28. Telehealth: The Good, The Bad, The Funny with Dr. Rachel Schare

As pediatric practices incorporate  more telehealth, what tips and tricks can help us navigate the challenges of virtual healthcare? Pediatrician Dr. Rachel Schare joins us to share the Good, the Bad, and the Funny in the world of Pediatric Telehealth.
We discuss:

Practical strategies for how to incorporate telehealth into busy pediatric practice:

• Focus mainly on follow-up visits for established patients
• ADHD follow-ups are great, sometimes also depression/anxiety 
• Offer same-day telehealth during last minute schedule openings to accomodate patients who call with urgent issues 

Tips to address common telehealth challenges:

• To manage connection issues, allow extra time for visits
• Make sure you have working phone numbers before the visit
• Send multiple reminders (text, email) with the connection link
• Engage kids with virtual stickers, reaction buttons, backgrounds, etc.

How to limit distractions and ensure pt/family safety:

• Clearly communicate your rules for telehealth before the visit
• Set boundaries, remind families of rules during the visit (i.e. no driving during the visit)

Dr. Rachel Schare is a board-certified pediatrician with extensive experience incorporating behavioral health in primary care pediatrics. For the past 4-5 years, she has been practicing telehealth in both urgent care and primary care settings.

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to psyched for paeds, the child mental health podcasts for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco. Gluco child psychiatrist and mom. Today, we're talking about practical strategies for how to incorporate telebehavioral health into a busy pediatric practice, as well as how to address common challenges. In the telehealth world. I'm really excited about our guests. We have a delightful pediatrician, Dr. Rachel Schare, who has extensive experience. Taking care of behavioral health in the primary care pediatric setting. And she has been practicing tele-health since before the pandemic. Welcome Dr. Rachel Schare.

Dr. Rachel Schare: 1:03

Thanks for having me and I love your pod and congratulations. I think this is really a really cool thing.

Dr. Elise Fallucco: 1:08

Thanks so much. So we're going to talk about the good, the bad, and the funny about tele-health. So starting with the good, which patients do you think telehealth works best for?

Dr. Rachel Schare: 1:20

I Would say well established patients that have maintained continuity with the practice. If you have a well established patient that Is stable on their medication or they only need mild increase or decrease in medication. Those would be the patients we would want to center on the most. You can't have your first visit through telehealth, because one of the limiting factors is we can't do screening tools through telehealth.

Dr. Elise Fallucco: 1:47

I wholeheartedly agree that it is very challenging to do a new patient visit over TELA unless you have a fantastic patient portal system and way of getting completed screening tools quickly and efficiently to help with your assessment. And I agree that telehealth can work beautifully for follow-up visits. And I would say specifically for ADHD, that is fairly well controlled. And even sometimes for kids who also have anxiety and depression who have been stable on their meds for the past couple of visits and have not required dose changes, those are. Ideal cases for tele-health followups. Now let's switch and talk about how do you incorporate tele-health into a busy pediatric practice. Most pediatricians currently are doing a majority of in-person visits, if not a hundred percent in-person visits, but you have experienced blending tele-health visits, incorporating tele-health visits into a busy pediatric schedule of in-person visits. Can you give some advice to pediatric clinicians about how to integrate these telehealth visits in a schedule that already has a lot of in-person visits?

Dr. Rachel Schare: 2:55

I think most practitioners are choosing certain times to do their telehealth if they're doing it at all. sometimes practitioners are doing it at lunchtime, which I don't always recommend because I think we all need our own downtime for our own mental health. You could do one virtual visit every two hours just to give yourself a break to sit down and get out of the practicing part of your office. It is an easy way to get an extra visit in where you may have space or a gap or somebody that really needs advice quickly. Instead of just giving telephone advice, which it's very difficult to bill for, you could actually meet with them on their phone and see a rash or the child or, and actually bill for it so there is that concept too of just increasing the amount of patients per day. In the offices that I cover, if they see a gap or they have a no show, or Somebody's called and canceled their visit. If somebody calls in, they'll say, do you have the ability to do a televisit instead of driving all the way in, cause I have a spot like in the next 20 minutes that I could take you

