National Clinical Training Center



Official VCB TranscriptTitle: Telehealth for Family Planning ServicesSpeaker: Evelyn Kieltyka, MSN, MS, FNP-BCDuration: 00:29:05NCTCFP (00:00):Hello, and welcome to this Virtual Coffee Break sponsored by the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning is one of the training centers funded through the Office of Population Affairs to provide training to enhance the knowledge of family planning staff. In this presentation entitled Telehealth for Family Planning Services, Evelyn Kieltyka, MSN, MS, FNP-BC, will discuss using telehealth methods to provide family planning services.NCTCFP (00:31):Evelyn Kieltyka is a board certified nurse practitioner in women's health and family health. Since 1995 has worked at Maine Family Planning, where she's currently the Senior Vice President of Program Services. At Maine Family Planning she oversees the operations of 18 health centers and also administers all sub-recipient's clinical grants for the reproductive health services across the state. Evelyn received her nursing degree from Sacred Heart University and holds a Master's degrees from Simmons College and the Harvard T.H. Chan School of Public Health.NCTCFP (01:06):Before we proceed, we must go over disclosures. Conflict of interests. In accordance with the continuing education guidelines, the speakers and our planning committee members have disclosed commercial interests or financial relationships with companies whose products or services may be discussed during this program. Our speaker Evelyn Kieltyka has no conflicts of interest to disclose. The planning committee, Katherine Atcheson, Angela Bolen and Sharon Colbert have nothing to disclose. Jacki Witt serves on the advisory panel for Afaxys, which has been resolved.NCTCFP (01:38):Acknowledgement of funding. This presentation was supported by Grant #5 FPTPA006029-02-00 from the United States Department of Health and Human Services (HHS), Office of The Assistant Secretary of Health (OASH), Office of Population Affairs (OPA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, OASH or OPA.NCTCFP (02:11):Successful completion. This course offers 0.5 contact hours. To receive contact hours, participants must complete the course with a satisfactory grade of 80% or higher on the quiz and complete the Evaluation/Request for Credit form. CNE and certificates of completion will be emailed to the participant within four to six weeks.NCTCFP (02:34):Commercial support or sponsorship. There is no commercial support for this training. Non endorsement of products. The University of Missouri, Kansas City School of Nursing and Health Studies, and the ANCC do not approve or endorse any commercial products associated with this activity. Accreditation statement. Continuing nursing education. The University of Missouri, Kansas City School of Nursing and Health Studies is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. This webinar offers 0.5 contact hours for nurses. And now onto our speaker, Evelyn Kieltyka.Evelyn Kieltyka (03:15):Thank you so much. It's a pleasure to be with everyone today. I'm really happy to be able to still share this information with you particularly. I imagine many of you are doing telehealth right now because of COVID-19. I jumped into the fray very quickly so I hope what I can share with you today will help you with what you're coping with in your own particular areas. As the objectives outlined here, hope to talk about different models, discuss reasons for using telehealth to supplement in-person services, factors that go into supporting telehealth services and family planning, and analyze your own clinic settings for telehealth initiatives.Evelyn Kieltyka (03:53):So with that, just want to say a little bit about who we are in Maine, just to give you some context. As Catherine mentioned, we ourselves operate 18 health centers, but we also subcontract with 20 FQHC sites and five school-based health centers and four Planned Parenthoods. We together have over 45 sites in Maine serving a little over 22,000 patients. As you would imagine, we're doing the full range of sexual and reproductive health services, as you can see there. I will add that we do also offer hormonal therapy for transgender patients through what we call our Open Door Program. When you hear me refer to Open Door, you know it's our transgender services. We also have an educational department that provides comprehensive sexual health to middle school and high school students and those folks working with youth. We do advocacy and work at our state house in the federal level. That's a little bit about who we are.Evelyn Kieltyka (04:47):We got involved with telehealth back in 2014. We really wanted to take a look at what might we be able to do. I just want to outline what are the types of telehealth because you'll hear very soon there's a live video conferencing, which is what I'm going to be talking about today, principally, but just also to know there's something called an asynchronous video where you store and then forward and then remote patient monitoring. A lot of folks use that for glucose