Los Angeles County Department of Public Health- Telehealth Therapeutics

The COVID-19 pandemic resulted in a public health emergency that has contributed to over 34,000 deaths in Los Angeles County. The Department of Public Health (DPH) has worked to prevent illness, hospitalization, and death due to COVID-19 and developed the Therapeutics Program with the goal of providing equitable access to lifesaving therapeutics by implementing multiple strategies with a focus on vulnerable populations and reducing health inequities. When COVID-19 medications initially became available in LA County and were in limited supply, medications were prioritized to meet the needs of those at greatest risk which were those over the age of 65. As medication availability increased, strategies were implemented to expand access to address everyone who was eligible with a strong focus on ensuring access in vulnerable communities. Although seniors are the center of the focus, anyone eligible and testing positive for COVID-19 can take advantage of therapeutics throughout LA County.

The COVID-19 Therapeutics Program began in November 2021, with an objective to establish a broad provider network to ensure equitable access to patients across LA County. Presently, this network consists of over 1000 COVID-19 therapeutic providers across the county. To prioritize distribution to our most vulnerable communities, we ensured that over half of the 1,000 network providers are situated in HPI Plus zip codes (a measure of social vulnerability and COVID risk), serving the most underserved communities. Our provider network receives allocations of medicines on a weekly basis, in accordance with requests made via surveys distributed by the therapeutics team. To further assist our providers, the DPH Therapeutics Program holds weekly provider office hours to ensure that providers are aware of any changes or updates to product availability and efficacy as a result of changing variants, relevant studies, and ordering processes and procedures. In addition, providers can ask questions and discuss successful prescribing and patient care strategies during these office hours, allowing providers to collaborate and share any lessons learned.  The DPH Therapeutics Team also ensures there is constant communication amongst all stakeholders. Despite this extensive network being established, there was still a need to ensure access to therapeutics for uninsured and underinsured individuals.

In March, a second objective was implemented through our COVID-19 DPH Call Center to provide a support mechanism for patients to receive information on the resources available and help patients navigate the process to access therapeutics.  What we found in receiving these calls was that there were many barriers in accessing therapeutics despite the vast network of providers established.  As a result, the DPH Telehealth Therapeutic Service was launched in April of 2022 as the first public health sponsored telehealth service for COVID-19 therapeutics in the state of California with the objective to ensure equitable access for all and assist COVID-19-positive individuals in accessing COVID-19 treatments in a timely manner through telemedicine. Persons testing positive for COVID-19 and who are within 5 days of symptom onset can phone the DPH Call Center and be directed to our Telehealth Therapeutics Service team. The staff is always available to answer questions, can refer the patient to a test to treat site if preferred, connect patients to the DPH Telehealth Therapeutic Services, speak to a provider who will assess eligibility for COVID-19 medication, and if eligible, deliver medications to the patients' home overnight or send a prescription to a pharmacy near the patients' home on the same day. Our telehealth patients can anticipate a response from our team within less than 24 hours, 7 days a week. Utilizing telemedicine as a platform to link patients to health care services allows for equitable access to the treatment team made up of clerical staff, nursing staff and providers who provide patient centered care in a timely manner without any cost to the patient.  The Telehealth Therapeutic Team has had a profound impact on our residents' lives. To date, Paxlovid accounts for 57.75% of the 4,428 COVID-19 oral medicines provided by the telehealth therapeutics team. In addition, the initiative performed exceptionally well in reaching vulnerable communities including individuals of color. Nearly 6% of those getting therapeutics were African American, while a vast 40.3% were Latinx. Furthermore, according to the HPI+ list, 59.15% of these patients we encountered supplied an address in a high-priority zip code. The Telehealth Therapeutics Team has proven to be successful in assessing and providing treatment for COVID-19-positive outpatients with mild to moderate symptoms. As a result of this project, we have been able to provide early treatment to eligible patients which can improve patient outcomes, alleviate healthcare facility pressure, and potentially save lives.

In order to further meet our objective to ensure equitable access to vulnerable populations, DPH established a Mobile Therapeutic Team to further boost the availability of therapeutics in target communities. This initiative targets our senior population by partnering with Community Care facilities that have three or more patients with COVID symptoms and a positive test. The facility is able to make a request for the mobile therapeutic Team to come out and screen its residents and prescribe onsite therapeutics to those eligible. As of October 2022, five mobile therapeutic clinics have been scheduled and deployed in Congregate Care Facilities where COVID-19 rates are high. Despite being a relatively new initiative, we anticipate that demand will expand as COVID-19 instances continue to climb.

