EngageWell Independent Practice Association (fiscal sponsor: Housing Works)

Telehealth holds promise to expand access to care, especially in areas with provider shortages like behavioral health.

However, uneven telehealth use during the COVID-19 pandemic exacerbated disparities in health care access. People of color, people with low incomes, those who speak a primary language other than English, older adults, and rural residents face barriers to telehealth use, including the digital divide (lack of technology and internet access), unfamiliarity with digital tools, and privacy and trust concerns.

EngageWell Independent Practice Association is a network of 15 New York City-based health and human service organizations, whose members provide integrated primary care, behavioral health, case management, and social services to more than 46,000 patients a year, primarily in the South Bronx, East and Central Harlem, and North and Central Brooklyn. EngageWell implemented a hybrid telehealth and in-person program called “Care Your Way” to help patients at 36 sites across its network manage their health. In 2022, NYHealth awarded EngageWell, through fiscal sponsor Housing Works, a grant to help patients navigate telehealth and digital tools to manage their chronic disease and behavioral health symptoms.

Under this grant, EngageWell designed engagement strategies for patients that reflected their needs, preferences, and digital and health literacy levels. It also developed a peer-based workforce—individuals who have shared experiences with the patients—to help patients navigate telehealth and digital tools and assess their experiences. EngageWell engaged patients over one year in telehealth services and digital interventions for medication adherence and nutrition assistance. A community health worker and two peer educators, shared across sites, supported patients in home and community-based settings. They helped patients navigate telehealth platforms, set up health apps, offered coaching, and provided technical support. Providers were also trained on tools and offered ongoing technical assistance. EngageWell conducted an evaluation of the model, gathered patient feedback and used data from digital tools to track management of chronic disease and behavioral health symptoms. Finally, it created a proof of concept to attract value-based contracts and reimbursement from health plans and offered providers a replicable model to support high-need consumers in using telehealth.