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J Prim Care Community HealthJ Prim Care Community HealthJPCspjpcJournal of Primary Care & Community Health2150-13192150-1327SAGE Publications Sage CA: Los Angeles, CA 3007979010.1177/215013271879215410.1177_2150132718792154Case StudiesIntroducing Primary Care Telephone Visits: An Urban Safety-Net
Community Clinic Experience Kyanko Kelly 1Hanley Kathleen 12Zabar Sondra 12Joseph Jennifer 1Bateman William 12Schoenthaler Antoinette 11 New York University School of Medicine,
New York, NY, USA2 Gouverneur Health, NYC Health +
Hospitals, New York, NY, USAKelly Kyanko, Department of Population
Health, New York University School of Medicine, 227 East 30th Street, Room 735,
New York, NY 10016, USA. Email: kyanko.kelly@gmail.com06 8 2018 Jan-Dec 2018 9 2150132718792154© The Author(s) 20182018SAGE Publications Inc unless otherwise noted.
Manuscript content on this site is licensed under Creative Commons
LicensesThis article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which
permits non-commercial use, reproduction and distribution of the work
without further permission provided the original work is attributed as
specified on the SAGE and Open Access page(https://us.sagepub.com/en-us/nam/open-access-at-sage).Background: Telephone consultation is widely used in primary care
and can provide an effective and efficient alternative for the in-person visit.
Gouverneur Health, a safety-net primary care practice in New York City serving a
predominately immigrant population, evaluated the feasibility and physician and
patient acceptability of a telephone visit initiative in 2015.
Measures: Patient and physician surveys, and physician focus
groups. Results: Though only 85 of 270 scheduled telephone visits
(31%) were completed, 84% of patients reported being highly satisfied with their
telephone visit. Half of physicians opted to participate in the pilot. Among
participating physicians, all reported they were able to communicate adequately
and safely care for patients over the telephone. Conclusions:
Participating patients and physicians in a linguistically and culturally diverse
urban safety-net primary care clinic were highly satisfied with the use of
telephone visits, though completion of the visits was low. Lessons learned from
this implementation can be used to expand access and provision of high-quality
primary care to other vulnerable populations.

primary careoffice visitstelephonesafety-net providersNew York City Health and Hospitals
Corporationhttps://doi.org/10.13039/100006735cover-dateJanuary-December 2018
==== Body
Introduction
Telephone consultation between physicians and patients is widely used in primary care
and can provide a convenient alternative for the in-person visit.1 One approach has been to substitute in-person follow-up visits (as compared
with triage or urgent visits) with telephone consultation.2, 3 Implementation of telephone
visits may have unique benefits and challenges for an underserved and immigrant
population. Underserved patients may have restricted work schedules and limited
resources for travel and value the convenience of a phone call. Home-bound elderly
or disabled persons may similarly prefer telephone visits. However, language,
cognitive, and literacy barriers may complicate scheduling and performing telephone
visits in this population. Cultural preferences for in-person versus telephone
visits may also be unique.

Gouverneur Health, an urban safety-net clinic in New York City, implemented in 2015 a
quality improvement initiative to use telephone visits instead of in-person visits
for regular follow-up in adult primary care. We aimed to determine the feasibility
of using telephone visits with a culturally and linguistically diverse patient
population. Secondary aims include characterizing patient and physician
acceptability of telephone visits.

Methods
Patient Population
The study was conducted in the ambulatory care practice at Gouverneur Health in
New York City. Gouverneur employs 20 predominately bilingual primary care
providers and serves almost 9000 patients a year. This community-focused
practice serves a culturally and linguistically diverse population. Only 24% of
patients indicate English as their primary language, 40% are Spanish-speaking,
and 20% speak Chinese dialects.

Intervention
The telephone visit pilot was conducted during a 6 month period in 2015, though
the intervention has been sustained to present after the initial pilot data
collection period ended. During the initial pilot period, only attending
physicians were included. The project was introduced to the staff through a
series of brief presentations at staff meetings during which the potential
benefits of telephone medicine, guidelines for billing and documentation, and an
orientation to the telephone visit note in the electronic health record were
discussed. Physician participation in the pilot was optional.

