Creating an equitable virtual urgent care service

Partnering with a large vendor might have been less expensive and would likely have allowed for a faster rollout. However, NYC H+H wanted to be able to customize the new service to ensure a positive patient experience. If patients didn't like the service, they wouldn't use it—which would have hurt the most vulnerable populations and widened inequities.

NYC H+H instead partnered with Bluestream Health, a small, New York-based telehealth vendor, to craft and launch Virtual ExpressCare. This partnership allowed NYC H+H to satisfy three “experience imperatives” that the system viewed as nonnegotiable.

“From day one, [Bluestream Health] had the same goals as us: meeting consumer demand and co-developing a solution with us as partners. Large vendors just don’t do this in my experience. If we had gone for a big vendor, we would have gotten up faster or gotten more scale, but we wouldn’t be able to reach that nuanced and diverse NYC consumer demand as fast or effectively as we could with Bluestream.”
-Erfan Karim
Sr. Director, Mobile Integrated Health

Imperative 1: The service could not be portal- or app-based

Typically, virtual urgent care services are app- or portal-based, and users must take extensive action to access care (e.g., download the app, sign up, set log-in and password, two-factor credentialling, etc.). Cumulatively, these actions result in a worse experience that can even deter users from completing registration steps. This imperative drove NYC H+H to choose Bluestream Health over a larger vendor, as Bluestream could provide a web-based digital platform for Virtual ExpressCare. This platform requires minimal action to acquire access—all patients need to do to access Virtual ExpressCare is navigate to the website and click a link. No smartphones, apps, or high-speed internet necessary. (See the Virtual ExpressCare landing page in the Supporting artifacts section on page 16 of the PDF.)

Imperative 2: The service had to seamlessly connect to community partners and internal services

For any virtual ED alternative, there will always be a group of patients that will require in-person care (patients with trauma, homicidal/suicidal ideation etc.). It was therefore imperative that the new virtual urgent care platform could be easily accessed by partners and services such as emergency/ambulance services or NYC H+H’s internal nurse triage center. If the platform did not connect to these services, transitioning patients between the different modalities would be cumbersome, time-consuming, and confusing for the patient—ultimately disrupting their care journey and worsening their experience with the service. It would also result in a slower time-to-treatment and a higher number of costly, unnecessary ambulance visits.

Bluestream Health’s virtual urgent care platform can be easily accessed via web-link or phone by NYC H+H’s external partners, including homeless shelters, EMS, the city’s Covid-19 test and trace services, and others. To ensure seamless care transition for complex or acute cases, the system directly connects to 911 and relays the patient’s location data to emergency services to improve time-to-treatment. And it is also easily accessible to many of NYC H+H’s internal services including their call center and nurse triage and remote monitoring program—ensuring a smooth transition between care modalities.

Imperative 3: The service had to provide a diverse set of communication channels for patients to choose from

The population of NYC is extremely socioeconomically and ethnically diverse, and patients utilize virtual services in different ways depending on their own preferences. Additionally, many patients would prefer to access care in their own language. NYC H+H knew that their virtual urgent care service had to offer more than just an on-screen/video option so patients could use a communication channel they felt comfortable with. They also had to find a vendor that could plug in language and translation services.

NYC H+H selected Bluestream Health’s platform because it provided an audio-only option as well as an on-screen video option. To use the audio-only option, all patients needed to do was dial a number and they would be connected directly to Virtual ExpressCare. Additionally, Virtual ExpressCare enabled NYC H+H to use their partner Language Line’s translation service on both the web-based and audio-only options. This service provides translation for over 200 languages, including American Sign Language.

Historically, structural friction—inflexible, arduous access barriers or steps—in the virtual care pre-visit pathway has been a significant deterrent for vulnerable people to rapidly access care. Three of the most common sources of friction are the technological and socioeconomic barriers to access, burdensome steps when enrolling for care, and stringent eligibility criteria that may prevent those who most need the service from accessing it. NYC H+H and Bluestream Health designed Virtual ExpressCare to overcome these challenges.

Virtual ExpressCare proactively addresses common historical barriers to patients accessing virtual care

NYC H+H had to reduce the structural barriers that prevented its patients from accessing the new service—otherwise the system would become disconnected from its targeted audience, vulnerable patients. NYC H+H tailored Virtual ExpressCare to remove five key access barriers in the following ways.

1. Limited smartphone access and digital literacy: NYC H+H’s vulnerable patients are often not able to use smartphones due to their cost and the IT literacy required to use them. Virtual ExpressCare is largely web-based, meaning patients with lower IT literacy can access it and patients don’t need to be able to afford a smartphone to use the service

2. Insufficient broadband access: NYC has a significant proportion of socioeconomically deprived residents, and 30% of all the city’s residents don’t have access to broadband. Virtual ExpressCare’s audio-only option means this patient cohort could still access the service.

3. Service siloed from key referral partners: Many of NYC H+H’s most vulnerable patients typically presented to the in-person ED via community partners including homeless shelters and 911. Virtual ExpressCare directly connects with these services, ensuring the most vulnerable patients can still access virtual urgent care when they need it.

4. Communication barriers: Approximately 25% of all NYC residents aren’t proficient in English. To continue equitably serving this cohort of patients, Virtual ExpressCare’s plug-in language services allow patients who are not proficient in English or are hard-of-hearing to get the same level of access to care as other patients.

