Telehealth as a Tool for Obesity Care

1. Telehealth as a Tool for Obesity Care Melissa Gallagher Landry, RD, LDN Lead Dietitian, Optimal Weight for Life Program

3. The Academy says… • Use the Nutrition Care Process: • Assessment • Diagnosis • Intervention • Education • Behavioral Modification • Monitoring • Evaluation

4. The Academy says… • …make maximum use of the multiple strategies for cognitive behavioral therapy: • Self-monitoring • Stress management • Stimulus control • Problem solving • Contingency management • Cognitive restructuring • Social support

6. After today’s talk, we will have… • Reviewed practice tips for delivering virtual nutrition care via Telehealth while maintaining “therapeutic alliance” and the ADIME method. • Demonstrated implementation of a Telehealth intervention from BCH research study • Discussed “lessons learned” from the BCH Telehealth research

7. Considerations for Treatment Design and Delivery Practice tips for Delivering Virtual Nutrition care

8. Terminology • Telehealth: use of electronic information and telecommunications technologies to support long distance clinical health care or patient and professional education. May occur over the internet, email or fax lines for multiple healthcare purposes. • Telemedicine: Use of medical information exchanged from one site to another • Telenutrition: Interactive use of electronic information and telecommunication technology to implement the Nutrition care process • Telehealth Media: Software, application, or platform through which care is delivered

9. Practical Functions of Telehealth • Self-Monitoring and Feedback • Consultation • Education and Counseling

10. Telehealth Care Delivery Methods • Real-time communication • Secure video conferencing • Store-and-forward • Transmission of digital images or data for diagnosis.

11. Technology

12. Also Consider… • Privacy and Security • HIPAA compliance (encryption and Business Associate Agreement or “BAA”) • Administrative Requirements • Privacy and security standards • Professional licensing (must be licensed in “originating site”) • Standard Operating Procedures: Operations and orientation • Technical Requirements • Software Videoconferencing platform/connection (adjusts video quality to available bandwidth) • Hardware: webcam, speakers, microphone (headset) • Quality and Efficacy of Care

13. Quality and Efficacy of CareHow do we create an authentic counseling space online? The outcome of “Therapeutic Alliance”: • Feeling understood • Being respected • Having someone be interested in you • Being encouraged to face and overcome difficulties • Being accepted

14. The Face to Face Setting

15. Telehealth Setting

16. Clinical Factors: The Nutrition Care Process • Rapport building and patient experience • Assessment Diagnosis • Intervention • Monitoring and Evaluation

17. Rapport Building • Transmission Latency (lag time) • Facial visibility • Patient orientation and etiquette: where and how would you take a home visit? • “Backup plan” if technology fails

18. Assessment Diagnosis • Anthropometric Measures • Self report, consider training • Wireless scales • Online forms and use of “app” data • Use of electronic health record/patient portals • Set up for monitoring evaluation? • Ease of use for patient and provider • Security

19. Intervention • Use existing strategies! • Create electronic copies of existing education materials for screen sharing (PDF) • Anticipate online “translation” issues using Telehealth media • Apps and web-based programs may be searched and shared at point of care

20. Monitoring/Evaluation • Follow outcomes via videoconferencing, via email, through web-based programs/“apps”

21. Use Telehealth When You Have… • Adequate reimbursement (often limited by Licensure, Regulations, Cost Concerns) • Private Payers: Varies by company, product/plan • Medicaid: Varies by state • Medicare: Limited to certain geographical areas and CPT codes • Evidence or reasonable ability to simulate effective in-person care • Providers trained to deliver care online (including troubleshooting) • Adequate technologyand infrastructure to meet quality, security, and confidentiality standards Bottom Line: Not every intervention can be or should be delivered via telehealth!

22. Optimal Weight for Life (OWL) Program via Telehealth

23. The OWL Program • Initial Consult: 60 minutes EACH with Endocrinologist, RD, and Psychologist • Follow-Ups: Varies by provider mix and determined by needs. At least every 2 months

25. Wareham Pediatrics • 12 providers • 5500+ patients • 25,000 visits/year • Member of BCH Primary Care Network • Each enrolled participant received technology if they didn’t have it already. Orientation provided for all participants about how to use the video conferencing tool.

