key: cord-310779-4puiao40
authors: Mehta, Pooja; Stahl, Marisa G.; Germone, Monique M.; Nagle, Sadie; Guigli, Rebecca; Thomas, Jacob; Shull, Mary; Liu, Edwin
title: Telehealth and Nutrition Support During the Covid-19 Pandemic
date: 2020-07-14
journal: J Acad Nutr Diet
DOI: 10.1016/j.jand.2020.07.013
sha: 
doc_id: 310779
cord_uid: 4puiao40

nan

With hospitals and medical institutions across the world scrambling to find safe care for 1 their patients during the ongoing Covid-19 pandemic, telehealth is rising to the forefront of 2 medicine. While the Covid-19 pandemic has highlighted the benefits of seeing patients virtually, 3 telehealth has been used for decades to increase access to care. 1 For example, the Ontario 4

Telemedicine Network began in the late 1990's 2 and has expanded its care over the years to 5 provide care to over 350,000 patients between 2018-2019 alone. 3 In the United States (US), 6

Kaiser Permanente Northern California began the widespread use of video visits in 2013 4 and 7 has sustained telehealth capabilities until the present time. Despite this, the uptake of telehealth 8 has been slow but has seen a recent rise during the current Covid-19 health crisis. 5 9

Increased use of telehealth during times of crisis is not new; in fact, the US government 10 held several seminars and conferences discussing telehealth as a disaster-relief tool over the past 11 20 years. 6 More recently, in 2017, telehealth was used to provide pediatric care to Florida 12 residents in response to Hurricane Irma. 7 It was successfully employed in hurricane shelters with 13 patients reporting that telehealth prevented them from unnecessary emergency department 14 visits. 8 physically distancing from other people and limiting group gatherings, 13 is an effective way of 28 preventing the spread of infectious agents including coronavirus. 14 In health care settings, social 29 distancing has had huge implications on the ability to provide care. While social distancing may 30 halt the spread of the pandemic, some health providers are worried that it may lead to poorer 31 health outcomes for patients without 16 Non-emergency surgeries and procedures 32

were halted, many in-person visits were cancelled and delayed, and providers were left in limbo 33 regarding balancing societal needs and the needs of individual patients. 34

For RDNs, necessary encounters such as education on a four-food elimination diet for a 35 child with newly diagnosed eosinophilic esophagitis, weight management visits for obesity or 36 malnutrition, and visits for those with enteral or parenteral nutrition were questioned. Telehealth 37 visits offer not only the ability to keep patients and health care providers safe, but also, allow for 38 the continued care of patients. Moreover, in some cases, telehealth may even provide the ability 39 to improve health care delivery beyond the standard of care. 40

One-on-one visits 42

Perhaps one of the most intuitive first steps in using telehealth is to transform existing 43 outpatient one-on-one visits to telehealth visits with an RDN. Telehealth visits have been used in 44 multiple diseases to provide nutrition-related interventions. [17] [18] [19] Through this type of visit, RDNs 45

can both obtain a thorough history as well as visualize a patient's home environment. For 46 example, an RDN providing gluten-free diet education may note that gluten-free flours are 47 directly adjacent to wheat flours. In children specifically, observing mealtime and parent-child 48 interactions in the home environment has provided insight regarding how to best counsel 49 families. 20 For patients with parenteral nutrition, direct observation of home supplies and 50 equipment setup has the potential to prevent readmissions and central line-associated 51 bloodstream infections. 21 While anthropometry cannot be independently measured using direct 52 contact, several interventions have been tested and can be used as limited surrogates. For 53 example, there is some evidence but no strong agreement that self-reported weight and height are 54 accurate. [22] [23] [24] For those without a scale, waist circumferences can be used 25 and are even more 55 accurate when paired with video instructions. 26 56

Telehealth allows for easier coordination of group visits while still allowing for social 58 distancing. A group visit can consist of multiple guardians of the same patient, a 59 multidisciplinary visit with several health care providers caring for the same patient, or several 60 patients and one health care provider. This is especially useful for pediatric patients who may 61 spend time in two different households. By using telehealth, guardians who split custody, 62 grandparents, or even home health nurses can join the visit without physically being in the same 63 location. This helps ensure that all people engaged in the care of the patient hear the same 64 message and stimulates conversations and questions amongst the group. 65

Similarly, telehealth has also been used to facilitate the ongoing use of multidisciplinary 66 clinics. Multidisciplinary clinics consisting of providers in multiple specialties have been shown 67 to improve outcomes. 27,28 While these clinics are often crowded with people and may not allow 68 for following social distancing guidelines, telehealth allows for continued multidisciplinary care. 69