monitoring and heart rates and things like that. More and more popular now is mobile health where everyone's using their phone or tablet to do this sort of thing. That's the types of tools. Just to remind you, we're going to be talking about live video conferencing in this particular talk.Evelyn Kieltyka (05:30):So why use telehealth? For us, we became interested in seeing maybe we could reach more patients because of the ability to have a patient reach us from anywhere. Also it decreased costs for patients and you'll see in the testimonials, they talk a lot about their time and their travel. We felt it's been really helpful for staff needs and provider shortages. I'll talk a little bit more about that and then frankly, consumer demand. I think with COVID-19, we're just simply not going see telehealth go away after we get through this pandemic. That's what I've been reading across the board with various health experts, looking out into the future. Often people talk about the cost so I just want to put this right upfront in terms of cost versus revenue. You can get a sense of whether or not this is doable for you.Evelyn Kieltyka (06:16):There's a lot of different ways of doing telehealth in terms of how a platform works. There are ones where you can do $50 per month per provider for say 500 minutes. Then there's also a flat fee where it's still per provider, but unlimited minutes. There's also the setup fees and it can range from, as I've put here $900 to $2,500. That includes customization if you want your logo on it, that sort of thing, as well as thinking about staff training. Our average revenue, this is revenues, this is actually the amount of money would get paid, whether it's insurance plan or our Medicaid program, is $76 per visit. That's an average based on our data. As you may imagine, I'm not going to talk a lot about coding, but when you're really doing telehealth, you're doing time-based coding. That's important to understand and as many of you know, in 2021, the CPT coding is going to be changing to a more time-based way of recognizing the time you're spending with a patient. You can do the math in terms of whether or not you think this could financially be a reasonable approach for you.Evelyn Kieltyka (07:22):Next I want to talk about telehealth models that we're using currently at Maine Family Planning. The one that everyone thinks about, and a lot of people are using, are the clinic to clinic model. The patient's in one health center with staff and the provider's in another health center. Why is this convenient? Busy clinic, you can move a client to a telehealth visit. You've got a couple of walk-ins that really need to be seen, but you've got a patient scheduled for a birth control method start. That could easily be moved to a telehealth visit at another location. Then all of a sudden you can see those walk-in patients and not disrupt your schedule. Also, we found it's been great for a provider search or call out. You have a provider call in sick that morning. You can't find someone to do it.Evelyn Kieltyka (08:06):A lot of times we've been able to move more than half of those visits to a telehealth visit and be able to salvage that day for patients and for our staff. We've found telehealth to be very helpful with training and particularly with our Open Door services, where it's our transgender services. For instance, clinician and patient are in one location and the more experienced clinician's in another location, and they can actually see that patient together. The provider that's training in transgender services actually gets mentored and advice from that clinician who's more experienced. It's really allowed us to do this in a very efficient and effective way. The other model that we're using is where we have a medical assistant out into the community who's meeting with patients in their locations. We've particularly been working with organizations that are doing substance abuse treatment. That has been a great way for us to connect with that community and be able to then have the medical assistant set up the patient to be then seen by one of our providers in the office.Evelyn Kieltyka (09:11):It's been a really tremendous way for us to get out and do outreach. In the old days, you really couldn't send a clinician to an entity like one of these, because it just wasn't cost efficient. But now sending a medical assistant there and having them telehealth in, it makes it very cost effective and it's a real value to the patients who are interested in our services but just can't get into a health center. The other way, and this is probably how most of you may be doing it right now, is where the patient is at home, in a dorm, on a lunch break, at work, and they are telehealthing in on their smartphone. We're connecting them with the provider that way. This has been used for many sexual reproductive health services, such as contraceptive starts, pregnancy testing, options counseling, UTIs, STD services, problem visits, our Open Door. We can do a lot of our follow-up that way as well as prenatal, infertility and pre-pregnancy care. You can