Telehealth to Connect with Specialty Services

Interdisciplinary Care Team Meetings

One strategy utilized across numerous practices was hosting interdisciplinary care team meetings or care conferences through telehealth. This allows multiple clinicians, families/caregivers, and other health care professionals to join one meeting, or visit, at the same time and discuss plans of care. Specific strategies to implement these meetings, and resources needed to support this care, are outlined below.

• Host a pre-meeting prior to the care team conference to review any technology issues.
• Train families/caregivers and clinicians on how to use the technology platforms prior to hosting a virtual care team meeting.
  • Training for clinicians could include in-person or online trainings, both in group or individual settings. Trainings could include information on the workflow for virtual team meetings,
  • For more information on how to prepare families/caregivers for telehealth visits, view this tip sheet.
  • Offer on-call support to patients, families/caregivers, and clinicians during the care team meeting in case of any technology issues.
  • Appoint telehealth champions to support families/caregivers with signing up for technology platforms and patient portals so they can access the telehealth platform.
• Develop meeting agendas in advance. Ensure agenda items align with scheduling availability of all clinicians and families/caregivers.
• Distribute follow up surveys after each meeting to identify successes and areas for improvement.
• Invite home health care professionals to participate in these meetings as well. This may be particularly helpful for children with medical complexity and their families.
• Coordinate availability of language interpreters as needed.
• Establish partnership across different clinicians to help support coordinated and efficient interdisciplinary care meetings. This could include establishing formal agreements across institutions if needed.
• Coordinate in advance with clinicians to support scheduling for both telehealth and in-person options when needed.
  • While telehealth provides many advantages to these interdisciplinary care team meetings, it is also important to schedule in-person visits for certain procedures or assessments that require hands on care.
  • Due to scheduling challenges, it may be difficult to schedule in-person interdisciplinary care team members with the same subspecialty clinicians who participate in telehealth visits. These scheduling challenges need to be considered when switching between telehealth and in-person visits.

Implementation of these strategies resulted in some of the following preliminary outcomes:

• Time savings for families/caregivers, as they spend less time away from work or home that would typically be spent traveling to and from multiple subspecialty appointments.
• Less disruptions during care team meetings (due to training for clinicians and families/caregivers prior to care team meetings).
• Decreased no-show or reschedule rates for appointments.
• Increased opportunities for family engagement with multiple clinicians.
• Appointments are more likely to start on time and appointment length is decreased.
• Similar health outcomes to in-person care, and in some situations, health outcomes may even be improved as compared to in-person care as patients/families have more opportunities for follow-up with their clinicians.

^{The tips and strategies outline on this web page were provided by Kentucky's Office for Children with Special Health Care Needs and La Rabida Children’s Hospital.}

Connection to Specific Specialty Care Services

A number of practices provided examples of how telehealth can support access to specific types of specialty care and/or for specific populations of children. These specific examples are summarized below.

Caring for Children with Burns

One practice used telehealth to increase access to evaluation, care, and perioperative follow up for children with burns. Strategies to support this initiative included the following:

• Facilitate multidisciplinary participation of specialists via one virtual visit. This could include surgeons, pediatricians, care coordinators, rehabilitation therapists, and nurses.
• Use secured text messages and/or phone calls to supplement virtual offices.
• Develop a workflow process that supports use of telehealth. This includes:
  • Developing a scheduling process that obtains parental consent
  • Training staff on the use of different telehealth platforms
  • Integrating telehealth into the documentation process
  • Developing a secure way for families/caregivers to send text messages of videos or photographs (to support visual inspection of wounds by the clinician during the telehealth visit)
  • Incorporating follow up telehealth appointments into care planning

Preliminary outcomes include improved access to specialty burn care and subsequent follow-up, particularly for underserved children and families. The elimination of transportation needs and hotel stays for families/caregivers often translated into cost savings.

^{The tips and strategies outlined in this promising practice were provided by Shriner’s Hospital for Children – Boston.}

Providing Pre-exposure Prophylaxis (PrEP) Care to Adolescents and Young Adults

One practice used telehealth to provide adolescents and young adults with PrEP counseling as well as frequent follow-up. Strategies to support this initiative included the following:

• Pediatric and/or adolescent health clinicians that are trained to provide PrEP counseling provide this service via telehealth appointments.
  • Clinicians do not have to dedicate their entire practice to virtual care and can provide in-person and virtual counseling if/as needed.
  • Visits occur via a two-way audio and video HIPAA compliant platform. Visits are supplemented by a two-way asynchronous messaging system between patients and clinicians, to assist with any questions or issues that may arise between appointments.
• PrEP navigators work alongside clinicians to help to support youth through frequent virtual follow ups. This facilitates improved PrEP adherence, follow up, and assistance in navigating programs that can help cover medication costs.
  • PrEP navigators can be medical students, medical assistances, nurses, or other staff dedicated to and interested in adolescent and sexual health.
• Support telehealth visits with in-person lab work, which can be performed in-person by the patient at a local laboratory. Some lab work may not be readily available in community settings and can be completed by the patient and mailed into a tertiary care clinic.
• Recruit patients to participate in the program through some of the following strategies:
  • Webinars for clinicians to increase awareness and understanding of PrEP
  • Presentations at Grand Rounds and other meetings with clinicians
  • A PrEP web site that outlines how to sign up for the program (both for clinicians and youth)
  • A social media campaign
  • Advertisements through online search engines
  • Media relations campaign for pediatric clinicians
  • Ongoing support for recruitment and advertisement of this program is needed to support sustainability and success.

