COVID-19 Crisis Exposes Missing Social Determinant of Health Domain

The Visiting Nurse Service of New York (VNSNY), established in 1893, is the oldest and largest not-for profit home health care agency in the country. VNSNY established its Community Mental Health Services (CMHS) division in 1986 with the first community based mobile crisis program. As a division, we now encompass over 30 community-based programs serving some of the most disenfranchised populations in New York City. We provide a wide range of services, including psychiatric assessment and treatment, crisis intervention, and care management. The variety of programs and services we offer allow us to reach many underserved populations, many of whom are on Medicaid or uninsured. In 2019, we served over 16,000 NYC residents, providing over 120,000 visits in their homes and communities. Given our expertise and ability to reach these populations where they live, we are well positioned to capture social determinants of health (SDH) data.

Since the beginning of the COVID-19 emergency, we have provided critical behavioral health interventions to nearly 7,500 residents. Never has the need for mental health interventions been so important to prevent isolation, escalation, and institutionalization. Those we serve have a higher incidence of trauma, anxiety, and depression as well as the need for assistance accessing benefits and necessities such as housing, food, and medication. However, we went from making close to 10,000 in person visits per month to roughly 100 per month during the height of the pandemic. COVID-19 disrupted our normal service delivery and in order to keep staff and clients safe, telehealth quickly became an effective means to provide care. There has been a significant increase in the use of telehealth nationally with a “… 154% increase in telehealth visits during the last week of March 2020, compared with the same period in 2019 [which] might have been related to pandemic-related telehealth policy changes and public health guidance” (L.M. Koonin, et al, Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic – United States, January-March 2020, 2020).

Telehealth is the method of providing medical and mental healthcare via technology while the clinician and patient are in different locations. The American Psychiatric Association (2020) outlines the benefits of telehealth as the following, but not limited to: improving the continuity of care and follow up; reducing travel time and waiting room time; bringing care to the patient’s location where they may be more comfortable; reducing the barrier of stigma; and reducing delays in care. Emergency regulatory waivers and policy changes allowing for telehealth visits during the pandemic were temporarily established and were crucial for continuing to provide accessible and vital services while social distancing orders were in place. Coalitions of behavioral health and care management providers have been advocating with New York State to make many of the emergency regulations permanent.

However, what we have learned is that access to technology and broadband service – and therefore telehealth – is not equal. Low socioeconomic status individuals and communities “face financial barriers to afford smartphones and the internet” and are also “associated with less freedom of leveraging the technology when and where one wants which encumbers timely help-seeking behaviors and treatment delivery” (Y. Zhai, A Call for Addressing Barriers to Telemedicine: Health Disparities during the COVID-19 Pandemic, 2020). In NYC, “there is a gap in the adoption of broadband, particularly among older adults and lower-income residents of the City” (nyc.gov, Broadband Access, 2020). Many of our clients live in residential settings such as NYC public housing and homeless shelters where broadband services are not available. The relationship between poverty and poor health is clear, only further evidenced by this pandemic. Many of the highest rates of COVID-19 infection and death occurred in poor neighborhoods, where many people live in the same household – often multigenerational, and access to medical care, food and other necessities are the most limited. Poverty, however, also has a major impact on access to technology, which has become a more critical factor than ever in one’s ability to get timely and quality healthcare.

Prior to the COVID-19 emergency, we were planning to implement a comprehensive SDH survey in order to help us understand and address barriers that clients are facing to achieving healthy outcomes. The survey was designed using: the National Association of Community Health Centers’ Protocol for Responding and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool; the Centers for Medicaid and Medicare Services Accountable Health Communities (AHC) Health-Related Social Needs screening tool; our own observations of the populations we serve. But when the COVID-19 crisis hit NYC, our plans changed. To better understand our clients’ more immediate needs during the pandemic we created other survey tools, one of which was a Telehealth Survey. It included questions about urgent social determinants of health needs (e.g. housing, benefits, and food), access to technology and broadband service, and client preference for different service delivery methods.

The Telehealth Survey collected responses from 473 clients and results indicated that over 30% of them were unable to participate in video visits due to a lack of broadband access and/or video capable devices. Results also indicated that over 90% of clients prefer to receive their services with at least some telehealth component – whether exclusively by telehealth visits or a combination of in person and telehealth visits. This clearly demonstrates that the clients prefer, and could benefit from, telehealth services but many lack access.

The COVID-19 crisis, which has led to a substantial increase in the use of telehealth as a service delivery method, has exposed a gap in the variables we initially planned to include in our original SDH survey. Access to technology and broadband service is a key social determinant of health domain.

Public health professionals have long recognized the impact that SDH have on overall health and wellbeing. The COVID-19 crisis has highlighted this knowledge for a broader audience, exposing how deeply disparities in income are linked with poor health outcomes, especially among those with complex behavioral health conditions. The behavioral health world is moving toward increasing the use of telehealth because “[t]he rapid spread and high economic cost of COVID-19 have exposed the shortcomings of the healthcare system writ large and have highlighted the urgency of rethinking how services are delivered in the USA” (E. Whaibeh, H. Mahmoud, H. Naal, Telemental Health in the Context of Pandemic: the COVID-19 Experience, 2020). We must ensure that the populations we serve have access to the tools and technology required to participate in these services. Initiatives to address SDH must include not only improved access to medical and behavioral healthcare, healthy food, stable housing, and education, but also to the technology required to participate in telehealth sessions. Access to technology and broadband service is a basic social determinant of health for obtaining healthcare services in an environment where telehealth has become a primary service delivery method. As a social determinant of health domain, broader access to technology and broadband service is a medical necessity and should be treated as a right, not a privilege. It is now a critical factor in being able to connect with medical providers and have full access to medical and behavioral health services.

Leah Blumberg, MPH, is Division Manager, Susan Rabinowitz, MBA, is Director, Quality Improvement and Special Projects, and Neil Pessin, PhD, is Vice President, Visiting Nurse Service of New York (VNSNY). You can find out more about VNSNY at www.vnsny.org. If you have questions or comments about CMHS and/or this project, please email Leah Blumberg at leah.blumberg@vnsny.org.

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