Dr. Elise Fallucco: 4:00

it sounds so smart to be able to look at your schedule and instead of just having a last minute cancellation that you're pretty sure you're not going to be able to fill, to offer that as a telehealth option for people who urgently need to be seen and don't want to wait till the next day, that makes sense. You have to have a really brainiac scheduler though,

Dr. Rachel Schare: 4:18

yes, yes

Dr. Elise Fallucco: 4:19

So we've talked about the good parts about tele-health and how it offers accessibility, especially for urgent patients, and we've talked about how it can be used flexibly. To fill in gaps in your schedule. Now let's talk about the bad part or rather the challenges of tele-health.

Dr. Rachel Schare: 4:37

WIfi and tech connection issues can become so frustrating especially when you don't have a lot of time and you're running a busy practice. SOmebody is trying to check your patient in virtually and you're waiting for them to connect or you start the visit and then they lose signal. I don't know if this has happened to you all the time, every

Dr. Elise Fallucco: 4:57

day, just like fast forward 10, 15 minutes of trying to figure out. Do they need help asking your staff to try to troubleshoot with them? I feel like a miniature IT assistant at times. It's added challenges to the day.

Dr. Rachel Schare: 5:13

Yes. Which is why one of the takeaways I definitely would make in this situation is Unless you do this frequently like I do on a daily basis visits should probably be 30 minutes you've got to make sure that your connection is good. Sometimes, you can't give them that 15 minute leeway that you can in the office before you have to cancel the visit. You have to keep moving. But that allows your Assistant in your office to hopefully get it connected or to call them and say, Hey, we've got to find another way to link, pull up your phone. Let's try it in a different format.

Dr. Elise Fallucco: 5:50

So allow for extra time when booking these visits, anticipating that they're going to be technology issues, especially when they're connecting for the first time and trying to figure this out.

Dr. Rachel Schare: 6:00

I do think that having that support system of being able to send reminders whether it be by text or email or both just like with any other visit, it makes a big difference. Send the link as much as you can, as every place you can. make sure you have working phone numbers to connect.

Dr. Elise Fallucco: 6:17

So in addition to the tech challenges inherent in doing tele-health, there are also unique situations that come up while you're doing tele-health that you have to navigate. Do you know what I'm talking about?

Dr. Rachel Schare: 6:29

We get people all the time that are driving and our guideline is we cut off the visit. We just say, I'll wait till you pull over, but you cannot be driving during this encounter. We definitely have people eating dinner. They're watching TV and they're not paying attention to you.

Dr. Elise Fallucco: 6:50

Or the parent will be driving the car and they're like, don't worry, you can talk to my child and they throw the phone in the backseat

Dr. Rachel Schare: 6:58

We don't see people when they're driving their car. We will not give you advice if your child is not with you. Cause you have to see the patient and you have to have a parent or your guardian present with you.

Dr. Elise Fallucco: 7:13

I know a lot of our listeners appreciate scripts. in theory, the boundaries make sense. We can't see you while you're driving. We can't see you without your child. So when you encounter either of these situations where there's a family who's driving or Patient without guardian or guardian without patient. What are the words you use in a way that, maintains a therapeutic relationship that also sets up your boundary?

Dr. Rachel Schare: 7:35

we will say I see that you're driving your car. If you would like to pull over, I can continue the visit. And if you can't, we will waive this visit. We are happy to see your child when you get to a stationary position or you are back at home and that's that. Or if we have a patient that the family is not with them, we Just tell them that per our corporation's guidelines, the child has to be present with the guardian in order to be seen for a visit. There are those boundaries that you have to set with parents just like if they were coming into your office There are boundaries.

Dr. Elise Fallucco: 8:13

I'd like the positive phrasing that you had to, if you want to pull over to a safe place, I can see you. Otherwise we need to disconnect. It's just very simple and no judgment, now you have a choice. Here's what the boundary is and here are your choices.