see there's a lot of ways that you can use on telehealth even when the patient's at home.Evelyn Kieltyka (10:11):This is what our website looks like. As you can see right there, it says click in for virtual visits. The patient clicks on that and then goes to this next screen where you can see that they can schedule a telehealth appointment. If they already have an appointment, they'll start there and start their visit. We've just incorporated this one where no visit time, click in there and it's kind of like our walk-in and we're just experimented with that right now. But we thought there're times when people really just want to be seen right now and we are looking at our capacity to do that by having a medical assistant at our call center, whose job is to monitor that particular link and be able to connect with patients right away and look at the schedule and find out where they might be able to fit them in.Evelyn Kieltyka (10:57):I want to move to the patient's side here. Typically, I would do this live, but I've got some screenshots for you, so you can see what it looks like. The patient comes in to the waiting room and we are with a particular platform called InTouch. It's branded to Maine Family Planning. This is what the patient sees. This will show up on either their tablet or their smartphone and they check in. When they go to check-in, they write their name and we confirm that's the right person and they confirm. Then they go right to our telehealth consent form and you'll get these slides I'm sure, so I won't read all of it. Like many States, there are certain things you need to follow when you're offering telehealth services in the informed consent, such as they can stop this at any time, that this isn't meant to the emergency treatment of any kind, that sort of thing, and that they actually are consenting to this.Evelyn Kieltyka (11:52):The other important thing, that last bullet, because we've been asked about this, is they're also telling you that they are in the state where the provider is licensed. They are consenting that they are in the state of Maine, not in another state getting these services. It goes on to say, in case of a technology failure, what we do, we get a phone number so we can call them. Now with COVID, if there are technology issues, we're allowed to actually finish up the visit using the phone. They sign in, we see their signature there, they put down their reason for visit. They then go into our waiting room. Then they're picked up by the medical assistant, just like they would in a regular office, where you walk in and they see the medical assistant, they would go over their pertinent history for that particular visit.Evelyn Kieltyka (12:41):We have been asked about blood pressure. It certainly is acceptable and considered evidence-based to accept a self report blood pressure if you're starting them on a combined hormonal pill. That was something we were questioned about on another webinar we did back in the spring. This is where they go and then they get picked up by the provider side. Then this is what the provider sees. They see that they're ready. They've got one person in the waiting room. They're all set up, ready to go. Then they just click connect. Then voila, they then see that the consent form has been signed. That's important. Then here you are, video-conferencing. The person in the larger screen is the patient and on the smaller screen is the provider. They start their visit and have their conversation. It's that simple. It's like being on FaceTime or Skype or anything else. It's that easy.Evelyn Kieltyka (13:33):What I want to talk a little bit now is lessons learned. I would say start small with a minimal investment in the technology. There's so many things out there right now, even Zoom, I think, has a HIPAA compliant product now for doing telehealth visits. Look at your costs. Look at the provider per visit per user fixed costs. Chooses parts of visits rather than a whole visit like STD treatment follow up, things like that. Just kind of start slowly. Staff training, I cannot emphasize that enough. Have the expectation that everyone is trained in telehealth. We have found in our organization that we don't want to make this a specialty service. We want everyone to know how to use this. Obviously with COVID-19, everyone needs to know how to use the technology. Need to appeal to the different learning styles. Some people like checklists, other people like to have an algorithm.Evelyn Kieltyka (14:25):Practice, practice, practice. Practice also by solving problems, you lose a video feed, you lose the audio feed, that sort of thing. That's what you want to do. Put systems in place for the longterm. That's what I would recommend. Prepare patients and always have home phone numbers ready nearby. Here I just threw in some quotes from patients as to why they like telehealth. I think I mentioned it earlier. They mentioned no drive, using gas, that sort of thing. The fact that they have kids, a job, a life, it's really helpful.Evelyn Kieltyka (14:58):The interesting thing is on the next slide. I think people actually