Building on Solutions Devised During the Pandemic: Meeting the Health Needs of Marginalized Communities

Dr. Andrew Hsi

In the throes of the pandemic, New Mexico successfully instituted telehealth visits for many behavioral health issues, especially for adolescents. Further, the state quickly added telehealth to the payment schedule and ensured that virtual visits pay at the same level as in-person visits. The speed and efficiency with which these things got done showed how nimble the system can be – that, in fact, it can turn on a dime if needed, especially when health systems and state government have informed and compassionate leadership. But it has been harder to find that capacity on display when it comes to providing equitable access to services and supports for New Mexico’s Hispanic, African American, and American Indian/Alaskan Native populations, many of whom are essential workers. I have watched firsthand as the pandemic, in many instances, has put marginalized communities at even greater risk than before, with few, if any, solutions offered for the issues they have faced. However, I cannot discount some positive changes we have seen as well. While some may be tinged with caveats, there is room to build upon and improve them.

Program and Policy 
The biggest change we have seen is the willingness of Medicaid to reimburse at the same level for both office and virtual visits. The impact of this decision is significant given New Mexico’s sizeable rural population. The reimbursement is also the same for early intervention whether services are provided virtually or in person. It is incredible how quickly this new policy got enacted. And it makes one wonder why other decisions could not be made as quickly. 

Another change we have seen is that for families that have a working smart phone or other digital technology, access has improved through the virtual environment. This is helpful from an equity standpoint, specifically for families living in rural communities in proximity to more urban areas. In addition, more frequent contact via technology has been helpful on an emotional level to the families we serve. The red flag here is that for the working or middle class families that we serve – many of them essential workers in food service, or working in big box stores or warehouses -- the virtual world can’t accommodate their after-hour and continually shifting schedules. And for these families, there is additional stress with regard to child care.

Service Delivery 
We have been able to follow children with special needs virtually, particularly those with prenatal opioid and other substance exposure and developmental delays or risks for delays. We think that this is a positive and we would like to continue this practice going forward. We have incorporated psychiatric services into primary care for adolescents holding combined medical and psychiatric clinics weekly for youth released from detention facilities. This model has greatly reduced access problems for adolescents with complex mental health issues and substance use disorders. Going forward, we know that in-person psychiatric care is important but perhaps we can mix Zoom and in-person care. We can see benefits for the children involved.

Family Support
Families who were texting and communicating virtually before the pandemic have been able to stay engaged. But for families who were not previously engaged, we are still experiencing challenges. Many, for example, cannot afford the cost of cellphone data or plan minutes. The effort to support our families is not always smooth. We do a lot through Zoom but it is important to stress that our families are high risk and that it was tough to do this previously and remains so. Further, we see persisting issues in the interface between the hospital experience and the community early intervention experience. This is particularly true when hospital systems Have implicit biases against specific parents as those from underrepresented minority populations or parents with substance abuse disorders. Changing this by policy or practice would be an important step in anti-racist medical practice. 

Innovations to Sustain and Develop

  • Make sure that we have systematically provided our families not just with smart devices but also with the payments for the data services and the data access that they need. 
  • Continue virtual health care team meetings. They provide the opportunity for communication among various constituents, schedules to be reviewed, and patients to be discussed. This is particularly helpful regarding populations in rural locations.  
  • Virtual training of health care staff will help with medical supervision and observations, and has real potential.
  • Worksite policies that allow parents to have time for communication with healthcare providers.  

My experience with a 15-month-old opioid-exposed toddler needing medical and developmental services is illustrative of this last point. Her mother receives medication-assisted treatment in our program. As a health field worker, her expanded work schedule during the pandemic has not permitted her to participate in her child’s virtual early intervention services. She takes time off for her own treatment visits and her toddler’s medical visits, but she cannot afford more time off to be at home when early intervention therapists can contact her.

As a policy, primary clinical sites should make some accommodation for expanded visits while allowing providers to maintain social distancing or for employers to provide expanded medically necessary leave so parents can participate in virtual visits to expedite complex care for young children with developmental risks.

Moving Forward
The innovations we devise and expand on during and after the pandemic must consider the needs of the most marginalized communities. Further, they must be based on a model of health care that requires a comprehensive approach, bringing together physical and behavioral health care, care coordination, and the mothers and family members with their babies. We need to create a deeper continuum of support, outside of our hospital system. But, thinking about a new way going forward, we must do more with our primary care networks and our supportive and recovery services. This should be reconceptualized as family services, directed at all members of the families to assist them and to improve their health and well-being. Health is very large - economic, physical, intellectual, behavioral - and it all needs to be better integrated in the future.   

 

About the Author

Dr. Andrew Hsi is a primary care clinician who founded and directs the Institute for Resilience, Health and Justice to address the racial inequities facing Hispanic, African American, and American Indian/Alaskan Native children in New Mexico. The Institute focuses on infants with prenatal exposure to alcohol and drugs and their mothers, thus connecting primary care and early intervention in a coordinated program that is comprehensive in its approach to parents and young children. It also focuses on adolescent physical and behavioral health services, particularly regarding teens involved in the juvenile justice system. His work is grounded in racial and economic justice.