5. Wait times: Predicting demand for a new service can be difficult. NYC H+H implemented Virtual ExpressCare initially at only one provider to learn about demand for the service and match staff accordingly. Then, NYC H+H expanded the service to all their providers and can now forecast demand and match supply accordingly. There is now a 2.5-minute average wait time for patients to access the service.

NYC H+H’s “wants versus needs” framework ensures minimal friction in the pre-visit workflow

Access to many virtual care platforms is limited by the amount of patient data the platform requires. This is a major problem for two reasons. First, patients are often uncomfortable sharing their information, especially as they are often unclear where the data will end up. This is particularly true for the most vulnerable patients in society. Second, asking for a lot of information before the virtual visit starts can make the service feel transactional—it loses the personal touch of in-person care. Essentially, forcing patients to share more data than you need risks pushing them away from the system and from the care they require.

NYC H+H assess what information was absolutely necessary—separating the “need to know” from the “nice to know”. They decided that the only pieces of data they needed from patients who accessed Virtual ExpressCare were the patient’s name, date of birth, and symptoms, as well as a phone number where the patient could be reached. Other details (address, email, Social Security number, etc.) weren’t vital to patient care, so patients didn’t have to provide them. Instead, these other pieces of information could be tracked down if they became necessary later. (See the Virtual ExpressCare access form in the Supporting artifacts section on page 17 of the PDF.)

By limiting unnecessary steps to accessing care, NYC H+H proactively limited friction between patients and the health system.

“‘Three clicks or less’ was our mantra. The value was getting someone in front of the patient as soon as possible, not mining the patients for their data…We are obsessed with experience in a way that’s no different than Amazon’s obsession with the customer.”
-Erfan Karim
Sr. Director, Mobile Integrated Health

Virtual ExpressCare is the first urgent care platform in the US to not use ‘ability to pay’ as a defining eligibility criterion

In some jurisdictions, including the United States, many systems limit access to a service to only those patients who can pay for it. NYC H+H found when reviewing other urgent care models that it was common for uninsured patients or patients who could not afford out-of-pocket expenses, some of whom were the poorest residents in the city, to be denied access to these services.

Virtual ExpressCare goes against the U.S. industry standard by not looking at ability to pay as a defining factor for eligibility. Virtual ExpressCare does not ask for payment or insurance information up front as a gateway for patients to access care. Instead, the service deals with payment after the patient is treated by working with payers—including CMS—to reconcile outstanding bills. NYC H+H covers the cost of visits for which they are not paid. Not only did this prevent further widening of health and access disparities, but it made the Virtual ExpressCare care pathway more streamlined and seamless for the user.

NYC H+H didn’t stop there. As part of Virtual ExpressCare and to help their patients access affordable care, NYC H+H actively helps enroll patients who aren’t covered by insurance into appropriate payment plans. These health plans can be offered through a competitor or a public option such as NYC Care, or patients are enrolled into NYC H+H’s own low-cost health plan, MetroPlus.

This concierge-like service greatly improved patient’s experience of virtual urgent care. Patients who use these services feel like the system really cares for their health and financial security. This makes patients feel more engaged with their care and with the health system as a result.

Attracting patients to use a new virtual urgent care service, especially one they have not used before, requires an element of trust. This is especially true for vulnerable patients who often feel unsupported by virtual care offerings, which many patients wouldn’t have used before and therefore are unsure how to utilize these services and where they fit in the patient’s care journey. This is a problem if health care providers want to encourage these patients to use new virtual urgent care services instead of going to the in-person ED unnecessarily.

To enhance vulnerable patients’ experiences with Virtual ExpressCare, NYC H+H created a staffing model to help guide and support them throughout their care journey and ensure it felt familiar by using two tactics. Firstly, Virtual ExpressCare employed staff who culturally matched the communities they served, which helped to build trusting relationships with patients. Secondly, NYC H+H hired a person to provide dedicated pre- and post-visit support for vulnerable patients, which makes it easier for patients to understand their care journey and move through the system smoothly. The new staffing model helped make the experience with Virtual ExpressCare feel like an in-person clinic, making patients feel at ease throughout their journey and increasing the “stickiness” of the service.

Staffing model matches cultural profile of patients with providers

NYC H+H uses an on-demand staffing model similar to that of Uber. Clinicians from across the United States can offer blocks of time to see patients in NYC, so long as the clinician has a license to practice medicine in the state of New York. This model has greatly expanded NYC H+H's staff supply and allowed the organization to easily hire people who match the diverse population it serves, which has helped foster trust and build a connection between NYC H+H and its patients. Because they are no longer held back by geography, NYC H+H can find providers that represent diverse racial, ethnic, and linguistic backgrounds to support their equally diverse patients within their care journey. Connecting patients with staff they can trust and that can facilitate their access and journey through the system greatly enhances patient experience both with the virtual urgent care service and the health system as a whole.

‘Support heroes’ facilitate the patient journey and build trust with patients

NYC H+H created a unique staffing position called support heroes. These are members of staff that serve as the pre- and post-visit interface with the patient. They are hired from within the health system, tend to be multilingual, and live in the target community they serve. Support heroes have practical experience of working in the ED of ambulatory settings and take the non-clinical work away from clinicians. The support heroes help patients sign up for primary care and insurance, perform registration tasks, facilitate data collections, and work with the clinician and patient to determine next steps after the visit. This enables clinicians to practice top-of-license care.