find this to be more private. Originally we were worried that people would not feel that this was a way that they could feel like they had the confidentiality. But in fact, it's the opposite. Think about it. They're not driving to a clinic, worried if they're going to see a friend in the health center or some people, even if you're here in a rural state like me, some of them will drive by and see someone's car at the family planning center and then say, "Hey, I saw your daughter's car at Maine Family Planning today when I drove by."Evelyn Kieltyka (15:30):That's how it actually has been a little more private for folks. I love this one and I'm pretty used to talking to people through a screen so it's quite normal. I'm a teenager so that's all we do is talk through screens. So again, thinking about our cohort, which is mostly young people and folks that are natives to this particular technology. We found that even older patients, I don't want to stereotype at all, because we found that even all of us have used FaceTime with grandchildren or other people. Everyone's pretty comfortable with this technology. I would not say it's exclusively youth, everyone's comfortable using this technology.Evelyn Kieltyka (16:05):I just want to go back to some lessons learned and what to think about and some challenges. Starting or adding services. You might want to see what's going on in the field. For us, we know that people are doing birth control starts, counseling. We're doing uncomplicated UTI. There is a evidence-based way of making that available. Really looking about what you want to do. I would recommend signing up for a free platform. There certainly are some out there. We were originally using VC, which is a product that's very inexpensive. It was developed by one of the founders of Google. It is HIPAA compliant. You want to check your current equipment. What's your bandwidth? Can you easily do this on your current equipment? Establish one or two visit types to offer to existing patients. Again, just getting started, taking little baby steps to get yourself warmed up and into this particular model of providing care. Obviously, look at the billing, coding, and state requirements in your particular state. They've changed a lot since COVID, and I hope those changes are here to stay because it's made it much easier to make this particular service available because you are able to bill all the payers now and they've loosened up a lot of the requirements.Evelyn Kieltyka (17:20):The visit types. Now I've mentioned clinic to clinic, and this is when you have an MA or an RN available who can do testing and lab work for you, even though the clinician's in another location and a visit does not require a physical exam. This is a great way. Think about all the things you can offer by doing it this way. We often have a lot of folks who are interested in STD screening, not because they're symptomatic, but they want to start a new relationship or they just feel a need to be screened. That certainly is a visit you could include because the MA or RN can capture that sample and get it sent off to the lab for processing.Evelyn Kieltyka (17:57):Direct to patient, which is what I'm sure many of you are doing now, counseling, consenting, where we're even thinking well before COVID of really doing a direct to patient as a way to do all the counseling for an IUD or any procedures, say Nexplanon, as well. Before they come in, that's all done through the telehealth and then when they come in for their visit, they're simply coming in, getting the device and leaving. That's particularly important now with COVID because you really want to minimize the time that someone's in your health center for any particular service.Evelyn Kieltyka (18:29):Follow up results, as I mentioned earlier, this has been a great way to work with our transgender patients because they need a lot of lab works in the beginning of their transition. Being able to have them go get their labs then come back into the clinician and then they do the followup through telehealth as well as giving results. Prescription checks and refills obviously, I mentioned birth control starts and restarts.Evelyn Kieltyka (18:51):I want to talk a little bit about technology. You need to know what your bandwidth is in your setting. That's really important. In Maine, we still have issues with bandwidth. The fact that we just passed a referendum this past week that will help set up improving the bandwidth in the state. What's the patient's access to the internet, cell phones, computers with cameras? It may be a little more difficult now with COVID because sometimes people could go to a library and be in a secure place and be able to use the internet and the cameras. Think about that. As you're planning this, do look at what your particular area. [Pugh 00:19:27] Center's done a lot on telehealth and access to cell phones and things like that.Evelyn Kieltyka (19:32):Again, look at the costs. You want to look at your per visit per provider per cost for the practice and functionality that is HIPAA compliant. Can you take online payments? Form