PHN Grand Rounds:

Caring for Quaranteenagers: Telehealth & Confidential Care

April 14 @ 12:00-1:00PM Presented by: Division of Adolescent & Young Adult Medicine, Children’s National Hospital

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A few notes about today’s Grand Rounds

• All lines are muted throughout the webinar.

• Please use the Chat function to ask questions or make comments.

• To avoid feedback noise, please do not have computer audio and phone audio active at the same time.

• Today’s Webinar recording and slides will be posted to the PHN website following the presentation. www.pediatrichealthnetwork.org

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COVID-19 Response (as of April 7,2020)

• Children’s National Hospital is open for business.

• Telehealth is deployed system-wide. Patients can request telehealth during scheduling appointments with the call center.

• Full time specialists available for real time consults – to contact dial Physician Access Line 202-476-4880 (M-F 8a to 5p; hospital operators 202-476-5000 after hours).

• Explore and participate in shared learning opportunities Childrensnational.org/webinars.

• Drive up/walk up specimen collection site (limited to patients age 22 or under as referred by a primary care physician). Childrensnational.org/COVID19testforms.

• Most elective surgeries are postponed.

• Hospital is preparing for a surge in patients and is taking measures to preserve the health of clinical staff in the event of influx.

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Children’s National Resources

Stay informed with the latest resources for providers, staff and patients on the Children’s National Coronavirus (COVID-19) Resources for Primary Care Practices

https://childrensnational.org/healthcare-providers/refer-a-patient/covid

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Upcoming April Grand Rounds

April 23 @ 12:00-1:00PM Primary Care Management of the Infant Born to a Mother with COVID-19 & Resources to Support Families of Newborns During the Pandemic

Presented by: Karen Fratantoni, MD, Lamia Soghier, MD, and the Child Health Advocacy Institute Team

Our speakers will provide guidance on:

• Primary care management of an infant born to a COVID-19 positive mother

• Management in the perinatal period including how to screen for concerns

• How to provide support and resources when needed by our families

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Neuroscience and Behavioral Medicine Lecture Series

April 15 Pandemic Exacerbation of Stress and Depression: Diagnosis Management and Prevention Adelaide Robb, M.D. Chief, Division of Psychiatry and Behavioral Medicine

April 22 Home Management of the Autistic or Disruptive Child during the Pandemic Kelly Register-Brown, M.D. Medical Director, Center for Autism Spectrum Disorders

April 29 Home Schooling: Challenges for Children with Learning and Attention Difficulties Laura Kenealy, Ph.D. Director, Executive Function Clinic

May 6 Anxiety in Children in a Pandemic: Diagnosis, Management and Prevention Lilia Mucka, Ph.D. Director, Research in Anxiety Disorders Program

All meetings occurring on Wednesdays, 12pm-1pm

View all future Virtual Lunch and Learns at ChildrensNational.org/Webinars

Caring for Quaranteenagers: Telehealth & Confidential Care

Division of Adolescent & Young Adult Medicine

Children’s National Hospital

Meet Our Panel

Moderator Patricia Kapunan, MD, MPH

Panelist Sharyn Malcolm, MD, MPH

Panelist Katherine MacDonald, MD, MPH

Panelist Joseph Waters, MD

Panelist Natasha Ramsey, MD, MPH

Road Map

• Overview of health services for youth in the time of emerging COVID-19

• Telehealth with Teenagers: • Access to Care and Consent

• Negotiating confidentiality

• Managing Contraception

• STI Management

• AYAM Division Resources

• Q&A

Learning Objectives

• Describe changes to health service delivery necessitated by the current public health emergency and their potential impact on health services for teenagers and young adults

• Recognize issues with telehealth service delivery to teenagers related to minor consent and confidentiality

• Discuss limitations and opportunities presented by virtual management of reproductive and sexual health issues

• Identify resources to enhance care for teenagers and young adults in your practice

Changes during the COVID-19 Pandemic

How has health care changed for youth during the COVID-19 pandemic?

• Ambulatory services have been transformed from primarily in-person to virtual care as strict social distancing has been mandated in the DMV

• Traditional barriers to care relevant for teenagers are now augmented by restraints to traditional access, and requirements to seek care in a new modality

What other new health risks exist related to the current public health emergency?

Telehealth & Teens: Access to Care

• Minors’ access to confidential services for certain health conditions are supported by state and federal law

• Reduction of in-person services due to strict social distancing poses new barriers to care

• Telehealth is a promising opportunity to deliver both general and confidential care to youth, which poses its own unique barriers

Telehealth & Teens: Access to Care

• Traditional strategies for digital communication offered by many practices do not reach teenagers (e.g. email, web-portals)

• Practices should have established methods for direct communication with youth including for appointment management and telehealth

• Accommodating both teens and their guardians in telehealth management is operationally complex but necessary

Questions From the Field

› Can you talk about telemedicine well visits & Curbside Vaccinations?

› Show rates appear higher during this current COVID-19 crisis. What policies and practices can we employ after the crisis to maintain teenagers' attendance rate to sessions? Please address whether Telehealth sessions may be a preferred treatment modality for this population.

Telehealth & Teens: Consent for Telehealth Services

• When teenagers present independently for care for which they are legally able to consent, they also can consent to access these same services through telehealth

• For visits in which teens are accompanied by a guardian, we recommended consenting both

• Consent should be discussed in plain language accessible to both parties

Telehealth & Teens: Confidentiality

• Confidentiality is developmentally appropriate and essential for accurate, comprehensive care

• Telehealth creates new challenges for maintaining confidentiality

• Appointment management

• Execution of video visits

• Billing considerations

Telehealth & Teens: Confidentiality

Setting the stage for confidential care is important for privacy and safety

• Pre-visit planning – right time/place

• Setting expectations - appropriate behavior and sharing over telehealth

• Privacy strategies – headphones, alternate communication strategies

• Privacy check before starting the encounter

• Terminating the visit early or rescheduling if necessary for confidential care or safety

Questions From the Field

› How do we ensure privacy during a telehealth visit?