Participating physicians determined at the end of an in-person visit whether or
not a patient was eligible for telephone follow-up. Physicians excluded a
patient from a telephone visit for a variety of reasons, including impaired
patient communication or cognition or need for physical exam at follow-up.
Patients could decline a telephone visit, even if the physician believed they
were eligible. Patients received a scheduled time for a telephone call with
their physician and a reminder call was performed prior similar to in-person
visits, though telephone visits could be performed unscheduled as well. The
number of telephone slots per session varied based on availability in the
physicians schedule, but ideally were scheduled 1 per 3-hour session, and 2 per
4-hour session. A Frequently Asked Questions sheet for physicians and a flyer
for patients were developed to clarify the billing and scheduling process.

Measures
Assessment of Patient Acceptability
Within a week after their telephone visit, all patients were contacted by a
research assistant by phone for a brief (10 minutes) satisfaction survey.
The survey was a modified version of previously developed instruments, but
it also included de novo items.4,5 Surveys were conducted
in English, Spanish, Mandarin, and Cantonese.

Assessment of Physician Acceptability
After 6 months of the telephone visit pilot, all physicians who conducted
telephone visits (n = 10) completed a brief satisfaction survey. Physicians
(including those who chose not to perform telephone visits) were also
invited to participate in a focus group to elicit their beliefs regarding
the logistical, organizational, and administrative barriers to conducting
telephone follow-up visits, usefulness and suitability of telephone visit to
address patient concerns, disadvantages, and advantages of using telephone
visits, opinions on which patients benefit the most from the service, and
suggestions for improving the process.

Patients and physicians could participate in the telephone visit pilot but
choose not to participate in its evaluation. The New York University School
of Medicine Institutional Review Board determined that the study should be
considered a quality improvement project rather than research.

Analysis
Descriptive statistics were used for results of the patient and physician surveys
and chart review. Focus groups were recorded and transcribed by the research
assistant. The study team reviewed transcripts for themes. A sample of
participating physicians reviewed focus group findings to verify completeness
and accuracy.

Results
Data were collected from April 2015 to January 2016. During this time, 85 of a total
270 scheduled telephone visits were completed. This represents a “show rate” of 31%
(85/270). Of the remaining scheduled telephone visits, 27% (73/270) of patients went
in-person during the scheduled time either because of confusion or by choice, 25%
(68/270) were unreachable (ie, patient did not answer phone or the phone went to
voicemail, wrong number, or phone disconnected), 9% (24/270) refused the call (ie,
patient was too busy to talk), and in 7% (20/270) the physician did not call the
patient as scheduled.

Patient Satisfaction Survey
Seventy-five of the 85 patients (88%) who received telephone visits completed a
survey about their experiences with the telephone visits (Figure 1). Overall, the majority of
patients (84%) reported being highly satisfied with receiving telephone visits
for their medical care. For example, over 90% of patients felt they could talk
to their doctor about everything they wanted to on the telephone and that their
doctor also understood them well. In contrast, approximately one-third did not
like having a telephone visit with the doctor because the doctor could not touch
or see them and 50% reported that they would prefer to discuss their medical
problems with their doctor in person.

Figure 1. Patient satisfaction survey.

Physician Satisfaction Survey
Ten of the 20 primary care physicians in the practice opted to participate in the
pilot and completed a survey about their experiences delivering medical care via
telephone. All physicians felt they were able to communicate adequately with
patients over the telephone; they could safely care for select patients over the
phone; and that telephone visits could improve continuity of care for patients.
Majority of physicians also felt that patients followed up on recommendations
(eg, blood tests, vaccinations) after telephone visits just as much as they did
for in-person visits (89%) and that telephone visits are more time efficient
than in-person follow-up (78%).

In terms of the potential reach of telephone visits, on average, physicians
estimated that telephone visits were appropriate for 27% (SD 19.8%; range
10%-60%) of their patients. The following services were considered the most
appropriate for telephone visits: (a) lifestyle/behavioral
counseling; (b) acute, nonemergency care (eg, flu symptoms);
(c) medication titration; and (d)
discussing laboratory results.