For example, in our institution, patients from across the country are referred to the 70 Gastrointestinal Eosinophilic Diseases Program. A visit to a multidisciplinary clinic within this 71 program frequently involves consultation with a team of providers including a gastroenterologist, 72 allergist, RDN, feeding therapist, and psychologist. A typical telehealth visit consists of a nurse 73 screening the patient's medical concerns and a medical assistant recording weight and height as 74 well as ensuring the technology is working correctly. Then, each provider sees the patient 75 sequentially and ends by sending a secure message via the electronic health record to all of the 76 other providers including concerns and suggested plans. The next scheduled provider then sees 77 the patient, formulates a plan, and reports it in the same manner. Frequently, the RDN and 78

feeding therapist see the patient together as a joint visit within this process. This process 79 continues until the patient and family have seen the entire team. The patient then leaves the 80 "virtual room" by disconnecting from the telehealth video app, and all the providers reconvene in 81 the same virtual room to discuss their visits and determine global recommendations for the 82

Finally, telehealth allows for continued group education. In our own institution, we began 84 offering group gluten-free diet educational sessions for newly diagnosed patients with celiac 85 disease via telehealth in January 2019. This was initiated in response to the fact that many of our 86 patients live in rural areas that 1) require significant travel for specialized pediatric care, and 2) 87 do not have access to registered dietitians with training on the management of a strict gluten-free 88 diet. After doing so, we measured the effects of type of education (in-person versus telehealth) 89 on patient gluten-free diet knowledge, health-related quality of life, and diet adherence at their 90 first follow-up visit post the diagnosis of celiac disease. Over the course of approximately 9 91 months, 57 families took the in-person classes and 13 took the telehealth-based classes. Not only 92 did we find no differences in self-reported improvements in gluten-free diet management, but for 93 some families, the telehealth classes had marked reduction in hours taken off work and need for 94 childcare. Of the 39 children who returned for follow-up, there were no differences in RDN 95 adherence assessments, scores on a gluten-free diet quiz, or health-related quality of life. 96 

In order to preserve personal protective equipment and in an effort to avoid unnecessary 102 patient contact, many inpatient consultations have been converted to telehealth encounters during 103 the Covid-19 pandemic. These can occur through a hospital-provided telehealth cart equipped 104 with a telehealth application, or through the patient's personal device such as a smartphone or 105 tablet. Some telehealth platforms are designed specifically for inpatient visits but with the 106 loosening of Health Insurance Portability and Accountability Act (HIPAA) guidelines during the 107 Covid-19 pandemic, 29 even other modalities such as FaceTime, Skype, or Zoom can be utilized. 108

Access to technology such as available high-speed broadband service or wireless 110 networks is critical to successful telehealth implementation. Thus it is not surprising that slow 111 internet connection and poor connection to wireless networks negatively impacts communication 112 between health care providers and patients during telehealth visits. 30 Although three-quarters of 113 US adults have broadband internet service at home, this service is not evenly distributed with 114 racial minorities, older adults, rural residents, and those with lower levels of education and 115 income less likely to have broadband service at home. 31 The Covid-19 pandemic has highlighted 116 this digital divide 32 and while the Federal Communications Commission has made some recent 117 efforts at closing this gap such as creating an interactive broadband map and increased financial 118 support for the Rural Digital Opportunity Fund, 33 lack of access to the technology needed for 119 telehealth remains an ongoing barrier. 120

Other frequently cited barriers to telehealth use include health provider and patient 121 acceptance, reimbursement, and regulatory barriers. 1,20 A recent article in the Journal of the 122 Academy of Nutrition and Dietetics provides guidance on how to address many of these barriers 123 and practice telehealth specifically as an RDN. 34 However, during the Covid-19 pandemic, it has 124 become easier to practice telehealth now more than ever. Prior training and use of familiar 125 technology lead to better acceptance 30 by both patients and providers thus many institutions 126 perform a tech-check before scheduled appointment times. With social distancing in place, many 127 providers have quickly adapted to telehealth and are finding that it's easier than they initially 128 perceived. 35 Under our current extraordinary circumstances, the federal government is also 129 making telehealth even easier by allowing covered health care providers subject to HIPAA Rules 130 to communicate with patients in ways that may not fully comply with the requirements of 131 In times of natural disasters, successful responses and preparedness has been associated 161 with ensuring that structures such as people, equipment, systems, administrators, and legal 162 organizations are already in place to respond effectively. 48 The ability of hospitals to convert in-163 person visits to telehealth visits is variable with 89.5% of hospitals reporting telehealth 164 capabilities in Minnesota but only 36.9% in Louisiana. Moreover, the number of hospitals 165 providing telehealth has not kept up with demands. 49 In our institution, we were able to quickly 166 adapt to telehealth gluten-free diet classes because the framework for this class was already in 167 place. Because of this, we suggest that institutions continue to offer some form of telehealth even 168 after the effects of this pandemic have subsided. Moreover, future research is needed regarding 169 how to best combine telehealth and in-person visits in order to best meet the needs of patients 170 and improve health-related outcomes. 171

. 172 173

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