct response to serious needs that already exist.”
How hubs work
When M Health Fairview set up the first telehealth hubs at St. Joseph’s Hospital, the idea was to mimic the usual patient experience as much as possible. The two hub rooms are located near the hospital’s outpatient mental health and addiction clinic, where many patients were used to seeing their provider pre-pandemic.
Staff at the hospital helps walk patients through the virtual visits, showing them to the hub rooms, explaining how to use the equipment and connecting them with their doctors. Levine added that there are plans to expand hub services to other M Health Fairview clinics, where a “skeleton staff” outfitted in PPE would check in patients, and help get their appointment started. “For the most part the process is extremely simple,” he said. “Hopefully for most people it doesn’t feel too far off from an in-person visit.”
Scheduling a telehealth hub appointment should be as easy as scheduling an in-person appointment. “When people call in to schedule an appointment with a provider, our central intake team asks them questions about if they can use a phone or a computer for a video visit or if they have a private place to be able to talk,” Levine said. “If they aren’t able to do any of those they are offered to go to the telehub location.”
Telehelath hub visits aren’t limited to mental or chemical health providers, he added. “The idea would be that the hub isn’t just one provider. It is based on the patient’s need. Any provider could see someone in a virtual visit at their home or in a hub.”
Ready for patients
The Opportunity Center hub is ready to go, Joncas said. It took a couple of weeks to iron out issues with medical records and grant access to front-desk staff, but now patients just need to sign a release form authorizing virtual care. The computer is set up, and the room is awaiting patients.
“It has not seen any clients yet,” Joncas said of the Opportunity Center hub. “We had our dry run to make sure it was all fine.”
Levine said that M Health Fairview is making tentative plans to expand the telehealth hubs to other locations close to communities that could benefit the most from using them.
“The hope would be that we could start putting some of the hubs in strategic locations for people who don’t have a safe place to talk or the equipment they need to handle a call. Because many people have limited transportation, these places will be in areas that they can get to easily with public transportation.”
It would also be helpful to locate the hubs near hospitals in case of a crisis that can’t be handled remotely. At the St. Joseph’s hub, for instance, if a physician or other medical professional determines that a patient is a risk to themselves or others, on-site staff will be directed to step in and bring them to get help. “If, like at any other appointment, we determine that someone is at risk, is suicidal, feels unsafe, then we do direct them to the emergency room,” Levine said. “We have staff there who can walk them down to the ER if needed.”
‘With COVID, there’s no playbook’
The mental and chemical health issues faced by people she works with at the Opportunity Center are troubling, Joncas said. For clients diagnosed with serious and persistent mental illnesses like schizophrenia or struggling with major addiction, the many unknowns circulating around the virus, a deep-seated fear of the police and a general unease that comes with social upheaval are a recipe for relapse or worsening of symptoms.
“One thing I have seen a lot of in Minneapolis and St. Paul is this rise in suspiciousness that leans over into paranoia,” Joncas said. “People are very afraid. You think about COVID: There are so many things we can’t control. In a homeless community there are also other harder things. We serve so many people of color here: George Floyd’s murder added to the fear and stress level that has already been really high.”
Some people self-medicate for stress, depression and anxiety with drugs and alcohol, Joncas said. This can be a dangerous strategy at any time, but people who live on the edges of society are at greater risk of death from accidental overdose.
Part of Joncas’ job is overseeing a group of mental health staff. She reviews their incident reports, and has noticed a rise in 911 calls for clients seeking emergency medical assistance.
“A recent report was about a gentleman who was overdosing on cough medicine,” Joncas said. “People get overwhelmed and don’t have the coping skills to manage all that is coming at them. Oftentimes their coping skill is substance use.”
Joncas said she tries to tell her staff that we are living in an unprecedented time, that the rise in cases of mental illness and addiction, while expected, is sometimes still hard to comprehend.
“With COVID, there’s no playbook,” she said. “I tell my [mental health staff], ‘This is the stuff they don’t teach you in school.’ COVID has pushed us to be as creative as possible to meet people’s needs.”
Even before this spring’s string of traumas, Levine said that he and his behavioral health colleagues had been seeing an increase in demand for their services. He said that compounded crises drive up the need for therapy, addiction counseling and medication management. He’s hoping — though it hasn’t been long enough to measure success — that the telehealth hubs will increase access to patients in need while easing some of the burden for providers.
“Time will tell if this service is used,” Levine said. “We would really like people to consider this as an option, not only in urban areas but also in rural areas, where there is also a real provider shortage.” The idea of the hubs, he explained, is getting care where it is needed to the people who need it.
And Levine sees potential for the hubs even after the COVID cloud has finally passed. “In the future,” he said, “we hope to continue to use the hubs to reach a wider population even as we reopen our clinics.”