Today, we will talk about telemedicine staffing models and team-based approaches to care. I'm Mindy Berger, I'm a Program Manager of clinical informatics. One of the things I remember about our response early in the pandemic was from answering calls on our video visits support team. The support team phone line accepted calls from patients and from my team members with technology questions. A specific call I took was from a patient one evening. He was confused, and frustrated, and anxious about how to join his video visit the next day. By walking him through a test of his device, assisting him with the electronic check-in, and ensuring he knew how to join the video visit the next day, he felt much more comfortable and ready to meet with his provider on video. I'm Maura McGuire. I'm a general internist and Director of Education here at Hopkins Community Physicians. I remember working with Mindy and her team as we all pivoted into telemedicine, and just how instrumental her work was in helping our whole team work together to allow me to deliver the care that I wanted to. These are our learning objectives for our module today. We want to talk about the impact of telemedicine on patients, providers, and staff in ambulatory settings. List four categories of telemedicine benefits and challenges and how staffing models can help with these, and defined best practices for team based telemedicine care for achieving quality goals. We want to take just a minute to review a quick timeline of telemedicine over the last year. We know the pandemic resulted in a clinical need for virtual care, and this accelerated policy and payer coverage for telehealth services. Like others, our health system had been preparing for telehealth and the pandemic allowed us to exponentially grow these services. Because of rapid growth and the pandemic, patients providers and teams initially adapted to telehealth as best they could. However, multiple workflows and inefficiencies were noted early in the transition, in particular challenges related to clinical skills in telehealth were lacking, scheduling and triage decisions like structure and patients providers and staff were challenged by their new roles in technology. In addition, in primary care practices that rely on team based care to achieve our quality and preventive service delivery like immunizations, cancer screening and testing, we needed a way to reassign this work in a new environment. We organized pretty early to crosswalk many in-person services into telehealth and trained our teams accordingly. Many professional organizations like the American Medical Association published guidelines, in fact, for effective team based workflows. The essence of these recommendations were that team based telehealth would work best when, one, there were well defined roles for each team member, and two, training to support these roles within the practice was developed. In the next few slides, we'll discuss some of the challenges in more detail, and we'll highlight some of the solutions our system adopted. But this slide discussed many of the initial impacts and challenges that we encountered as we adjusted to the new care modality of telemedicine. Our daily work and our general understanding of what happens at a provider visit offer primary care shifted suddenly. The shift in thinking affected everyone on the care team, patient, and their care companions. Some of the challenges that are really highlighted on this slide include the technology that is [inaudible] lack of knowledge of telehealth workflows, and certainty for what concerns and visits could be handled via telemedicine. The need for new skills to complete an investment via video, and to how completely remote coordination for follow-up orders such as diagnostic testing in a resource appropriate way. In addition to the newness of telehealth for everyone, changes related to physical distancing and clinical care update as well societal changes impacted our team and the patient. In this next slide, what we did to help develop telehealth staffing solution, is we've thought of many of our benefits and challenges in telehealth into four domains. This slides called it several of those key features we've focused on, and how we could optimize the benefit and rise to the challenge in each domain. Let's talk through some of those a little bit. For technology, many patients and team members have access to a smartphone, you're experienced with the Internet. Our staffing solution then aim to focus on the patients who needed more assistance, who needed additional assistance due to lack with tech familiarity. We train telehealth navigators with the assistance of our video visits support team, and the experience that we developed from that fall line. This allowed our practice team members to become more comfortable with their technology, to assist each other, as well as patients. For patient experience, communication and timing is a key feature in [inaudible] care. With telehealth, we could actually leverage the increased flexibility of appointment time. Well, one of the challenge with it was with remote team members. We had some challenges with communication in handoffs, so we leverage standardized models with telehealth care, and use technology to communicate the patient's solution to just [inaudible] messaging, to assist with that our team formation and communication. For utilization, the focus here was really to ensure that the right patient was seen at the right level of care at the right time. We aim to share best practices and encouraged to continue the preventative care whenever appropriate. To overcome the challenge of how to shift the health to telehealth care, we really are shared our findings when we found a good mobile resource, or remote solution within our network providers to work together, to make sure we're all following best practices. Finally, in quality and safety of primary benefit of our telehealth was minimizing pandemic viral exposure and allowed lab for physical distancing while providing for patient care, especially early in this pandemic. Well, the concept of telehealth is new to many. We reinforced our current standards of clinical care, and continue to use the decision support