12/11/2017 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR?

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1 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS December 13, 2017 Exploring Telenutrition: Evidence, Operationalization and Opportunities Moderator: Lisa Diewald MS, RD, LDN Program Manager MacDonald Center for Obesity Prevention and Education Nursing Education Continuing Education Programming Research DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? If you are calling in today rather than using your computer to log on, and need CE credit, please and provide your name so we can send your certificate. OBJECTIVES Discuss the evidence for using telenutrition in nutrition care. Describe best practice guidelines for a successful telenutrition program. Identify next steps for practitioners seeking to implement telehealth in practice. 1

2 CE DETAILS Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration The American College of Sports Medicine s Professional Education Committee certifies that Villanova University College of Nursing Continuing Education, Center for Obesity Prevention and Education (COPE) meets the criteria for official ACSM Approved Provider status (2015-December, 2018). Providership # CE CREDITS This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians Suggested CDR Learning Need Codes: 1020, 5125, 5370 and 6000 Level 2 EXPLORING TELENUTRITION: EVIDENCE, OPERATIONALIZATION AND OPPORTUNITIES Nina Crowley, PhD, RD Metabolic and Bariatric Surgery Program Coordinator Medical University of South Carolina Molly Jones, RD, LD Outpatient Bariatric Surgery and Telehealth Dietitian Medicaul University of South Carolina 2

3 DISCLOSURE Neither the planners or presenter have any conflicts of interest to disclose. Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. Exploring Telenutrition: Evidence, Operationalization and Opportunities Nina Crowley, PhD, RDN, LD Molly Jones, RDN, LD Medical University of South Carolina, Charleston, SC Objectives Upon completing this activity, the learner will be able to: 1. Discuss the evidence for using telemedicine in nutrition care 2. Describe best practice guidelines for a successful telenutrition program 3. Review next steps for practitioners seeking to implement telehealth in practice 3

4 What is Telenutrition? Definitions Top benefits to the patient 4

5 What is the evidence? Academy s Evidence Analysis Library EAL Telenutrition Workgroup Graded several questions related to the clinical and cost effectiveness of telenutrition when provided by an RDN Grade 1 (highest) level of evidence given to 2 questions: What is the effectiveness of telenutrition interventions and counseling provided by RD when part of a healthcare team? What is the effectiveness of telenutrition interventions and counseling provided by an RD? Lack of evidence related to cost effectiveness or cost benefit of telenutrition; more research needed in this area 5

6 Dilemma of long-term weight maintenance Participation increases success in maintenance Losing weight and keeping it off are different processes Most long term programs require continuous high level of time and resource commitment Patients don t often take advantage of programs Use of technology allows professionals to provide individualized approach in a cost-effective manner and reach a greater audience Haugen et al., 2007 Colorado Weigh High Tech - wt maintenance Weight loss regain was prevented equally effectively with a formal, behavioral, group-based program and a telehealth program Haugen et al., 2007 Without support lost weight is regained Haugen et al.,

7 DSME intervention by RD/CDE in underserved area using telehealth strategies Goal to improve glycemic control and cardiovascular risk through improved diabetes self-management Diabetes TeleCare was a 12-month DSME intervention with 13 sessions, 3 individual and 10 group Usual care consisted of one 20-min diabetes education session, using ADA materials, conducted individually at the time of randomization by the LPN Davis et al., 2010 Outcomes at 12 months A significant improvement of GHb at 6 and 12 months and LDL cholesterol at 12 months is proof of concept that Diabetes TeleCare is effective in an underserved and rural setting Davis et al., 2010 Telemedicine consults for Children and Adolescents with Obesity Telemedicine consultations consisted primarily of one-on-one patient evaluations provided by a weight management specialist and/or endocrinologist with a rural healthcare provider present at the remote site Most patients (80.6%) treated by the weight management specialist showed improvements in their diet, activity level, or weight while in treatment Shaikh et al.,

8 Integrated Telehealth Model for Child Obesity in Community Primary Care Compared BMI changes between 2 groups over 12 mo cross over after 6 months Group 1: PCP in-person visit every 3 mo + obesity specialist tele-visits using VidyoDesktop Group 2: PCP in-person visit only every 3 mo Interdisciplinary Team RD and psychologist Weekly meetings using case formulation model Develop individualized treatment plans together 1 hour RD visits during 6-week intensive phase and 30 minutes for follow up visits Tele-consultation with teams to discuss patients weekly Fleischman et al., 2016 Study Design Fleischman et al., 2016 Results 3 and 6 months greater decrease in BMI following the frequent specialist tele visits After crossover at 6 months, BMI remained significantly different from baseline for Group 1 at 9 months ( 0.12, P = 0.004) and 12 months ( 0.11, P = 0.03), despite discontinuation of specialist tele visits Found the program more helpful, more likely to recommend to others, would not have don t any visits if tele not available Fleischman et al.,

9 Lessons Learned from Pediatric Obesity Treatment Program Telemedicine approach may not be suitable for all families Clinicians should demonstrate flexibility in approach Positive clinician-family relationships are key Take advantage of face-to-face visits, opportunities for social interaction, and clinical resources Partnering with physician practices improves care delivery Anticipate technical difficulties and establish protocols to overcome them Cohen et al., 2008 Best Practice Guidelines for a Successful Telenutrition Program 9