Physician Focus Groups
Two physician focus groups (n = 7 and n = 10, with some overlap in participation)
were conducted in December 2015 and February 2016. Physicians who chose to
participate in the telephone visit pilot were more likely to be advocates for
the approach, and generally had very positive feedback. One of the focus groups
included nonparticipating physicians, but we were unable to elicit reasons for
nonparticipation.

Physicians who had participated in the pilot were very supportive of the
intervention and the benefits of telephone visits. Specifically, they believed
that telephone visits improved time management because of their brevity. One
stated, “These televisits are gifts to me, they really help me to manage my
days.” They felt that patients had different expectations for telephone calls,
which made them more focused. For example, if a patient came in-person, they
might expect laboratory tests to be done, but over the telephone this was not
expected. One commented, I think their (patients’) expectations is that you’re not going to spend
an hour on the phone . . . it’s a different environment . . . it’s like
the more they waited [in the clinic waiting room] the more you feel
obligated to spend more time, and which on the phone is not a thing.



Many felt that formalizing the telephone visit helped them get “credit” for work
that had previously been doing but did not have protected time for in their
schedules. Physicians felt that telephone visits improved patient-centeredness
through greater access to and continuity of care, and convenience for patients
who did not have to take off work or travel to clinic.

Focus groups also provided valuable feedback on drawbacks of the implementation
of telephone visits and recommendations for improvement. Issues such as
scheduling, reminder calls, billing, and confusion about documentation were
addressed. Physicians also commented on what types of patients and issues were
most appropriate for telephone visits, such as medication management for chronic
disease, discussion about laboratory test results, lifestyle counseling, and
depression follow-up. They did not think telephone visits were appropriate for
patients with cognitive challenges or hearing problems, diagnoses that require
an examination or point-of-care testing, or new patients.

Discussion
We found that participating patients and physicians in an urban safety-net clinic
serving a predominately immigrant population were highly satisfied with the use of
telephone visits to replace in-person follow-up visits in primary care, though
completion of the visits was low and only half of physicians participated.
Physicians estimated that telephone visits were suitable for about one-third of
their patients, and were most appropriately used for lifestyle/behavioral
counseling, acute, nonemergency care (eg, flu symptoms), medication
titration/chronic disease management, and discussing laboratory results. Physicians
felt that the visits were efficient and improved their time management, and were
patient-centered.

In our patient surveys, patients indicated that they were highly satisfied with their
telephone visit (84%) yet preferred in-person visits (50%). While we did not conduct
interviews or focus groups with patients and are unable account for this seeming
contradiction, it may be that while patients found their immediate needs adequately
met via telephone, they may find additional value in the rapport building of the
in-person visit with their physician or interaction with other clinic staff. Prior
qualitative work has shown that patients are more likely to address a wider range of
issues and engage in small talk with their physician at in-person rather than
telephone visits.6 Focus groups performed before the implementation of scheduled telephone
visits at the Veteran’s Administration primary care clinics found that patients
viewed them as potentially beneficial for routine care but feared losing touch with
their providers.7

We encountered several implementation issues that other clinics considering telephone
visits should consider. We found that telephone visits were most likely to be on
time if scheduled at the beginning of a session rather than later when a physician
was running behind. Only about a third of scheduled telephone visits were performed,
in comparison to the clinic’s in-person show rate of 80%. Some patients were
confused by the telephone visit and showed up in-person. Initially, some patients
received automatic reminder calls misdirecting them to come in-person rather than
await a phone call. The electronic health record initially did not automatically
generate a billing sheet for telephone visits and required updating. The clinic’s
largest payor, a Medicaid managed care organization, reimbursed for telephone
visits, however the rest did not, including Medicare, and the clinic decided not to
bill the uninsured.

We anticipated issues with recommended follow-up from the telephone visit. For
example, arranging an appointment with a specialist or laboratory or radiology tests
may need to be done on-site rather than remotely. However, on our survey the
majority of the physicians felt that patients followed up on recommendations after
telephone visits just as much as they did for in-person visits (89%), though we were
unable to quantify this from chart review. Further research is needed to ensure that
recommended care such as vaccines, HIV testing, or smoking cessation counseling that
are provided on-site and same day are received by clinic patients who participate in
telephone visits.