Preliminary outcomes include increased access to PrEP care for adolescents and young adults, especially those that may be geographically located in areas without dedicated PrEP clinics.

^{The tips and strategies outlined in this promising practice were provided by Stanford Children’s Health.}

Expanding Access to Pediatric Palliative Care

One practice established a state-wide virtual pediatric palliative care program, which increased access to this subspecialty care for families/caregivers and children regardless of geographic location. Strategies to support this initiative included the following:

• Conduct a community assessment to understand the needs and gaps related to access to pediatric palliative care services.
• Refer patients in need of pediatric palliative care from inpatient units (such as NICUs) and outpatient services (including those caring for children with medical complexity), and/or through family/caregiver referral.
• Ensure coordination with the medical home by requiring identification of a primary care pediatrician for all participating patients/families.
• Establish resources that are needed to set up a virtual palliative care program. This includes:
  • Incorporation as a Limited Liability Corporation.
  • Purchase of equipment such as a computer, monitor, high speed internet, cell phones.
  • Develop a web site for your program services.
  • Establish administrative procedures such as, forms and templates, set up an electronic health record, billing system, malpractice insurance, and a third-party payer credentialing
• Establish baseline knowledge and skills to support this program, including:
  • Understanding of evidence-based practices for provision of pediatric palliative care and pediatric telehealth.
  • Training and competency in use of telehealth equipment.
  • Recruitment of interdisciplinary care team members.
  • Assessment of family/caregiver and clinician satisfaction.
  • Established networks and partnerships with community organizations, family groups, and clinicians.
• Implement workflow adaptations to support program implementation including addition of an administrative assistant and nurse practitioner, as well as expansion into a physical location.

Preliminary outcomes include increased access to pediatric palliative care services, improvements in care coordination, increased clinician and family/caregiver satisfaction, improvements in communication across clinicians, and cost savings due to reduced need for transportation and travel.

^{The tips and strategies outlined in this promising practice were provided by Patti’s Place: Vital Pediatrics for Complex Kids LLC.}

Caring for Children with Cystic Fibrosis

One practice is using telehealth to support ongoing care for patients with cystic fibrosis across multiple rural counties. Strategies to support this initiative included the following:

• Purchase spirometers and baby scales that families/caregivers can use in their homes during telehealth visits. The purchase of the materials can be supported through grant funds.
• Convene with patients, families/caregivers, and multidisciplinary clinicians via one telehealth visit. One visit could include respiratory therapists, social workers, dietitians, child life specialists, among others.
• Leverage technology within the care team such as instant messaging platforms for pre-clinic visits and reminders. Use text messaging and instant messaging to notify team members when to join a telehealth visit.
• Schedule telehealth visits in large blocks of time, as it is often challenging for clinicians to see patients with complex needs both virtually and in-person during one day.
• Use telehealth to support the transition process to adult centered care by inviting adult health care clinicians to join interdisciplinary care meetings as the patient is preparing to transfer to an adult clinic.
• To help offset large upfront costs of starting a telehealth program, one strategy proposed by this practice is to partner with other health entities or accountable care organizations, particularly to support purchasing of equipment for families/caregivers and clinicians.

Preliminary outcomes include cost savings for families/caregivers due to decreased transportation needs, similar patient/family satisfaction scores when compared to in-person visits, and the potential to mitigate disparities in access to care for rural populations.

^{The tips and strategies outlined in this promising practice were provided by Geisinger Health System.}

Supporting Post Pediatric Intensive Care Unit (PICU) Discharge

One practice used telehealth to support transition of children with medical complexity and technology-dependence into a variety of different care settings, including transitional care facilities, rehabilitation institutes, and residential centers. Strategies to support this initiative included the following:

• Facilitate an interdisciplinary team discussion between the PICU team and the transition care team to outline the patient’s PICU course and needed care needs.
  • This allows for virtual assessment of the patient by the care team.
  • This supports the family/caregiver by providing them an opportunity to meet their child’s new care team prior to the care transfer.
• Utilize a telemedicine cart that can be wheeled into the patient’s room so that the patient, family/caregiver, PICU team, and transition care team can be in the same room together during the telehealth appointment.
  • The telemedicine cart is supplied by the hospital. Families/caregivers are able to fully engage in the telehealth visit if they are at the bedside with their child. Families/caregivers who are not physically located within the PICU may also join the visit but must have their own device and a reliable internet connection in order to join.
  • Engage language interpreter in these meetings as needed by the family.
  • Include subspecialists and other team members in the meeting to fully support the warm handoff.
• Schedule a follow-up appointment 24-48 hours after the care transition via telehealth to clarify any care plan questions, medication regimens, and follow up appointments.

Preliminary outcomes include improved care coordination and the potential to decrease readmission rates, which may translate into cost savings. Preliminary outcomes also include high family/caregiver satisfaction with the transition process.

^{The tips and strategies outlined in this promising practice were provided by Advocate Children’s Hospital – Oak Lawn.}