Telehealth and Adolescent Health Care: What Can Pediatric Clinicians Do?

Before the Visit

Utilize office staff to help with organization and preparing the patient and family/caregiver for the visit. This includes:

• Prepare to integrate a strengths-based approach into the visit by reviewing this tip sheet from Bright Futures. 
• Establish family/caregiver consent for the visit (if adolescent is younger than 18 years or has a cognitive disability requiring caregiver support).
• Ensure that all phone numbers (for the adolescent and family/caregiver) are up to date.
• Establish the ability to access and utilize the platform for the telehealth visit (including access to Wi-Fi or mobile data).
• Document the reason for the visit.
  • Note: Recognize that this may change once the adolescent is speaking with the clinician during the visit – be flexible.
• Identify any cultural considerations or disability accommodations that may impact the patient and family’s/caregiver’s ability to have a telehealth visit. If closed captioning or an interpreter is needed (including for America Sign Language), ensure that this arrangement is made.
• Ensure that any necessary questionnaires are completed before the visit, by the appropriate person, and that these can be successfully transmitted electronically. For example, make sure that a social/emotional health screening tool is completed by the adolescent as well as screening tools for depression and suicide; and a sports participation history is completed by the adolescents and family/caregiver. When administering a screening that assesses risk of suicide, consider administering during the visit.
• Have a plan in place should any adolescent/family safety concerns arise (related to mental health or a medical crisis) during the visit. This could include a list of local emergency numbers for the adolescent/family’s location and alternatives to police response.
• Make sure that you are informed about the laws within your state regarding providing telehealth care across state lines. Be aware of potential legal implications, and implications for billing compliance. Click here to view an interactive map of telehealth laws by state.
• Review with the family what to do in the event of a technology failure during the visit. Consider asking for a phone number at which the adolescent/family can be reached if the visit is disconnected.

During the Visit

Set Expectations for the Telehealth Visit

• Let the adolescent and family/caregiver know how much time is allotted for the visit. For example, “Just so you know, we have about 20 minutes scheduled for this visit.”
• Communicate that the adolescent will need time alone with the clinician. For example, “Just like we spend time in private when you come into the office, I would like us to spend part of this telehealth visit speaking privately as well. Do you think that’s something we can do today?”
• Let the adolescent and family/caregiver know that they can follow-up with another telehealth visit, or with an in-person visit, if needed. For example, consider saying something like:
  • “There might be some things that come up today that we will need to further explore with an in-person visit. We will arrange for that if we need to.”
  • “Don’t worry, we don’t have to get through everything today. We can schedule a follow-up visit to continue the conversation.”

Focus on Adolescent and Family Strengths

• To build rapport with the adolescent, ask about what they like to do when not in school or at work. Telehealth provides a unique opportunity to see into the lives of adolescents. Make sure that the adolescent knows that it is good to talk to them and have this visit virtually as soon as the visit begins! Listen to what the adolescent is sharing so you can understand what makes them feel happy and what makes them feel stressed. Assess and address the strengths of the adolescent at the start of the visit. If families/caregivers are present for any part of the visit, ask them how things have been going for their adolescent – are there any highlights?
• A strength-based perspective helps adolescents and their families/caregivers become aware of and maximize an adolescent’s strengths, even amidst challenges or behaviors that do not appear healthy. Approaching adolescent visits with a strength-based perspective is an important component of the therapeutic relationship between the adolescent, family/caregiver, and clinician.

Maintain Confidentiality

• It is important to explain confidentiality with the adolescent and family/caregiver early in the visit. This should include the limits of confidential care, such as when the clinician is worried about the adolescent’s safety, or if the adolescent is considering hurting themselves or someone else. Be sure the families you care for are aware of your office’s policies regarding confidential care for adolescents, including time alone with a clinician at every visit. This information can be posted on your website, sent via the patient portal, or mailed to families. AAP and Bright Futures recommend that pediatricians spend time alone with their patients as early as age 11.
• If you are seeing an adolescent alone, you can share that you are also happy to speak with their family/caregiver about their general health and wellbeing but will not share confidential information.
• If a family member/caregiver is with the adolescent and refuses to, or cannot leave during the visit, try to make sure the adolescent has earbuds or headphones to complete the private component of the visit. You may be able to ask a limited set of “Yes/No” questions with some degree of privacy (eg, “Do you feel safe in your home right now?”).
• Plan for how to document patient information. As with an in-person visit, take steps to ensure that sensitive or confidential information is not inadvertently revealed to the family/caregivers in the electronic medical record or patient portal, or in billing statements that may be sent to the home.
  • Consider requirements of the 21st Century Cures Act Final Rule.
    • Review this joint statement between the North American Society for Pediatric and Adolescent Gynecology (NASPAG) and the Society for Adolescent Health and Medicine (SAHM), which was endorsed by the AAP, for recommendations for protecting health care privacy for adolescents.
    • For additional information for pediatricians about the 21st Century Cures Act, click here.

After the Visit

Follow Through

After the telehealth visit, make sure that you follow through on commitments you made to the adolescent - whether it is setting up an appointment for labs, scheduling a follow-up appointment, or making a referral.

Hybrid Visits

In some cases, more information will be needed than what will be collected in a telehealth visit, like vital signs, blood tests, immunizations, or STI screening or testing. For these visits, have a plan in place to arrange for in-person follow-up. Let adolescents and families know the process for this:

• Will someone call them to schedule? Note: The ability of clinicians to schedule appointments themselves has been helpful for some in improving telehealth practice and experience with families.
• Should they call the office?
• Can they schedule online?

Make sure to be specific about when this visit needs to be done (for example, let them know if you need the blood test before starting a medication they are expecting to get). Also, advise them of any requirements for testing (eg, fasting for metabolic screening blood tests, geographic location). If the adolescent is seeing another clinician in-person (like a clinician at their college), some services can be provided at that visit (height, weight, blood pressure). It may be possible that tests can be added on in that visit and shared back with the adolescent’s primary care clinician.

It is important to determine if components of hybrid care will need to be kept confidential (eg, STI screening). Discuss with the adolescent how confidential services will be kept private as part of the in-person visit, similar to regular in-person visits.

Billing

• Document the start and end time of the call.
• Stay up to date with billing regulations within your state.
• Ensure that sensitive or confidential information is not inadvertently disclosed to families in the explanation of benefits (EOB).
• The AAP has several resources to assist with coding and billing for adolescent health and telehealth services, including services provided via telehealth. Visit AAP.org/coding.

Connecting Adolescents and Families to Needed Resources

Encourage the adolescent and family/caregiver to use the patient portal to communicate with you, if possible. Think about having community resource information available to you that you can provide verbally or send electronically to the adolescent and/or family/caregiver as needed, like:

• Addiction medicine support
• Educational resources
• Family to Family Health Information Centers
• Food Banks
• Grief Networks
• Intimate Partner Violence/Family Violence Support
• Local National Alliance on Mental Illness (NAMI)
• Mental Health Providers
  • Facilitate a virtual “warm-handoff”, if possible.
  • Does this provider see patients virtually?
• Sexual and reproductive health services
• Shelters
• Social work services
• Suicide hotline
• STI Testing sites
• Tobacco cessation services
• Trauma recovery services (such as rape crisis counseling)

Review the Bright Futures Implementation Tip Sheet: Tips to Link Your Practice to Community Resources for more information.