“There is no doubt this has been the most difficult year in the history of healthcare, but in many ways, it was also our finest hour,” reflected Jeffrey Hughes, interim president and CEO of Wentworth-Douglass Hospital.

When last year’s stay-at-home order altered the way people interact, local healthcare providers were quick to respond. We reached out to several providers to learn how the pandemic has changed the industry, how providers are making visits more accessible and how they’ve enhanced that care.

Our panel:

• Donald Reape, MD, Internal Medicine at St. Joseph Hospital Primary Care in Nashua

• Cathy Slack, Director (NHS), BAYADA Home Health Care

• Dr. William Brewster, MD FACP CHIE, Vice President Harvard Pilgrim Health Care – New Hampshire Market

• Jeffrey Hughes, Interim President & CEO, Wentworth-Douglass Hospital in Dover

Donald Reape, MD, Internal Medicine at St. Joseph Hospital Primary Care in Nashua

Q: How have patients adapted to virtual visits?

A: “The pandemic created a situation where utilizing virtual health was not optional, but rather the only way for patients to receive care for a long period of time. This situation has provided a large pool of patients and providers who experienced virtual health for the first time, while research points to the fact that a number of them will continue to utilize virtual health as an option moving forward. Also, it is encouraging to see that providers and patients alike rate virtual visits onpar with in-person visits – in our own internal surveys as well as broader national surveys on provider and patient experience. The pandemic has and will continue to change the way care is delivered, and the changes we saw are more of a long term change than a temporary shift.”

Q: Why would/should someone choose a virtual visit?

A: “Virtual health is a timely, convenient and cost-effective solution for patients to receive healthcare services. A large percentage of healthcare services can be delivered safely and appropriately to patients in their home on their personal devices so it is a valid option. Virtual health also expands access to care so even patients in remote locations can get access to high quality specialty services close to home. Virtual health saves money as well by avoiding the need to travel to meet the provider.”

Q: How can someone take advantage of virtual visits if they only have access to a telephone?

A: “During the pandemic, a number of health insurance companies have significantly relaxed regulations around billing so providers are able to offer ‘telephone consults,’ and get paid for the services offered. Also, patients that have a smartphone can meet their provider virtually with just one click in a quick and HIPAA secure manner.”

Q: In what ways was St. Joseph equipped to deploy virtual visits at the outset of the pandemic?

A: “We had experience offering virtual visits in Nashua before the start of pandemic.

Also, there was sufficient internal expertise and know-how regarding Telehealth, which enabled us to quickly identify and deploy a Telehealth solution to deliver services to patients in their home during the time the pandemic was about to start.”

Q: How are virtual visits changing healthcare?

A: “Virtual health has radically improved access to care, improved quality of care by providing timely access to care and reduced cost of care. The value proposition is now clear and evident and I strongly believe virtual health has entered the mainstream.

Healthcare organizations of all sizes have embraced it and will continue to do so for the foreseeable future.”

Cathy Slack, Director (NHS), BAYADA Home Health Care

Q: What is Private Duty Nursing? A: “Home care is a broad term and includes any professional support services that allow a person to live safely in their home. Many are familiar with the services provided by visiting nurse associations (VNA) but may not be so familiar with the services provided via private duty nursing (PDN), also commonly referred to as continuous care nursing or block nursing. PDN provides skilled long-term, hourly nursing care at home for adults and children with a chronic illness, injury, or disability. PDN nurses provide comprehensive one-to-one care for two to 16 hour shifts based upon provider orders and the client’s or family’s scheduling needs. Some of the common skills and interventions provided by PDN nurses include care for diseases and conditions such as traumatic brain injury, spinal cord injury, genetic disorders, ventilator care, tracheostomy care, monitoring vital signs, administering medications, ostomy, and gastrostomy care, feeding tube care, catheter care, and seizure management. BAYADA private duty nurses can help keep their clients safe at home, with their family and where they want to be. In addition, nurses from BAYADA follow the Center for Disease Control and Prevention (CDC) protocols to keep their clients safe and prevent the spread of COVID-19.”

Q: How has telehealth/virtual visits affected patient care?

A: “The short answer is-it has only enhanced it! Clients and their families feel safer because they can reduce foot traffic in their home when services can be successfully provided remotely. There is also the added benefit of increased flexibility and convenience for scheduling around what works best for the client. Of course, there is hands-on care that we cannot perform with telehealth; that is where we rely on our skilled field nurses who are highly educated in infection control and fitted with CDC recommended personal protective equipment (PPE). Overall, telehealth and virtual visits have enhanced our ability to connect, collaborate, and monitor our clients’ progress while ensuring safety as a top priority during these unprecedented times.”