Lastly, the LAC DPH Therapeutics Program maintains two primary websites, one for medical professionals and one for the general public interested in learning more about therapeutics and the therapeutic services offered in LA County. These websites are updated regularly with vital information from our federal partners, including CDPH, CDC, FDA, and pharmaceutical firms. The websites can be translated into over 120 different languages. These websites also provide connections to a Test to Treat finder, where users can input their address to identify the closest suppliers of medicines, the telehealth service, and a flyer for the Mobile Therapeutic Service for congregate care facilities. These websites provide doctors and the general public with pharmaceutical information, outreach information (flyers, infographics, etc.), and our Call Center phone number.

The target demographic for the Telehealth Therapeutic Program consists of all 10 million residents in LA County who may test positive for COVID-19.  If a person tests positive for COVID-19 and is experiencing symptoms, they can phone the DPH COVID-19 Call Center to determine their eligibility for lifesaving therapeutics. If eligible, the Telehealth Therapeutics team will deliver medications to the patients' home overnight or will send an e-prescription to a local pharmacy on the same day. To date, our telehealth therapeutics team has been able to prescribe 4,428 COVID-19 oral medications to individuals who are symptomatic, test positive for COVID-19, and who met the eligibility criteria. Persons who lack access to healthcare, a consistent income, are homeless, or lack housing/food security are the most susceptible to catching the virus and experiencing accessibility issues.

An MMWR released in 2022, stated that covid-19 therapeutics are essential to reducing health disparities. Oral antivirals are a crucial strategy that can reduce morbidity and mortality associated with COVID-19. Although the total number of antivirals administered has grown, this research reveals that high-vulnerability zip codes had the lowest dispensing rates. Additional public health, regulatory, and policy initiatives may assist in reducing obstacles to oral antiviral access, particularly in populations with a high degree of social vulnerability. As a result, DPH has made great efforts to deliver therapeutics in different ways such as through telehealth and our mobile teams, to decrease barriers to oral antiviral access.

               Over the past years, COVID-19 has taught public health that we must implement additional community-reaching strategies when making medications available to ensure equitable access and reduce health inequities by removing the barriers which deter people from accessing care. One of the strategies used to reach the community, is to provide therapeutics through a mobile service to the most vulnerable populations.  This ensures we are reducing inequities and reducing barriers to access by providing services onsite. The telehealth program is revolutionary since it utilizes telemedicine to provide free at home evaluations for this treatment. This means that sick persons no longer need to request treatment in a clinic or doctor's office. This platform prevents unnecessary exposure to COVID-19, aids in mitigating the spread of the virus, and helps reduce hospital and clinic surges by providing timely treatment. Additionally, the implementation of a telehealth specific program displayed innovation in increasing access to healthcare by reducing barriers such as those caused by lack of health insurance or access to their provider, lack of transportation and simplifying the prescription process considering that time is of the essence. This new approach enables healthcare providers the use of telehealth modalities and technologies to improve patient outcomes. Telemedicine is not new to DPH as it has been previously used with our clinic patients however never before had we opened up a telehealth service that was accessible to all in the community via a call center.  Another strategy, which was somewhat novel in the therapeutic sector, was to have DPH nurses make follow-up calls to patients after they received their medications. In addition to ensuring that patients received their medications, the nurses reevaluated their symptoms, provided additional resources and education. In all, the telehealth team ensured that the patient received quality care from start to finish.

In an effort to address health disparities across our jurisdiction, our therapeutics program utilizes the California Healthy Places Index (HPI), a powerful tool that examines the impact of community environments on life expectancy and societal factors. The HPI indexes 25 community attributes, including access to healthcare, housing, and education, into a single number. The HPI status of healthier communities will be categorized as low while vulnerable communities are categorized as high. This technology has enabled the team to prioritize certain populations thereby promoting equity and inclusivity. To further address these health inequities, in addition to leveraging the public facing DPH Call Center, the creation of a Therapeutics Line was created to assist with telehealth appointments. Our call center is available seven days a week and the teams work vigilantly to assist individuals who require therapeutic assessment. Lastly and most recently, the implementation of a Mobile Therapeutic Program was established to further address inequities in Los Angeles County in Residential Care facilities. Once the program is fully functioning, residential care facilities will utilize an outlook interest form, where residential care facilities can submit their interest and a Nurse from the Mobile Therapeutics Team will contact them to gauge further interest and schedule a mobile therapeutic event.  The following were all additional and innovative measures taken by the therapeutics program to address inequities.