Physician participation was voluntary with only half of the 20 clinic physicians
participating in the pilot, and survey data were limited to participating
physicians. Nonparticipating physicians participated in focus groups, however they
were mixed in groups with participating physicians. Perhaps for this reason among
others, nonparticipating physicians were not as vocal and we were unable despite
direct questioning to elicit reasons that physicians chose not to participate. In
addition to logistical challenges such as scheduling and reminder calls associated
with telephone visits, at the time of implementation, the clinic was experiencing
several major workflow changes, including conversion from ICD-9 to ICD-10 and
mandatory electronic prescribing, which may have decreased interest. Similarly,
patients also could have chosen not to use a telephone visit even if their physician
recommended it, and we did not collect data from those patients. Important
operations variables such as whether telephone visits replaced in-person visits, or
just added to the number of contacts that patients had with the clinic, were unable
to be assessed. The length of our study also did not allow us to include important
measures of chronic disease management such as hemoglobin A1c levels or blood
pressure in the study population.

The use of telephone visits has been sustained in the Gouverneur Primary Care Clinic,
and has now expanded to include nurses and nurse practitioners. The clinic is part
of New York City Health and Hospitals, the largest safety-net system in the nation.
In 2017, leadership at Health and Hospitals used information learned in the pilot to
develop a strategy and workflow for dissemination of telephone visits across 17
ambulatory care facilities. Lessons learned from our implementation can be used to
expand access and provision of high-quality primary care to other vulnerable
populations.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This study was
supported by a grant from NYC Health + Hospitals. The sponsor was not involved
in the design and conduct of the study; collection, management, analysis, and
interpretation of the data; and preparation, review, or approval of the
manuscript.

Author Biographies
Kelly A. Kyanko, MD, MHS is an assistant professor of Population Health
and Medicine at NYU School of Medicine, as well as a Primary Care Physician in the
Department of Medicine at Bellevue Hospital Center in New York, NY. Her research is
largely on policy-relevant questions addressing health care costs and delivery
system and payment models.

Kathleen Hanley, MD is an associate professor of Medicine and Associate
Director for the NYU School of Medicine Primary Care Residency Training Program and
an Attending Physician at Gouverneur Diagnostic and Treatment Center. She also plays
an integral part in NYU School of Medicine’s Substance Abuse Research Education and
Training program, leading module development, overseeing the summer research
training and electives, and directing the program evaluation for the project. Her
research focuses on using standardized patients to assess the impact of medical
education on clinical behavior including a recent study examining opioid
prescribing.

Sondra Zabar, MD is a professor of Medicine and director of Division of
General Internal Medicine and Clinical Innovation at NYU School of Medicine. She is
a practicing internist and engages in research in medical education focusing on
performance based assessment.

Jennifer Joseph, MPA is a senior research associate in the Department of
Population Health at NYU School of Medicine. Her interest in research primarily
focuses on health disparities amongst minorities mostly around cardiovascular
diseases.

William B. Bateman, MD, FACP was the chief medical officer at Gouverneur
Healthcare Services, a more than 200-bed skilled nursing facility and the largest,
community-based ambulatory care center in New York State from 2007 through 2015. His
career has been devoted to improving the health and health care of low income, new
immigrant populations in New York City, initially as a provider and teacher, and
later as a medical administrator and innovator in service delivery methods. He is a
clinical associate professor of Medicine at New York University School of Medicine,
now retired.

Antoinette Schoenthaler, Ed.D, FAACH is an associate Professor of
population Health and Medicine and fellow of the American Academy of Communication
in Healthcare. Her research focuses on examining the reasons for patients’ decision
to adhere to prescribed medications and lifestyle behaviors, with emphasis on
psychosocial factors such as depression, self-efficacy, and intrinsic motivation as
well as interpersonal factors within the patient-physician relationship. She has
also extensive experience in development and implementation of clinic and
community-based interventions targeted at cardiovascular risk reduction in diverse
settings such as faith-based organizations, senior centers, and primary care
practices.
==== Refs
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