key: cord-0750468-9sds3tkj authors: Reisinger‐Kindle, Keith; Qasba, Neena; Cayton, Colby; Niakan, Shiva; Knee, Alexander; Goff, Sarah L. title: Evaluation of rapid telehealth implementation for prenatal and postpartum care visits during the COVID‐19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America date: 2021-12-14 journal: Health Sci Rep DOI: 10.1002/hsr2.455 sha: 0153e6eabf3869cbaa2c9f6210b5e80d2081917e doc_id: 750468 cord_uid: 9sds3tkj BACKGROUND AND AIMS: COVID‐19 forced healthcare systems to implement telehealth programs, facilitated in Massachusetts by a policy requiring insurers to reimburse for telehealth visits. Prior studies suggest that telehealth is effective for obstetric care, but little is known about its implementation in response to policy changes in underserved communities. We utilized the RE‐AIM framework to evaluate telehealth implementation in a large academic urban obstetric practice that serves a medically underserved population. METHODS: RE‐AIM elements were assessed through retrospective review of electronic health record (EHR) data for all obstetric encounters between March 19 and August 31, 2020 and review of clinic implementation processes. Data extracted included demographics, number and type (in‐person or telehealth) of prenatal visits, prenatal diagnoses, delivery outcomes, and number and type of postpartum visits. Data were analyzed using descriptive statistics. RESULTS: A total of 558 patients (60.6% Hispanic; 13.2% primary language Spanish) had 1788 prenatal visits, of which 698 (39.0%) were telehealth visits. A total of 209 patients had 230 postpartum visits, of which 101 (48.3%) were telehealth visits. The Reach of the intervention increased from 0% of patients at baseline to 69% in August. Effectiveness measures were limited but suggested potential for earlier diagnosis of some prenatal conditions. Adoption was high, with all 30 providers using telehealth, and the telehealth was found to likely be feasible and acceptable based on uptake. Increases in the percentage of telehealth visits over time and continuation post‐lockdown suggested maintenance was potentially achievable. CONCLUSIONS: The COVID‐19 pandemic has changed traditional approaches to healthcare delivery. We demonstrate that the use of the RE‐AIM framework can be effective in facilitating implementation of telephone visits in a large academic urban obstetric practice after state‐level policy change. This may be of particular importance in settings serving patients at higher risk for maternal morbidity and poor birth outcomes. populations with disparate maternal mortality and morbidity outcomes is critical to optimizing the effectiveness of telehealth for prenatal/postpartum care. We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) implementation framework 20, 21 to evaluate the rapid implementation of telehealth services for prenatal and postpartum care during the COVID-19 pandemic in a large urban academic practice. The RE-AIM framework was selected because of its utility in evaluating multiple elements of implementation of an evidence-based intervention such as telehealth. 2 | METHODS This study evaluated the implementation of telehealth services for patients who received their prenatal or postpartum care at a large urban academic obstetrics and gynecology practice located in Springfield, Massachusetts in the United States, between March 19, 2020, and August 31, 2020. The clinic is located in a tertiary care hospital and provides care for both low-and high-risk pregnancies; high-risk pregnancies are co-managed by maternal-fetal medicine specialists. The clinic serves a population comprised of 60% Latina/x identifying patients, the majority of whom had low incomes as evidenced by 89.9% being insured by Medicaid, a government-funded health insurance plan available only to people below certain income levels. The clinic serves as the regional referral center for high-risk obstetrical patients as well as lower-risk patients for the surrounding communities for whom no referral is needed. Before the COVID-19 pandemic, the clinic utilized traditional prenatal and postpartum care models, which included only in-person visits at standard visit intervals. Patients began to be scheduled for either inperson or telehealth appointments beginning on March 19, 2020 in response to the declaration of a state of emergency and the initiation of significant restrictions on in-person visits to healthcare providers. Decisions about whether an appointment would be in-person or via telehealth were made based on patient preference, medical complexity, and/or the need for ultrasound/bloodwork or other congruent inperson services. leadership about the introduction of telehealth, provider and clinic staff education about options for the provision of prenatal and postpartum care, and appropriate billing. 