MMWR: https://www.cdc.gov/mmwr/volumes/71/wr/mm7125e1.htm

Since the therapeutics program's inception in November 2021, DPH has endeavored to distribute COVID-19 medicines in underserved communities of Los Angeles County. To date, the program has ensured broad access across LA county with a network of over 1,000 providers that provide residents with prescriptions in a straightforward and expedient manner.  However, to further prevent hospitalization and death amongst LA County residents, and make an effort to narrow the equity gap, the Los Angeles County Department of Public Health launched the Telehealth Therapeutic Service Program in April of 2022 and launched as the first public health sponsored telehealth service for COVID-19 therapeutics in California. Its' program is open seven days a week and is free of charge as a means to address challenges to access experienced by some of the most vulnerable people in Los Angeles. The teams' overall goal is to provide equitable access to lifesaving therapeutics by implementing multiple strategies with a focus on vulnerable populations and reducing health inequities. Stakeholders for the program as a whole included the state, community partners, and the community members themselves. The DPH Therapeutics Program has fostered collaboration with stakeholders by doing constant outreach to vulnerable populations, providers, facilities and communities.

     In addition, the LA County therapeutics initiative has worked with Healthvana to successfully disseminate vital public health and pharmaceutical information directly to approximately 500,000 email addresses. As previously stated, additional outreach is undertaken through telephone calls, emails, and educational outreach, with flyers, website information, and infographics. The therapeutic teams collaborate with physicians and other organizations to deliver life-saving medications to several inaccessible locations. The first therapeutic was authorized in December of 2021, and the Therapeutic Program which was in place by November of 2021 was already preparing for the arrival of medication into the county. The Telehealth Therapeutic Program was then launched in April of 2022.

    Delving deeper into our therapeutics effort, by allowing patients to utilize services from the comfort of their own homes, the telehealth program contributed to the reduction of disease transmission. To proactively inform patients who tested positive about these programs, the team has also collaborated with the department's Case and Contact Interview Branch (CCIB), whose responsibility it is to call all positive cases in Los Angeles County. This team interviews positive cases on their results and provides helpful materials, including treatment interest and referrals. All symptomatic patients older than 50 or residing in an HPI zip code are offered a referral by our interviewers. The success of this collaboration with the CCIB team has been demonstrated as new referrals are received daily. Moreover, the program effectively informs interviewees about the program. Even if they do not qualify for treatment or have no interest in it, patients are informed of the available resources so that they too can spread the word. To ensure that all individuals have access to therapeutics, the DPH Therapeutics Team has prioritized the equitable distribution of these potentially life-saving pharmaceuticals to our most vulnerable communities utilizing the HPI+ criteria.

     The therapeutics project is free of cost to the individual and has received funding from the ARP Crisis Coag, the ELC 577, and the CEO ARP Trance 2 grants, and the county has invested $12.1 million to employ our staff and implement the program. For our telehealth therapeutics efforts, there were very limited start-up costs as we relied on our current infrastructure for our electronic medical record, and our main costs came from the staff we employed which was about $6.77 million.

     The COVID-19 pandemic has had a terrible impact on people's health and economy. COVID-19 has resulted in more than 3.5 million confirmed positive cases as of December 2022, and over 34,000 confirmed fatalities in Los Angeles County. To date, the globe is confronted with constant surges, making the availability of treatments more important than ever. As we have seen, reliable access to therapeutics has assisted the state in preventing fatalities and in promoting the health of its citizens.  Providing oral antivirals through multiple platforms is a crucial strategy that can reduce morbidity and mortality associated with COVID-19. Overall, over 171,395 courses of oral antivirals have been distributed throughout LA County through the LAC DPH Therapeutics Program. Over 60% of these therapeutics have been allocated to providers located in the lowest HPI Quartile, again ensuring access to life-saving treatments for our most vulnerable communities. 

     As indicated earlier, the Telehealth Therapeutics Program was designed to increase access and address equity gaps which has shown to be an efficient and effective method of providing therapeutics to our residents. The team consists of physicians, nurses, call center employees, epidemiologists, and administrative personnel, among several others. Notably, the Telehealth Therapeutics Program has its own data team that aids in data collection and analysis in order to deliver superior patient care and results. With the assistance of epidemiologists, directors, and administrative assistants, the team is able to generate weekly reports to track the number of people receiving treatments, patients screened by nurses, total patients seen by provider, etc. The team utilizes excel, ORCHID, discern Reporting Portal (Cerner), Microsoft Forms, and Customer Relationship Management (CRM) as a way to keep track of demographics, screening information, and other important information. In addition, our program uses apps such as REDCap for the intake/referral procedure and Amazon Web Services (AWS) for call transfer and interpretation services on occasions. Currently, our telehealth team has access to over sixty distinct interpreting languages. Our staff undergoes extensive training to learn how to run these diverse systems and how to troubleshoot any issues that may occur from their use.