26. Technology Setup Patient/Family Secure Network OWL RD

27. Subject Baseline Characteristics • N= 40 (9 Males, 31 Females) • Age: 14 +/- 2 years old • BMI: 32 +/- 5 kg/m2 • Non-Hispanic white • Significantly low-income

28. Study Design Overview

29. Two Care Models • Telehealth Consultation: • Met with PCP every 3 months to for assessment and goal setting. • PCPs used Telehealth to consult with RD/MD/Psychologist weekly to inform care at the primary care level • Telehealth Intervention: • Alternate meetings with RD and Psychologist weekly for 6 weeks, then monthly until end of 6 month time frame. (12 visits total, split evenly between providers) • Met with PCP every 3 months for assessment and goal setting • PCPs used Telehealth to consult with RD/MD/Psychologist weekly to inform care at the primary care level

30. Telehealth Consultation Wareham Pediatrics and BCH (via VidyoDesktop) “Wait List” Control Group Primary Care Telehealth Consultation Telehealth Intervention * • Review goal setting and attainment “Immediate” Intervention Group Primary Care Telehealth Consultation * • Ensure continuity of care at cross over Telehealth Intervention * * * * * * * 0 6 12 3 9 Months

31. John’s Progress Behaviorist: __________________ Dietitian: __________________ It has been three months! Here’s a summary of what we’ve done so far!

32. Telehealth Intervention Patient and Dietitian or Psychologist (via VidyoDesktop) • Adapted from the model of care provided in the OWL Clinic. • Interdisciplinary • Collaborative assessment strategies and shared treatment plans. • Regular meetings to evaluate progress of patient in attaining goals. What are the specific problems? Is more assessment needed? What treatments will address the problems? Is treatment working?

33. Technology Equipment Needs Intervention Materials

34. Preliminary Outcome Data… • Retention: 90% at 6 months, 80% at 12 months • Attendance: 83% (10/12 visits) • Significant change for both groups: • Dietary Quality: Glycemic Load, Fiber, Carbohydrate • Satisfaction: Overall program and behavior change • BMI, BMI Percentile and z-score • Weight Loss • Waist Circumference

35. Preliminary Process Data… • 57.9% had necessary hardware and internet • 7.9% needed a webcam • 34.2% need an iPad with intenet • 82.8% could hear and 93.1% could see with average or higher quality • 62.1% would have lost more time from school/work • 48.3% prefer Telehealthover in- person visits • 24.1 had no preference • 57.7% would not have seen ANY weight loss specialist if not for Telehealth

36. It took a village…

37. Lessons learned

38. Therapeutic Alliance/Rapport Building • Being flexible and slowing down when there are issues with lag time, facial visibility, etiquette, or need to use the “Backup plan” when technology fails – this can be frustrating, hard work! But…

39. Assessment Diagnosis • Pros and cons of self-report data (anecodatal) • Unforeseen assessment benefit of being in the home: authentic context assessment of food availability, family dynamics, and the home built environment. • Avoidance behavior can block assessment

40. Intervention • Requires more advanced design • Less cancellations for weather • “Easier” to attend/improved access BUT, Telehealth does not guarantee: • Motivation to attend/prioritizing attendance • Behavior change

41. Monitoring/Evaluation • Very exciting to be on the same page with PCPs, but difficult to find case management time • Need for developing standard reporting and documentation methods meaningful for the entire care team – we had no EHR!

42. How we managed… • Reimbursement: Grant funding paid for the RD and Behaviorist salaries, technology, and study coordinators. Patients and paid copays for their in-person PCP visits. • Provider training delivered by a technologist, not a clinician. The clinicians were “digital natives” BUT there was still a significant learning curve with limited practice literature available at the time. • Technology and Infrastructure: we had major support from BCH Innovation Specialists

43. Next time… • Determine how to improve self-monitoring and actual measurement of dietary behaviors to supplement weekly sessions! • Provide a better orientation for online nutrition care etiquette!

44. The Academy says… • …make maximum use of the multiple strategies for cognitive behavioral therapy through the most effective delivery system. • Self-monitoring • Stress management • Stimulus control • Problem solving • Contingency management • Cognitive restructuring • Social support

45. Additional Training, Resources, and References • American Telemedicine Association • Academy of Nutrition and Dietetics: http://www.eatrightpro.org/resource/practice/getting-paid/emerging-health-care-delivery-and-payment/telehealth • HIPPA Compliance resource: www.himss.org/library/healthcare-privacy/ References: • Academy of Nutrition and Dietetics. Position of the American Dietetics Association: Weight Management. JADA. 2009; 109: 330-346. • Academy of Nutrition and Dietetics. Video Consultations and Virtual Nutrition Care for Weight Management. JAND. 2015; doi: http://dx.doi.org/10.1016/j-jand.2015.03.016

46. Thank You! Melissa.gallagher@childrens.harvard.edu