22 Communication with providers and staff regarding telehealth implementation took place via e-mail, memos, technical instruction regarding use of phone systems to contact patients, and mandatory virtual meetings. Video equipment was available if patients had the technology to support video telehealth visits, otherwise visits were conducted via audio-only telephone calls. New note templates in the electronic medical record also were made for telehealth visits, including the necessary information to meet billing guidelines. Providers were trained to properly confirm patient identity prior by confirming patient's full name and date of birth before engaging in any conversations with protected personal health information. We evaluated implementation of the telehealth program and selected health outcomes and processes through retrospective chart review of all pre-and post-natal care visits conducted between March 19, 2020, and August 31, 2020. These dates were chosen to coincide with the mandated lockdown restrictions in the state of Massachusetts that began on March 19, 2020 and began to be lifted at the end of May and throughout the month of June. Data were collected in July and August to evaluate the maintenance of telehealth as an option for prenatal and postpartum visits after state-mandated restrictions had been significantly eased. The following data were extracted for each prenatal and postpartum encounter using a structured data collection instrument: patient age, race/ethnicity, visit type, and pregnancy, delivery, and prenatal care outcomes as relevant to the encounter using REDCap 23-25 electronic data capture tools. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies. Application of RE-AIM framework: Reach (the proportion of a target population that participated in the intervention). Reach was assessed based on the percentage of visits across the specified time interval for each visit type (telehealth and in-person). Reach was further assessed based on population-level demographic information (eg, age, primary language spoken, insurance type, race, gravida, parity, and singleton vs multiple gestations). Effectiveness (the positive and negative outcomes of the intervention). Effectiveness was assessed by exploring various health outcomes in relation to the number of telehealth visits a patient had. Prenatal outcomes included hypertensive diseases of pregnancy (including gestational age at diagnosis), presence of pre-existing mental health disorders, and gestational diabetes (including gestational age at the time of diagnosis). Postpartum outcomes included gestational age at deliv- Implementation (the extent to which the intervention was delivered as intended). Implementation outcomes included the acceptability and feasibility of this intervention. 22 Acceptability was measured indirectly by comparing the number of telehealth visits over time, as the decision to proceed with telehealth at subsequent appointments was jointly made by the provider and patient at the preceding appointment. Feasibility was measured by the total initial uptake of telehealth services in the initial months of this intervention (March and April), as telehealth was not a service previously offered in this clinical setting. Maintenance (the sustainability of the intervention). Maintenance was measured as the total number of visits conducted via telehealth after the initial lockdown restrictions were eased at the end of June, and is displayed as the number of telehealth visits in the subsequent months of July and August. Data were analyzed using descriptive statistics, including means and SDs for normally distributed continuous variables or medians and percentiles for skewed continuous variables. Frequencies and percentages were utilized for describing categorical data. Graphical approaches were also used to illustrate the RE-AIM constructs. This study was determined to be exempt by the study site's Institutional Review Board (Reference: 1535131-2). This manuscript was created within the framework of the SQUIRE (Standards for Quality Improvement Reporting Excellence) and StaRI (Standards for Reporting Implementation Studies) guidelines. 27,28 A total of 558 prenatal patients and 209 postpartum patients who had 2028 outpatient visits were analyzed. Across both types of patient visits, mean age was 27 years, 60.2% identified as Hispanic, with 13.2% having a primary language of Spanish. The majority of patients were insured through Massachusetts's Medicaid program (89.0%). Additional demographic information is presented in Table 1 . Delivery data were available for 110 of the prenatal patients during the study interval ( Table 2 ). The results below are organized by RE-AIM construct and are summaritvely organized in Table 3 . Reach: Of the 2018 total prenatal and postpartum visits conducted during the study period, 698 visits (34.4%) were conducted via telehealth. Looking exclusively