Lack of internet access has been deadly during the COVID-19 pandemic. According to a study published in JAMA Network Open in March 2022, the absence of broadband, dial-up, or cellular was one of the factors most consistently associated with high risk of death due to COVID-19.
The pandemic made it clear: we must improve health care access now.
The health care innovators who participated in the third installment of the Nashville Health Care Council and Nashville Health’s “Meeting Patients Where They Are” series identified three methods to address social determinants and health disparities and enhance access to health care:
1. Improve Convenience
2. Build Trust
3. Prioritize Partnerships
CONVENIENCE: Access to Health Care Should Not Require a Car
According to Neighborhood Health CEO Brian Haile, one of Tennessee’s greatest failures during the pandemic was to take a “vehicle-centric” approach. Residents needed access to a car to get to many testing and vaccine sites. That requirement was a problem for a significant number of residents. While nearly a quarter of American households own three cars or trucks, about 10 percent do not have access to a single vehicle.
The problem went beyond access to a vehicle. The rural senior citizens Main Street Health (this doesn’t make sense) serves fear driving on highways, for example. “It’s the simple things,” Bennett Graham, president, said. The health care community needs to consider and address what is happening outside the clinic.
Neighborhood Health worked with WeGo Public Transit and Lyft to arrange free rides to testing and vaccines sites. The organization also started a street medicine program during the pandemic. This team includes doctors, nurse practitioners, a van driver, and a patient navigator who work together to provide basic medical care, information about testing and vaccination, and behavioral health services. The teams also distribute food, diapers, blood pressure cuffs, and sleeping bags for the homeless.
While technology was an imperfect solution during the pandemic due to unequal digital access, it did help thousands of Tennesseans stay healthy. Neighborhood Health provided one telehealth visit in 2019, but 30,000 in 2020.
To help the one-quarter of Americans who still lack fixed home broadband, University of Michigan scholars have advised that government leaders, the health care community, and other stakeholders must:
- Ensure reimbursement parity for telehealth programs;
- Create tablet and hardware loan programs;
- Establish community outreach programs to assist patients with technical issues;
- Provide Wi-Fi hot spots and publicly available kiosks;
- Standardize patient instructions for technology, connectivity, and access; and
- Not define telehealth as only video.
TRUST: Above All Else, Patients Want Clinicians Who Listen
According to a longitudinal, qualitative study conducted by Baylor College of Medicine and Rice University researchers, there are five actions health care providers can take to reduce patient anxiety and build trust: provide reassurance; tell patients it’s okay to ask questions; show patients their lab results and explain what they mean; avoid judgmental language and behaviors; and ask patients what they want.
An Everyday Health and Castle Connolly survey released in early 2022 found patients prize a clinician’s ability to listen over credentials. Sixty one percent of respondents said the ability to listen was an important factor in choosing a doctor compared to 48 percent who said clinical experience is a factor.
In the rural communities Main Street Health serves, understanding the social determinants of health is as simple as “knowing your neighbor.” Before Graham and his partners launched their practice, they spent time in different Tennessee communities asking residents what they needed to improve their access to health care. Bennett still regularly attends community events—even quilting club meetings—to listen to residents.
Jarod Parrish also has embedded himself in the community he serves.
A month before the pandemic shut down nonessential businesses, Parrish launched a research study to bring health care to Black men living in the city. In partnership with Vanderbilt University, NashvilleHealth, My Brother’s Keeper in Nashville, and others, Parrish visited barbershops to check vital signs.
Eight shop owners agreed to participate. Knowing Parrish had buy-in from their trusted barbers meant shop patrons were willing to participate.
People “aspire to have great health,” Parrish said. Lack of tools like cars and computers can get in the way, but trust also is an issue.
To earn the trust of the patients he saw, Parrish, a pharmacist, focused on non-drug interventions first. He discussed how health and exercise could positively impact not only a person’s physical well-being, but their family, their job, and their mood. The interventions helped the study’s 419 participants improve their blood pressure control.
Parrish said there are many places in the community that can become centers of care.
Haile agreed. Clinics should be where people congregate, and this co-location will help clinicians understand the full-scope of challenges—physical, social-emotional, and practical—that people face. Specifically, Haile suggested that dental practices are an excellent entry point for care since people are less likely to ignore severe tooth pain. Co-locating dental and medical practices would allow clinicians to screen for problems ranging from hypertension to HIV. In fact, Neighborhood Health has identified and helped treat at least one person with HIV using this model. A study published in the American Journal of Public Health in April 2014 concluded oral health professionals could play a bigger role in detecting chronic disease, potentially saving the U.S. health care system $42.4 million to $102.6 million in just one year.
PARTNERSHIPS: Know Who Is Doing Good Work in Your Community
Parrish’s success in Nashville barbershops highlights how looking for unique partnerships can improve outcomes.
Parrish suggested co-locating pharmacies and primary care services is another option to improve access to health care. According to the U.S. Centers for Disease Control and Prevention, more than 90 percent of U.S. residents live within five miles of a community pharmacy and patients visit their community pharmacist 12 times more frequently than their primary care provider. Co-location also is popular with patients. A 2020 J.D. Power survey found nearly half (48 percent) of retail pharmacy customers used at least one health and wellness-oriented service provided by their pharmacy in that year. That number was up from 43 percent in 2019. A January 2021 U.S. Centers for Disease Control and Prevention issue brief concluded community-based pharmacist navigation programs could improve access to health care, especially preventive services, and improve care coordination in neighborhoods at risk for poor health outcomes.
Main Street Health works alongside providers who already live and work in the area. It’s “relational medicine,” Graham said. “Health care is still very local.” Main Street Health embeds a health navigator at participating practices. These individuals are an extra set of hands that assist clinicians with patient education, health literacy, and care coordination. Health care is confusing, a “behemoth,” Graham said, and clinicians themselves often have a difficult time navigating the bureaucracy. Main Street Health has banned acronyms and helps clinicians demystify their language.
Haile agreed that care coordination is essential to improving access to health care. “The time tax on the poor in this country is enormous,” he said. Patients are overwhelmed by paperwork. Neighborhood Health is in constant communication with community organizations that are working to address problems like food insecurity, language barriers, housing and homelessness, and it works alongside these partners on the streets of Nashville.
Neighborhood Health partnered with 18 community stakeholders to vaccinate people struggling with housing insecurity. The result, by Memorial Day 2021, was that the COVID-19 vaccination rate among Nashville’s homeless population was higher than the vaccination rate for the entire adult population. The “Miracle by Memorial Day” partnership initially started with just a handful of organizations and grew from there—something Haile said was instrumental to its success. Chaos, confusion, and cross purposes often take over when care coalitions start off too large.
Ultimately, partnerships can help health care organizations reach deeper into communities—helping to address the problems of convenience and lack of trust that have kept millions of Americans from accessing the health care they need and deserve.
The Nashville Health Care Council and Nashville Health recently hosted a virtual discussion to investigate social determinants of health and access to health care. “Meeting Patients Where They Are: Solving the Access Challenge” was the third installment in the Council’s health equity series, which invited health care innovators to offer meaningful solutions that address social determinants and health disparities. “Meeting Patients Where They Are” was sponsored by BlueCross BlueShield of Tennessee. For more information on upcoming programs, visit healthcarecouncil.com.
Panelists were:
- Bennett Graham of Main Street Health, which provides value-based health care solutions for rural America.
- Brian Haile of Neighborhood Health, which provides convenient, affordable, comprehensive and high-quality primary healthcare to the Nashville area.
- Jarod Parrish, professor at Belmont University College of Pharmacy and VUMC population Health Clinical Pharmacist