     To date, our Telehealth Therapeutics Team has provided 4,749 COVID-19 oral medications to individuals primarily in Los Angeles County. 5,700 patients have been screened and scheduled in ORCHID (EMR) by Therapeutics Nurses, and 5,269 patients have been evaluated by Providers for COVID-19 treatment. There were 4,732 therapeutics prescribed utilizing an electronic prescription. It is also important to note, that over fifty percent of those who received the drug were at least 35 years old; the majority of these patients were prescribed Paxlovid, followed by Molnupirivar (Table A). Over 40.36 percent of those getting medicines identified as Latino, 9.13 percent as South Asian, and 5.66 percent as African American (Table B). Regarding the HPI+ list, 59.15% of the patients we encountered indicated residing at a high priority zip code address. The telehealth therapeutic effort has helped narrow enormous equity gaps so that our most vulnerable citizens do not suffer from severe symptoms or hospitalization. The team has even reached our Persons Experiencing Homelessness (PEH) population and provided the resources needed to recover from COVID-19. In just September alone, the therapeutics team was able to offer pharmaceuticals to 4 individuals who identified as experiencing homelessness.

     Our telehealth team delved deeper into data analysis by analyzing quantitative and qualitative data to evaluate findings. Additionally, the team utilized cross tabulation for quantitative data to split up the data by demographics, type of treatment received, age group, and whether or not the patient was part of an HPI+ zip code. The team utilized graph charts, data tables, and weekly reports to provide the number of therapeutics provided, the number of calls received, the number of individuals assessed, in addition to other measures. The utilization of qualitative data was also beneficial and documented by the team; in fact, our team has also gathered patient testimonials, of which more than half praise the health education, resources and follow ups offered by our nurses and are impressed by their professionalism and subject-matter expertise. This information assists us in bridging any potential gaps and recognizing the team's outstanding work. Our Call Center Therapeutics Line and Telehealth Therapeutics Team as a whole, takes pride in providing our patients with the greatest care and information. Understanding the features that can influence patients' adherence to treatment, vaccination, and mask use is essential for effective pandemic control.

                                                     0-17    18-24    25-34    35-44    45-54    55-64    65-74    75+    Total    Percentage Paxlovid (3088 | 57.74%)            46       165       598        690       617       512        355      105     3088    57.74% Molnupiravir (1342 | 25.11%)      0         14         98          155       250       329        305      191     1342    25.11% No prescription (848 | 15.90%)   22       36         167        164       157       124        110       68       848     15.90%

                                          Total    Percentage African / Middle Eastern    54     1.01% African-American               304   5.69% American Indian                23     0.43% South Asian                       79    1.48% East Asian                         488    9.13% Latin American                2157    40.36% European                        1072    20.06% Pacific Islander               242      4.53% Other                              926    17.32% TOTAL                           5345   100.00%

Since its inception, the Telehealth Therapeutics Team has gained numerous insights. The use of telemedicine between patients and healthcare professionals has been advantageous.

Today, telemedicine is more accessible and reduces barriers in access to care, especially for those who do not consider themselves computer savvy, or who do not have access to technology or internet service. Additionally, language barriers in the beginning were a cause for concern but with many technological advantages, telemedicine provides therapeutic options for LA County residents to have easy access to medication and translation services to combat COVID-19. Utilizing this system during times of social distance is a simple convenience. In addition, it reduces the potential travel required by both the physician and the patient, as well as the associated costs. Given that these individuals are COVID-19 positive, they should be isolating, and telemedicine enables them to obtain medication and be evaluated promptly in the comfort of their own home. In this method, infectious disease is also controlled. The delivery of medical care is being transformed by telemedicine, which has contributed to the containment of the COVID-19 outbreak through the administration of antiviral treatment to those who have tested positive for the virus and are symptomatic. The establishment of a telemedicine therapeutics program has also enabled uninsured/underinsured persons to obtain medications in the comfort of their own homes. Given the restricted time window for acquiring pharmaceuticals, the ability to screen remotely and pick up the medication at a nearby pharmacy or have the medication transported to the patient's home has proven to be of great assistance.