› What is the best way to address parents that are not willing to leave the room?

Telehealth & Teens: Contraception

Most concerns can be initially or entirely managed via telehealth

• Contraception counseling including pre-procedure counseling for Long Acting Reversible Contraception, Emergency Contraception

• Pregnancy concern and pregnancy options counseling

• Side effects of contraceptive medications

• Menstrual problems or other gynecologic complaints

Need for in-person essential follow-up care can be determined on an individual basis.

Telehealth & Teens: Contraception

Many forms of contraception can be prescribed without an in-person visit

• Provider comfort level with contraceptive management and familiarity with patient are key factors

• Subcutaneous depot medroxyprogesterone acetate (DMPA) is available for home administration by trained individuals

Discontinuing established contraceptive medications may pose unnecessary risk.

Telehealth & Teens: Contraception

What is essential reproductive health care?

• Continuation of DMPA when patients desire to continue and decline alternative options

• LARC contraception when medical/behavioral risk merit prompt placement, and alternatives are not desired or medically appropriate

• Implant/IUD removal is not essential in most cases with proven efficacy of Nexplanon® up to 5 yrs, Mirena® up to 7 yrs and the Copper IUD up to 12 yrs

• Abortion services are time-sensitive and community-based care is still available

Sensitive exams requiring a chaperone also require in person care when essential to management.

Questions From the Field

› Can you start OCPs without an initial negative pregnancy test over virtual visit?

https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf

CDC’s “Selected Practice Recommendations for Contraceptive Use” offers guidance on assessing pregnancy risk by history alone (LMP and date of last sexual encounter)

U.S. Selected Practice Recommendations for Contraceptive Use,

MMWR, 2016: 65(4)

The SPR considers a baseline blood pressure the only essential examination for initiation of COCPs

Telehealth & Teens: STI Management

• Most concerns can be initially or entirely managed via telehealth

• Detailed risk assessment, counseling and treatment planning can performed by telehealth

• Need for follow up in-person care determined on an individual basis

• Empiric or syndromic management can additionally limit in-person care

• New CDC guidance is available for syndromic management of STIs

Telehealth & Teens: STI Management

In-person care is indicated when sensitive physical exam or medical procedures are critical for management

• Suspected pelvic inflammatory disease

• Evaluation of genital lesions

• Failure of empiric or syndromic management

• Concern for HIV exposure requiring prophylaxis

• Sexual assault or other high risk situations requiring prompt comprehensive assessment and empiric therapies

• Labs or procedures if required after a video visit

• Confidential virtual care is not possible

More Questions From the Field

› What mental health resources for referrals are available through telehealth?

› With an already extremely limited pool of mental health therapists that are available and take insurance, and given the current crisis leading to increased anxiety, isolation, and likely depression, do you have any information or opinion about the use of commercial online therapy or other available resources?

More Questions From the Field

› How do you ask and counsel about social media use when kids have way too much time on their hands?

• Our aim is to provide high-quality medical care to youth throughout the adolescent years, with a focus on respecting individuality, supporting physical and emotional growth and development, and educating and empowering teens to ultimately take ownership of their healthcare and life decisions.

• Our services include primary care, consultative services, specialty clinics, inpatient management of specialty Adolescent Medicine patients

Division of Adolescent & Young Adult Medicine (AYAM)

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• We operate primary care, school-based, consult and specialty care clinics in DC & MD.

• Consult services are available at 3 Goldberg sites, Friendship Heights, and at Montgomery County ROC

AYAM in the Community

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• Medically essential face-to-face services: AHC (main campus), Friendship Heights, and Montgomery County ROC

• All school-based health centers are closed; telehealth services are available to students eligible for care at DCPS sites

AYAM in the Community: Modified Services

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Telehealth Services:

• Eating Disorders

• Youth Pride Clinic

• Sports Medicine

• General Adolescent Medicine Consultation (Sexual health, reproductive health including LARC counseling, other Adolescent health issues)

How to Find Us:

• Scheduling non-urgent consults: Call Angela Ellis 202-476-2178

• Peer-to-peer consultation: Call 202-476-4880 (Ask for Adolescent Medicine, outpatient consults)

Division of Adolescent & Young Adult Medicine (AYAM)

• Protecting Confidentiality for Individuals Insured as Dependents https://www.guttmacher.org/print/state-policy/explore/protecting-confidentiality-individuals-insured-dependents

• Minors’ Access to STI Services https://www.guttmacher.org/state-policy/explore/minors-access-sti-services

• Minors’ Access to Contraceptive Services https://www.guttmacher.org/state-policy/explore/minors-access-contraceptive-services

Resources: Minor Consent & Confidentiality

Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR; 65(RR-3):1–104. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html

Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR; 65(RR-4):1–66. https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm#usspr

Resources: Contraception Management

We recommend the app

There’s an app for this too.

https://www.cdc.gov/std/default.htm

New CDC guidance for STI care during COVID!

Resources: STI Management

Q & A

Thank you the work you do, and for caring for youth during this difficult time.

Let us know how we can help.

For more information, visit our website:

http://pediatrichealthnetwork.org

Email us at:

phn@childrensnational.org