Unbiased care, unequal outcomes: a nursing telehealth intervention reveals systematic inequities in COVID-19 care delivery.

Background: The Covid Connected Care Center (C4), a low-barrier telephone nurse hotline, was developed at an academic medical center to increase access to healthcare information and services across the state of Oregon, including to those without a usual source of care. Other studies have demonstrated that telephone triage services can positively influence health behaviors, but it is not known how this effect is maintained across racial/ethnic groups. The objective of this study was to show that the C4 reached throughout the state of Oregon, was valuable to callers, and that recommendations given affected callers' subsequent health-related behaviors.

Methods: This mixed-methods study, informed by the RE-AIM (Reach, Effectiveness, Addoption, Implementation and Maintenance) framework, assessed caller demographics and clinical care from March 30 2020 until September 8, 2021. Descriptive statistics, multivariable risk models and Zou's modified Poisson modeling were applied to electronic health record and call system data; An inductive approach was used for patient and staff experience surveys and semi-structured interviews. Approval was obtained from the OHSU Institutional Review Board (Study 00021413).

Results: 145,537 telephone calls and 92,100 text-based contacts (61% and 39%, respectively) were included. Callers tended to not have a usual source of primary care and utilized recommended services. Emergency department utilization was minimal (1.5%). Racial or ethnic disparities were not detected in the recommendations, but Black (RR 0.92, CI 0.86-0.98) and Multiracial (RR 0.90 CI 0.81-0.99) callers were less likely than non-Hispanic white callers to receive a COVID-19 test. Participants in the post-call survey (n = 50) would recommend this service to friends or family. Interviews with callers (n = 9) revealed this was because they valued assistance translating general recommendations into a personalized care plan. C4 staff interviewed (n = 9) valued the opportunity to serve the public. The C4 was a trusted resource to the public and reached the intended audiences. However, disparities in access to COVID-19 testing persisted.

Conclusions: Nursing triage hotlines can guide caller behavior and be an effective part of a robust public health information infrastructure.