     The Telehealth Therapeutics Program has also been effective in transforming people's lives. It is essential to note that a piece appeared in the Los Angeles Times talking about the telehealth therapeutic initiative. The article describes a person who tested positive for COVID-19 and searched for a 'Test to Treat' clinic, but after several unsuccessful tries, called the DPH COVID-19 Information Line. Her call was immediately answered, and nurses reviewed his medical history. Less than twenty minutes later, the healthcare professional phoned the patient to discuss symptoms and current medications to offer Molnupiravir. The provider sent an e-prescription to a local pharmacy and the patient's friend picked up and delivered the medication. The next day, a DPH nurse followed up with the patient to inquire further about their symptoms, which was unexpected because the patient did not anticipate anyone to do so. In light of this, the county has prioritized providing timely and effective care in a fantastic and courteous manner. They also ensure the patients are feeling better. This story in the Los Angeles Times enables other community members to see the positive results and encourages them to phone the call center information line. These types of narratives are significant to read because they describe our work and demonstrate that we have a positive impact on the lives of others. Link to the article: https://www.latimes.com/opinion/story/2022-06-22/covid-coronavirus-breakthrough-infection-antiviral-los-angeles-county-department-of-public-health

     In order to promote inclusiveness, variety, and culture, the telehealth team also consists of culturally diverse staff. Our team is therefore able to accommodate California residents with language restrictions. In addition, according to our telehealth therapeutic data, although English was the predominant language most spoken, 16.67% of those interested in treatments spoke Spanish, followed by Mandarin at 1.42%. Therefore, it was essential for our team to bridge the language divide and ensure that language does not prevent patients from obtaining treatments. In addition to having bilingual staff members, DPH collaborates with Language Line Solutions, which provides access to over 60 different languages. When a patient requires a language that is not spoken by our personnel, they can call the Language Line and a translator will translate over the phone. This encourages our community members to call the telehealth team without hesitation. Overall, this decreases linguistic barriers among vulnerable populations.  

    The Therapeutic Team as a whole also concentrated on outreach efforts to spread the word about the availability of medications. Outreach therapeutic campaigns leverage social media and local news to spread the word on the accessibility of therapeutics. It is important for teams to advocate for effective, culturally appropriate messaging that is tailored to the local community to boost confidence in these medications. Misinformation from a variety of sources, including the mainstream media, contributes significantly to the public's mistrust in COVID-19 medications. Trust in public health authorities about COVID-19 was a factor that may have impacted individuals' use of COVID-19 medications. LAC-DPH attempts to address this by utilizing various social media platforms such as Twitter, Facebook, Instagram and YouTube to provide accurate information to individuals about available therapeutic resources. Future public health initiatives to enhance COVID-19 medication acceptability among non-healthcare professionals should focus on increasing public trust and confidence, dismissing myths about its adverse effects and cost, and promoting the public understanding that these medications are free and accessible for all.

   Community partnerships are an essential public health strategy and has been of great assistance in promoting the therapeutic network. These partnerships increase the opportunities for communities to be aware of the possible treatment options available should they contract COVID-19. Partnerships with numerous community organizations and healthcare practitioners have enabled us to spread information about these treatments. Individuals have faith in their neighborhood, organizations, and local practitioners. Through regular communication from these trusted partners, the public will likely feel comfortable receiving these medications. Therefore, it has been essential to be in contact with numerous community partners throughout Los Angeles County to spread the news about COVID-19 medications. Further, to ensure providers are abreast of important updates regarding therapeutics, we utilize our Los Angeles Health Alert Network (LAHAN) and the DPH Physician Consult Line to spread new information to healthcare providers.

     In addition, demographic information has shown that people's willingness to accept medication is affected by a variety of factors, such as age, level of education, race, previous exposure to COVID-19, and perceptions regarding the efficacy and safety of therapeutics. Their decision to seek treatment was significantly impacted by a variety of factors, including the skepticism expressed by experts in the field of public health, worries regarding the possibility of unfavorable side effects as well as concerns regarding the treatment's efficacy, and a desire for additional information. There is a need for more research to be done on public health interventions that are designed to boost drug consumption.

     Little is still known about the variables that may affect healthcare and non-healthcare professionals' adoption of the COVID-19 therapeutics. However, local health authorities may be able to create more successful programs to increase therapeutic coverage. This can be accomplished through gaining a deeper understanding of the elements that influence people and subgroups in general. Plans for sustainability have been in effect since the beginning of the grant period. The team has concentrated on three aspects of sustainability: community engagement, communication, and accessibility. The lessons learned and the structures and frameworks developed have been recorded for future emergency responses, to protect the lives of our inhabitants and their families.