10 General Telehealth Guidelines Must meet the same privacy standards as an in-person visit Ensure communication with primary care providers Share documentation of telehealth encounter with referring provider in a timely manner Telehealth provider must be licensed in the same state the patient is located Some states require patient to sign a consent for telehealth treatment South Carolina Medicaid Guidelines 10

11 Telenutrition at MUSC Part of the VTC (Virtual Tele Consultations) program Connects specially-trained MUSC dietitians with patients throughout the state Reduces barriers to care Goal is to improve the health of South Carolina residents 32.3% of SC adults are obese (2016) 32.9% of SC year olds are overweight or obese (2016) 13% of SC adults have diabetes (2016) 37.8% of SC adults have hypertension (2015) The local PCP determines that a specialist consult (nutrition) is necessary and refers the patient for a telehealth visit. The specialist (dietitian) is able to video conference into the consult and communicate with the patient in real time. The patient goes to their local PCP s office that is set-up with telehealth equipment. The local nurse obtains vitals and acts as the telepresenter to assist with the visit (if needed). The specialist (dietitian) documents the assessment and recommendations in EMR and routes documentation to referring provider. 11

12 Current Telehealth Specialty Visits at MUSC Adult Services: Neurology Nutrition Psychiatry General Surgery Non-Acute Stroke Pediatric Services: Nutrition Dermatology Endocrinology Orthopedics Psychiatry Sickle Cell Surgery Urology Next Steps for those seeking to implement 12

13 The ABCs of Designing/Evaluating Telehealth Programs Assess the Need Patient population/target area Requests from patients and providers Specialty area Business Plan Licensure Financial analysis, reimbursement Equipment, office space, overhead Communicate, Market, and Educate Originating sites Physician groups Joanne Shearer FNCE 2012 The ABCs of Designing/Evaluating Telehealth Programs Design and Deliver the Service Referral forms Scheduling Data collection for outcomes collection Handouts to patient, use central website Evaluate Clinical and Cost Effectiveness Collect data Publish Results Report to Quality Improvement Committees Joanne Shearer FNCE 2012 Research Your State s Policies JUST RELEASED! Fall 2017 State Telehealth Laws and Reimbursement Polices No two states are alike Live video reimbursement is most common and requires GT modifier after ICD-10 code Example: GT Some states offer reimbursement for dietitians Arizona, Delaware, Georgia, Kentucky, Minnesota, Texas, Utah, and New Hampshire (possibly) 20Laws%20and%20Policies%20Report%20FINAL%20Fall% %20PASSWORD.pdf 13

14 HIPPAA compliant video software Start Small MUSC telenutrition started as a pilot program for the Center for Telehealth in 2012 No dedicated telehealth dietitian Current outpatient dietitian offered 2 telenutrition patient slots per month to prove need Conducted 11 consults in first year Funding allowed initial growth MUSC received state funds helping to expand the telenutrition program in 2013 Pediatric weight management dietitians started seeing telemedicine patients as part of their existing schedule 1 day per week Specialty Pediatric Nutrition 1 94 Adult Nutrition Total

15 New sites/partnerships continued growth As of July 2017, 90 contracted practices (71 primary care practices and 19 specialty) Located in 45% of SC s counties 1.3 dedicated telemedicine dietitians Consult numbers continue to increase Specialty Pediatric Nutrition Adult Nutrition Total Telenutrition Consultation 15

16 Lessons learned Offer patient time slots according to the originating site s need Pediatric patients often prefer after school Many rural clinics close mid-day for lunch Providing written handouts can be challenging Can often fax/ to clinic or mail/ directly to patient Utilize electronic screen sharing for patient education during visit The most valuable members of your team will be. Scheduler Coordinator IT support Are you ready to get connected? The demand for telenutrition continues to grow As dietitians, we must expand our reach to provide patients with reliable nutrition information If not us, then who?? Resources: Start up guide: American Telemedicine Association: MUSC Center for Telehealth: Center for Connected Health Policy State Reimbursement: nd%20policies%20report%20final%20fall%202017%20password.pdf South Carolina Medicaid reimbursement: 16

17 TO RECEIVE YOUR CE CERTIFICATE Look for an containing a link to an evaluation. The will be sent to the address that you used to register for the webinar. Complete the evaluation soon after receiving it. It will expire after 3 weeks. You will be ed a certificate within 2-3 business days. Remember: If you used your phone to call in, and want CE credit for attending, please send an with your name to cope@villanova.edu so you receive your certificate. UPCOMING 2018 COPE WEBINARS January 24 February 21 Sarcopenic Obesity: Is the Whole Greater than its Parts? John A. Batsis MD, FACP, AGSF Dartmouth Institute for Health Policy and Clinical Practice Provider Competencies for the Prevention and Management of Obesity Jeanne Blankenship, MS, RDN Vice-President, Policy Initiatives and Advocacy Academy of Nutrition and Dietetics QUESTIONS & ANSWERS Moderator: Lisa K. Diewald MS, RD, LDN cope@villanova.edu Website: 17

18 QUESTIONS & ANSWERS Nina Crowley, PhD, RD Molly Jones, RD, LD 18