case #1: multidisciplinary neurodevelopmental telemedicine … hack session 5_the new... · 2020....

8Saving Lives. Protecting Americans.

Case #1: Multidisciplinary

Neurodevelopmental Telemedicine

Clinics in Alaska

Matt Hirschfeld, MD, PhD

Randall Zernzach, MD

Alaska Native Medical Center

Anchorage, AK


Alaska

• 1st in land mass

1,420 miles (N-S)

2,400 miles (E-W)

• 33,900 miles of shoreline

More than all of the contiguous states combined

• 47th in road miles

75% of Alaskan communities are unconnected by a road to a

hospital

25% of Alaskan communities have no airstrip

• Population Density is 1.1 persons / square mile

70 times smaller than the national average


Alaska Tribal Health System

Typical Referral Patterns


Alaska Native Corporations


Village-Based Medical Services

• 180 Small Village Health Centers

Community Health Aides/Practitioners

Behavioral Health Aides

Dental Health Aides/12 Therapists

Home health/personal care attendants

• Average Alaska village: 350 residents


Newtok, Alaska Clinic


Community Health Aide Practitioners


Alaska Native Medical Center


Village-Based Medical Services

• Improved statewide healthcare coordination for women

and children across Alaska

• New clinic focused on developmental issues in children

Multidisciplinary clinic with all therapy services on site

Co-located with child psychiatry

Research and training center for pediatric development


Patient “Greyson”

• 25 month boy referred for developmental delays related to a complex past medical history and lack of follow up.

• Past Medical History

Late preterm birth, IDDM, congenital malformation, s/p surgical repair and complication, 3 month NICU stay for

respiratory failure, resuscitation, intubation status, surgery recovery, feeding problems

Development delays known early, early contacts with therapists, intervention services; lost to regular contact one year

ago, none since COVID shut down

• Family lives in rural Alaska

• Comprehensive assessment of child’s developmental status for medical and developmental intervention needs

requested with a Child and Family Developmental Services Interdisciplinary Team


The Plan

• Register Nurse-Case Manager reviews referral, ensures background documents available

• Case Management Support specialist reaches out to family, schedules with family through link sent via a “Virtual

Patient Room” function in the EMR.

• If the family does not have typical items used in the OT assessments, a kit is mailed to the family for use during

the assessment, and after, if therapy follows.

• Team members: Developmental Pediatrician (DB Peds), Pediatric Speech Therapist (ST), Pediatric Occupational

Therapist (OT), Behavioral Health Consultant (BHC). 90 minute visit planned.

• Primary Care Provider (PCP) is included for wrap-up and summary.


Occupational Therapy Kits


The Flow of the Visit for “Greyson”

• In-depth chart review occurred prior to the visit.

• DB Peds/BHC began visit. Obtained consent, outlined scope of visit, reviewed all medical history not already

known with focus on caregiver concerns, developmental, family and social histories. Any physical exam concerns

were addressed. Child was observed in free play with favorite toys, sibling.

• OT and ST “invited into the room” after first portion completed. OT and ST jointly conducted their assessments

while DB Peds/BHC continued clinical observations of the child.

• ST and OT assessments conducted using standardized tools (e.g. Rosetti Infant Toddler Language Scale,

Peabody Developmental Motor Scales, Milestone Charts)


VTC Therapy Visits


The Flow of the Visit for “Greyson” (Continued)

• DB Peds moderated evaluation sequence, feedback from the team, and parent’s questions.

• DB Peds “invited” the PCP into the virtual “room” via EMR Virtual Patient Room function at summary time

• PCP joined to listen to “around the room” for presentation of findings and recommendations to the parent

• All recommendations forwarded in note to the PCP

Labs, Radiology suggestions

Re-establishing communication with Early Interventions program

Referrals for therapies via VTC (e.g. Speech, OT) at ANMC

Medical consult recommendations (e.g. orthopedics, audiology)


VTC Multidisciplinary Assessments

Advantages

1. Virtual patient rooms allow for more effective

interdisciplinary collaboration and participation.

2. Less room movement time between specialty functions,

overall less in-office time needed, less travel time, one

encounter-many specialists.

3. Ability to see a child in their natural environment.

4. Ability for the PCP to quickly join for the summary.

Creates a powerful visual impression for family of “one

team” of providers that communicate with each other.

5. In time of pandemic-related travel restrictions, the only

way to have an assessment like this.

Disadvantages

1. Family must have internet connection, devices, technology

comfort level. Rural location, education, poverty are

factors.

2. Child must be able and willing to participate to a minimal

degree with the encounter for maximum benefit.

3. Inherent limitations with “hands on” for therapists, certain

physician physical exam items.

4. Billing/coding for team visits can be difficult.


Thank You!


Your Telemedicine Questions,

Answered

Please submit your questions through the Q&A box

case #1: multidisciplinary neurodevelopmental telemedicine … hack session 5_the new... · 2020....

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