at postpartum visits, of the 209 patients who had at least one postpartum visit, 108 (51.7%) had only in-person visits and 101 (48.3%) had at least one telehealth visit. A total of 8 of the 698 total telehealth visits occurred via video conferencing, with the remaining occurring via telephone only. Effectiveness: The overall prevalence of hypertensive disease of pregnancy and gestational diabetes mellitus and estimated gestational age at the time of diagnosis by visit type is shown in Table 4 . Findings Table 5 . Finally, as demonstrated in Figure 1 Table Reach Proportion of a target population that participated in the intervention. Demographic breakdown of population characteristics and proportion of telehealth visits compared to total visits before and after telehealth implementation. Percentage of telehealth visits compared to total visits on a month by month basis throughout the study time period. Implementation (acceptability and feasibility) Extent to which the intervention was delivered as intended. Indirect comparison of the number of telehealth visits over time, with particular focus on interval after state-mandated lockdowns began to lift (May and June), as well as the breakdown of percentage of telehealth vs total visits broken down by gestational age to assess for whether certain prenatal/ postpartum care intervals are more acceptable than others. Total initial uptake of telehealth services in the initial 2 months of the intervention (March and April). The results of this study suggest that rapid implementation of telehealth visits for prenatal and postpartum care is feasible in a practice serving a low-income, majority Latina/x patient population using a parsimonious set of implementation strategies. Measures of reach and adoption suggested that uptake of the telehealth intervention was ubiquitous in the practice and that implementation outcomes measured suggested acceptability and appropriateness of telehealth. Although additional evaluation post-COVID will generate a better understanding of maintenance of telehealth, this study's early assessment suggested that maintenance of telehealth visits once in-person restrictions were lifted in the state of Massachusetts was achievable and feasible. The risks associated with in-person medical encounters due to the COVID-19 pandemic created an unprecedented need for rapid innovations in healthcare delivery. The pandemic has also illuminated and exacerbated long-standing racial and ethnic inequities in health and healthcare. 7 Telehealth was technologically feasible before the pandemic, but the need to limit in-person visits coupled with statelevel policies to facilitate rapid adoption of telehealth led to a dramatic increase in remote healthcare delivery. Many medical specialties responded to the COVID-19 pandemic by implementing telehealth services. 12, 29 Given widespread patient dissatisfaction with the pre- compare implementation strategies in different contexts will extend the knowledge gained from the current study. Estimations of cost or cost-effectiveness will also be important to understand the long-term financial impacts of telehealth and its sustainability should it continue to be used for a substantial portion of prenatal and postpartum visits. The study was undertaken at a time when healthcare organizations were in crisis in Massachusetts and healthcare providers under substantial duress, so formal surveys and interviews to evaluate provider satisfaction with telehealth were not conducted but would be important in future studies as well. Previous studies have reported high patient satisfaction with the implementation of telehealth in obstetrics care, and given that patients had an active role in deciding whether or not they had in-person or telehealth visits in this study, suggesting that patient satisfaction might be high in this setting. 38, 39 Ascertaining patient's satisfaction with prenatal and postpartum telehealth visits among patients in lower-income and racial/ethnic populations will be important to be able to tailor services to patient's needs and better understand the role telehealth may play in addressing inequities in maternal health care and disparities in maternal morbidity and mortality. The RE-AIM framework was a useful tool for evaluating implementation and maintenance of a new intervention in the obstetric setting and should be considered for use more broadly. Given the extensive racial and ethnic disparities in obstetric care, future studies should determine the impact of telehealth specifically on these disparities. If telehealth is found to be associated with improved outcomes, it will also be important to identify the mechanisms through which it has an effect, such as removal of barriers to access to care (ie, transportation) or increased self-efficacy through joint decision-making. 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