Q: How does home healthcare provide safe care during the COVID-19 pandemic?

A: “During this pandemic, BAYADA private duty nurses continue to provide one-on-one medical care. BAYADA nurses receive comprehensive age and diagnosis-specific training, including annual, mandatory infection prevention education. During COVID-19, infection prevention education became a top priority, as BAYADA’s clinical leaders used CDC guidelines to develop ongoing and evolving trainings and communications materials on keeping nurses, their clients, and family members safe.

“Throughout the past year, private duty nurses faced fears of exposure, lack of PPE, additional responsibilities, and pressure with the on-going nursing shortage. They also were at risk of losing wages if there was a COVID case in a client’s home, a client declined non-family members in their home, or they were exposed to COVID-19 and needed to quarantine. BAYADA ensured that PPE was available for all of their nurses. In addition, the state of New Hampshire provided weekly stipends for hazard pay and BAY- ADA was able to assist with lost wages, in some cases.

“COVID-19 has emphasized the benefits of home-based healthcare delivery and the critical role the private duty nurse plays to decrease the follow-up hospital readmission. BAYADA is proud of the compassion displayed by the private duty nurses on their team and are grateful for the continued quality services through this critical time.”

Dr. William Brewster, MD FACP CHIE, Vice President Harvard Pilgrim Health Care – New Hampshire Market

Q: How has telehealth changed your practice/facility, and what has the patient reaction been?

A: “At Harvard Pilgrim, we’ve been including telemedicine as part of our plans for years. The benefits of having access to asynchronous messaging, video conferencing, and mobile provider apps have the potential to overcome some of the challenges that many people have experienced when it comes to receiving quality care that is accessible, affordable and convenient.

“Healthcare providers and insurance carriers have all recognized that the need for care doesn’t always happen when it’s convenient to get to your doctor’s office or a local urgent care facility, if you even have one in your area. As you can imagine, over the past year we have seen a significant increase in telehealth use for both medical visits but also for behavioral health visits. Before the COVID-19 pandemic started in 2020, only .05% of our medical visits were telemedicine. However, as facilities shut down and had to pivot their operations, we saw that telemedicine usage rose to over 67% and has now maintained at approximately 30 – 35% of all medical visits. The numbers are similar with behavioral health starting at less than 2% of the all visits, rising to over 85% and maintaining a strong usage today.

“Whether it’s an urgent care visit, an ongoing maintenance appointment or even a meeting with a specialist, the overall feedback from members has been extremely positive. When you match quality care from a provider with easy access and convenience for the patient, it really is a win-win.”

Q: What types of treatment are best served by remote visits, and why should I consider this approach?

A: “With real-time audio and video connections between a provider and patient, a virtual visit is best used for non-emergent care. If someone is experiencing a lifethreatening situation, they should always call 911 and/or go to the emergency room. But for other situations like annual appointments and follow ups with your primary care provider (PCP), urgent care visits for things like coughs, colds, flu, nausea, rashes, sinus issues or bronchitis, and behavioral health visits for depression or anxiety, telemedicine is a great option. And in many instances a paperless prescription can be sent to a preferred pharmacy if medication is necessary.

“Whether it’s telemedicine or through a face-to-face appointment, it’s important to remember that the quality of care is going to remain the same. But, with telemedicine, you do have some different conveniences. With just an internet connection and a smart device, you can receive care from a licensed medical provider. For those who live in rural areas, experience transportation barriers, or are even on vacation, a virtual visit provides convenience and care from the privacy of any location. Even things like bad weather become less of an obstacle for those seeking care. It also can help increase availability and access. If something happens in the middle of the night, using a 24/7 urgent care mobile app could provide the care you need right away. Or if you’re looking to schedule a behavioral health visit, a telemedicine appointment may be available more quickly.

We’ve seen that faster access to care can provide better outcomes, and telemedicine is one tool to help support that.”

Q: What telehealth policies and practices do you think will endure when the pandemic is over and why?

A: “Our brand new SimplyVirtual plan emphasizes a virtual PCP relationship for all adults on the plan while children under the age of 19 would continue to see an inperson PCP. The plan provides 24/7 access to telemedicine visits and easy referrals to providers and specialists when an in-person service is needed, all with a lower visit cost share than if you went into an office.