signings really, really helpful. A lot of the platforms do offer that and then integrated with your EHR. Our particular platform is not integrated at the moment, but we are working with our current EHR platform to look at their integrative models. It just makes it easier for form signing and things like that. It's not required, but certainly would make it more integrated. What happens is we split the screen. Patient's on one side of the screen and then the clinician will have the medical record on the other side of the screen.Evelyn Kieltyka (20:12):That's how they handle it on one device and then support. Who's going to support it and equipment? We found we needed to go out and buy some Chromebooks to put in our health centers because say it's a busy clinic, they want to have this patient is consented to do her visit by telehealth. They can put them in the room with a Chromebook and then they can have their visit that way. Look at what you need for additional equipment beyond the equipment that your staff are using for their day-to-day work. This is something to think about, dedicated telehealth staff or integrated with on-site appointment making. We use an integrated model at the moment. We just found it allows us a lot more flexibility. Again, we have 18 health centers and not all of them are open every day. Being able to have a patient on their smartphone want to be seen, even though they live in a particular area where that health center isn't open that day, doesn't mean they can't be seen.Evelyn Kieltyka (21:05):We're now saying to patients, we have a clinician, she works two different health centers. We're now saying this clinician's available to you four days a week, not just two days a week when she's in one health center because of tele. You can have access to her four days a week and five days a week to anybody else. Be thinking broad about how this can really expand a very small bricks and mortar that's only open one day a week, but with the technology that patient can be seen by one of your staff, five days a week. Can't say enough about training and support, tools for different types of learners. Again, I mentioned checklists versus algorithms. Practice, practice, practice, and don't practice too soon. We made the mistake early on of training staff and then that particular staff member wasn't going to do telehealth for say two or three weeks or a month.Evelyn Kieltyka (21:53):No, no, no. You really want to virtually train them and have them do a telehealth visit right away. You want to build up that muscle memory. It's so important that they know where to log in, click through. It really is helpful. It just becomes so much more natural to them when you train and then put them right into the field of doing the telehealth visits. Plan for technical difficulties. That's really important because you have some staff that can roll with technical difficulties. That'll figure it out. They're willing to experiment and other staff that just freeze up and they don't know what to do. Know that you're going to have a whole range of what people need for learning and for their ability to handle any technical difficulties. Here's a model of our, what I was saying in terms of how we would do it through an algorithm.Evelyn Kieltyka (22:38):This is for some people, they really love this way of looking at it. This is our direct to patient. They're in the waiting room. They complete all the forms. They're picked up by the MA. MA does what they need to do in terms of getting them ready, sets up the chart, just like they would if they were in a clinical office space, they're just doing this virtually. They collect the fee at that point. Then they alert the nurse practitioner that they're available. The nurse practitioner clicks in. If they're not available, they go back to the waiting room and then the clinician will go and pick them up and complete the visit.Evelyn Kieltyka (23:13):When you're doing this, create your templates that are specific for telehealth. Again, just like all of us, we're creatures of habit and if you have heart lungs on there or things that you know can't be done through telehealth, sometimes it's easy to click on that as being done. So we've created a particular telehealth templates that exclude things that you simply can't do by a virtual visit.Evelyn Kieltyka (23:40):Logistics and operations. Who's in charge? This was something we learned, so this a really good lesson. Have someone who's actually in charge of telehealth. There needs to be a point person for this so that everyone knows who to go to. This is the person that knows all the operations, all the logistics, and can be that go-to person. Early on, we dispersed it and everybody owned a little piece of it. You all know what happens when everyone owns a little piece, no one owns anything. I would say put somebody in charge to actually help you get this up and running and to be your guru on the telehealth. Since we've done that, it's just made it so much smoother. This person really is handling all the different logistics and algorithms and checklists and keeping them up to date and