Dr. Rachel Schare: 8:27

Or if you make it very clear in the email that you send

Dr. Elise Fallucco: 8:30

These are all really helpful pieces of advice about setting boundaries and over communicating and making sure that you've got communication backup in the form of accessible phone numbers Any other strategies to keep telehealth visits running smoothly?

Dr. Rachel Schare: 8:47

It really is about making sure nothing is distracting in the house that we wouldn't normally have in our patient rooms. There aren't TVs in our patient rooms in our offices. There aren't 16 children running around. It is you and the parent and the patient. Thank goodness the phone is usually not a distractor. most of the time when you're doing telehealth, most of these people are on their phones, as opposed to a laptop. And in our situation, you can't. Go out of our screen or you may disconnect. So it's not like they can be playing a video game, because it will disconnect the visit.

Dr. Elise Fallucco: 9:24

Oh my gosh. We have different experiences. I'll go to want to speak one on one with the child and I can tell that the child is not looking at me and I'm like, wait a minute. You have another phone you're playing on while we're talking on this phone. I can see you. I see what you're doing. Please put the phone away. Some tricks that I've tried with our school age kids to be able to engage them and connect with them. I use the little reaction buttons and the stickers or change my background to try to keep their attention or to try to engage them. We cannot compete with they're whatever Nintendo

Dr. Rachel Schare: 9:59

you're absolutely right. But I do find that when we do the younger kids for regular visits, they're really still very interested in the phone, because again, that's all what they're about is technology at this point, they want to look at me and they want to talk to me, they want to comply because they're more comfortable in their own space at home than sitting up on a table in an office.

Dr. Elise Fallucco: 10:21

so far we've talked about the good parts of tele-health the bad or challenges of tele-health and how to navigate them. So now let's shift and talk about the funny. Can you share one of your funny experiences from doing tele-health?

Dr. Rachel Schare: 10:35

Oh, okay. When you're in a home setting this is your time when you can really Look in the background and you can get an idea of, is there chaos in the home? All kinds of things. Can't tell you how many times mom or dad have walked behind whoever's on the film and just. They're undies or naked, and there's just nothing you can do except for, honestly can, I just need you to check your surroundings. And let's continue with the visit in just a minute. You just covered your

Dr. Elise Fallucco: 11:09

eyes for people who can't,

Dr. Rachel Schare: 11:11

sorry, you just cover your eyes. You just I cannot look at this.

Dr. Elise Fallucco: 11:16

Final tips and takeaways, do you have any advice for primary care pediatricians if they're about to start trying to incorporate more telehealth and specifically telebehavioral health

Dr. Rachel Schare: 11:27

what I would tell people to start is give it a chance. Do one or two visits a week just to see how you feel interacting with families and how the just how the whole technology part of it works. And then the biggest tips are, you have to have good Wi Fi, you have to have your quiet space, you have to have the reminders and the staff to support you with that.

Dr. Elise Fallucco: 11:52

Oh my goodness. Dr. Schare, this is amazing to talk with you. Thank you so much. I'm still cracking up thinking about the families that are walking around without clothes.

Dr. Rachel Schare: 12:02

It's alarming for sure.

Dr. Elise Fallucco: 12:03

They are very comfortable. Thank you so much. And I think these are really helpful tools and tips. And and this is very topical because so many of us are trying to figure out how do you navigate this in person versus virtual and. How can you take advantage of the benefits of being able to see people virtually for their sake, and then also for your own sake and flexibility but in a way that doesn't drive you crazy. So I like the start small and build approach to just start with a couple appointments, work out some of the kinks before you overload yourself with too many. And then think about, strategic scheduling throughout the day to give yourself a break from in person or just, block scheduling a certain time of day or a certain day, half day of the week or a couple of hours a week. That makes a lot of sense. Thank you so much.

Dr. Rachel Schare: 12:52

for having me. I always love seeing you.

Dr. Elise Fallucco: 12:55

And for our listeners, if you want a written copy of some of these key takeaway points and scripts and tips. Check out our website and click on the tabs, scripts and tips. Thanks again for joining us. If you liked this episode, feel free to share it with a friend and look forward to seeing you next time on psyched for paeds.