“Beyond just convenience and cost, the experience is important. With this virtual primary care plan, members have a seamless continuity of care for preventative, urgent, and behavioral health while still building relationships with a dedicated care team including their PCP, nurses, care managers, nutritionists and personalized care plans. While the SimplyVirtual plan is a first for our area, it is just one example of healthcare innovation.”

Jeffrey Hughes, Interim President & CEO, Wentworth-Douglass Hospital in Dover

Q: Why do you believe so many hospitals are partnering together to form larger healthcare systems?

A: “Well certainly the current economic reality of the industry is what’s driving the increase in these affiliations as a national trend. When you think about New Hampshire alone, it wasn’t long ago that our state had 26 independent hospitals. Now the vast majority of them are part of a multi-hospital system. And it’s really because the economic model of healthcare continues to change rapidly. We’ve seen a shift from a volumebased, fee-for-service reimbursement, to a value-based payment system that’s based on quality outcomes, cost-effective care, and financial risk for population health. That sort of shift has broad implications for both hospitals and physicians, and presents a fundamental change in the drivers for revenue and margin success. For Wentworth-Douglass specifically, a formal affiliation was necessary to secure our long-term economic viability and assure continuance of our mission to meet the healthcare needs of the community. As healthcare transforms, we have to continue to build the infrastructure, systems, and capabilities to thrive in a risk-based environment. Patients and their payors are increasingly seeking improved levels of quality healthcare and exceptional customer service at an affordable price. We need to continue to exceed national and state benchmarks in quality and patient satisfaction to keep pace. And becoming part of a larger healthcare system ensures our community access to a full continuum of services, increases and sustains our quality, and ultimately achieves better economies of scale. But in the end, every decision we make is grounded in what’s best for our patients. That’s our biggest priority in everything we do. So for us, the ability to collaborate with a world-class hospital system like Mass General Brigham was an exceptional opportunity.”

Q: How exactly do patients benefit from these affiliations?

A: “Integrating the uniqueness of each institution really broadens the impact we can have on the health of our patients, and the entire community we serve. Most notably, our affiliation with Mass General Brigham brings world-renowned healthcare directly into our New Hampshire communities. Wentworth-Douglass has now become a leading destination statewide for specialty services to treat conditions not traditionally available at community hospitals. We have a growing number of advanced medical offerings that are now accessible locally, without requiring patients to travel out-of-state. Patients also have a direct link to the entire Mass General Brigham system, when conditions and injuries require an even higher level of care. All of this equates to a seamless experience for patients. For example, you may seek care at different Mass General Brigham facilities across the Seacoast, or even into Massachusetts, but everything will be integrated and coordinated into a single medical record, accessible to all members of the patient’s healthcare team across the entire MGB system, regardless of where the patient might be receiving care. That allows us to deliver exceptional care and lower costs, while making the system much easier to navigate.”

Q: Are patients reluctant to return to healthcare facilities due to COVID-19?

A: “Unfortunately, yes. The CDC estimates that 41% of U.S. adults have avoided medical care, because of concerns regarding COVID-19. It’s an understandable, but alarming statistic. Our plea to the community continues to be: for the safety of yourself and your family, please don’t delay medical care.

Even routine diagnostic and preventative care is critical to your health and well-being. We’ve taken extraordinary steps to make sure all our facilities are outfitted with CDCcompliant best practices. And every aspect of our organization – from elective surgery, to emergency care, to dentistry – is currently operating and doing so in a safe manner. A virtual appointment remains an option for many patients, as well.”

Q: What impact has the pandemic had on the roles of nurses, nurse practitioners or physician assistants?

A: “There is not one of us who has not been impacted by COVID-19. I think the past year has unraveled at a frenetic pace for everyone in our industry. But I’m incredibly appreciative of the gargantuan efforts our employees have undertaken to surpass some incredible challenges. We quickly mobilized a system to safely screen, test, and isolate patients. We transformed the interior and exterior of Wentworth-Douglass in ways never seen before. And we worked rapidly to implement protocols to stop the spread of the virus – just to name a few. All of this was accomplished by our incredible staff, despite difficult and unforeseen barriers, and personal sacrifices. Over my 38-year career, I have never been more proud to work with individuals so dedicated to our patients, our community, and to each other. There is no doubt this has been the most difficult year in the history of healthcare, but in many ways, it was also our finest hour.”