connecting with staff that way.Evelyn Kieltyka (24:25):I want to say something about marketing. You want to set up this telehealth system, but you need to create demand for it. We started a campaign, I think I have some slides to show you, a campaign for patients, social marketing. The call center's really important to promoting this. Someone calls up and says, "I want to be seen in a particular health center that's closed that day." The call center will say, "Oh, that health center is not available right now, but we can put you in touch with another health center if you'd like to do that." Also, community partners. As I mentioned earlier, we've been going out into the community and making services available remotely from other organizations that want their patients or their clients to have access to these services, but really can't get into a bricks and mortar. This has been a great way to really do outreach and expand your reproductive health services to very needy populations.Evelyn Kieltyka (25:18):This is what we developed for our website and also as handouts to have. We call it virtual visits rather than telehealth visits, because we did a little bit of research and telehealth is a lingo for us, but not necessarily something that the community would understand. We call them virtual visits because people get that. Just highlighted you could do this without leaving your home. Some of the things that you can get. As I've mentioned, emergency contraception like ella, particularly, that's what we're thinking of. We know plan B is over the counter. Also, all they need is a computer or a smartphone. This has really worked well for us.Evelyn Kieltyka (25:52):Last thing I want to talk about is resources. I really cannot overemphasize how important it is to get in touch with your local telehealth resource center. For us, it was invaluable when we got started. What are the laws? What are the rules? How do we get paid? How do we even start to set up protocols? I don't even know where to start for what sort of resources there might be available for platforms. These telehealth resource centers are across the country. You all have them. You can see right here where they're located. So definitely reach out to them. They're your best friends. I've even used them to ask questions, payer sources that I didn't want to say, "Hey, this is Maine Family Planning I want to know about this." I could go to my telehealth resource center and they would actually ask the question for me. As you can see here as a map of the whole country of all the various telehealth resource centers available to you.Evelyn Kieltyka (26:42):Please, please make sure you reach out to them when you're thinking about starting telehealth. Here's some of the things they can help you with. They have great visual tools like this that can walk you through some of the logistics, costs, outcomes, satisfaction, all those sorts of things, giving you all sorts of guidance step-by-step. Very, very helpful. HIPAA and telehealth right here. Again, this is our particular one in the Northeast. We're actually physically located in Maine, even though it operates throughout New England and New York and New Jersey. Again, very visually easy to use. Just another example of how they can help you get started. Again, here are some useful websites you can go to. The northeast one is the one that I connect with, but there's a national consortium. Center for Connected Health Policy, even the American Telemedicine Association. You've got plenty of resources at your fingertips. Here's some additional ones now that we're dealing with COVID and how you can use telehealth.Evelyn Kieltyka (27:43):I can't say enough about that. There have been some really great resources out there and webinars now that we're all dealing with COVID and we're all learning as we go in terms of how to make these services accessible to our patients. I will say when we first started, with COVID and we shut down. Every woman's very, very scared, but in the month following, I looked at the number of visits we did through telehealth versus physical visits and it was remarkable. We did over 60% of what we would've done had it been a regular clinic and that's really remarkable. It was gratifying to say we have to move to telehealth. We have to keep every health center open. You're really vital service to your patients. They definitely still want to be seeing you, even though they have to do it virtually at the moment. So I want to thank you. If you have questions or so please reach out to me. I'd be happy to provide any additional resources or answer any questions.NCTCFP (28:35):Thank you, Evelyn, for sharing your time and expertise. Connect with us the National Clinical Training Center for Family Planning on our website, , where you can find other online learning and continuing education materials. You can follow us on Twitter @NCTCFP, or search for our podcast, The Family Planning Files. Thank you to the participants for watching today. We hope you'll join us for our next Virtual Coffee Break. ................
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