mechanism to continue to drive our quality of care. We'll discuss our quality a little bit more in a couple of slides. We've discussed this idea of our team-based app in model a little bit already, but let's take a closer look at what that really meant to our organization, and how we really looked at this. You can see here that each patient visit, we divide into four major activity of pre-registration, check in, the visit itself, and check out. Then we could take a look at each component of the visit, and assign that to an appropriate role, appropriate team member, and really define how that team member would complete that task, input operate with other team members to make sure that we met that all the patient are doing for a telehealth visit. For example, pre-registration involves reviewing and prepping the technology with the patient in advance of the video visit. This could happen as early as equipment scheduling to really help increase the comfort of the patient with their technology, meaning that provide their own video. During check-in, initial data collection was completed, appropriate completion of consents for telehealth were ensured to be collected, and we completed last minute troubleshoots to make sure that video would be successful. Finally, the check-in teams are also communicate the patient readiness with the providers to try to optimize appropriate use of time. During the visit, the provider completed their high-quality from the book here. Dr. Maguire, will talk about some more [inaudible] to help with that process shortly. Finally, check-out is an area that we continue to develop because of the difficulties in synchronous to check out in the remote visit. With possible remote team members, we leverage work queues and follow-up reports to ensure that patient complete those follow-up orders and additional [inaudible] need outside of the visit. These roles were defined, and [inaudible] was disseminated to the care team practice by practice, so that each team could understand the roles of the model, and how it all work together. We developed a one-page resource with reminders of the workflow and links to additional resources. One example of an additional resource that we created was actually a video of the patient view of remote check-ins, so that our care team members could understand what was the patient missing when they were trying to help them walk through that process. Our next slide talks more about the quality measure in preventative care that we discussed. Some of the defined task also are complimentary to achieving our quality best practices. This takes some of those same concepts of the pre-visit planning, and post-visit follow-up, and applies them specifically to quality measures. By activating an appropriate team-based approach to care, and resources, we could focus on heat and other quality metrics to increase the quality continuity of care that we provide for primary care patient. You can see here this slide summarizes this into those three distinct activities. Some examples here in that pre-visit planning include, sending questionnaires to patient via the patient portal in advance to the scheduled visit to get some of that information exam, as well as reviewing care gaps that the patient needs to achieve high-quality care during the visit, even before the visit. We complete that during chart review and then have team huddles before the start of the patient care section. Make sure we're all on the same page and understand what gaps we're going to fill for the patient during that visit. You can see even as we shift back, in-person visit, these ideas can be further developed and used to advanced care in an increasing virtual world. A lot of the things that Mindy discussed, orienting teams to their role in a remote care environment, clearly required a lot of training. As Mindy mentioned, her team created a number of one-page tip sheets to make it really easy for staff members to adhere to their functions in our medicine world. Mindy's team also trained more than 350 individuals through a series of virtual meetings and training sessions very early. As she also mentioned, we created videos to supplement our learning, so I just want to run through a couple of those. You can see those if you follow the link at the bottom of the screen on the right. One of the things we did was we developed clinical skills videos primarily directed at our provider group. This was based on the fact that our providers previously had no real training in how to approach an exam via telemedicine. In fact, early in the pandemic, really we're not considering ways where they could do in fact, a fairly effective and reasonably comprehensive exam remotely. You can see an example of one of those videos, clinical skills in telehealth in the upper right part of the box. As Mindy mentioned, we also developed a couple of videos directed at patients. One was a general welcome to video visits that would run a patient through how to prepare for a visit, how to familiarize themselves with the environment just so they would feel comfortable participating in virtual care. Also as Mindy mentioned, we created a tele medicine tips video, which would allow patients to run through a screen showing what their user interface would look like, so they could be ready for the visit and tee up any technological concerns in advance. Just summarizing all of this, we did find that we had to translate existing team-based workflows like huddles and roles into something different to make them work in the telehealth environment. We're continuing to adopt these workflows as the public health emergency ends. Like others, we found that team-based approaches with clearly defined roles so that everybody knew what they needed to do and training to support that could improve the patient's experience and the quality of care. Finally, that identifying new team functions as telehealth continues to evolve, like assisting patients with technology and modifying other existing functions like a virtual checkout in virtual care coordination will be needed for successful team-based care as we go forward. We'll continue to leverage our team as our organization goes forward in continuing telehealth care. Thank you.
