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Case #1: Multidisciplinary
Neurodevelopmental Telemedicine
Clinics in Alaska
Matt Hirschfeld, MD, PhD
Randall Zernzach, MD
Alaska Native Medical Center
Anchorage, AK
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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
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Alaska Tribal Health System
Typical Referral Patterns
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Alaska Native Corporations
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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
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Newtok, Alaska Clinic
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Community Health Aide Practitioners
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Alaska Native Medical Center
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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
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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
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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.
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Occupational Therapy Kits
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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)
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VTC Therapy Visits
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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)
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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.
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Thank You!
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