Objectives. Family Stress. Pediatric Diabetes Complications. Diabetes Self-Management Education (DSME)

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1 Objectives Recognize the problem related to lack of access to pediatric diabetes subspecialist in Rural Maryland. Appreciate the impact of pediatric telehealth delivery of care to improve access to pediatric diabetes care and parent satisfaction with services. Discuss nursing leadership role for implementing pediatric diabetes telehealth program. Discuss future pediatric telehealth use cases and nursing implications. Impact of Pediatric Diabetes Type 1 diabetes has increased by 23% & Type 2 diabetes by 21% from (CDC, 2012) Increased disparities related to access barriers and a large minority population with poorer overall health Diabetes Self-Management Education (DSME) ADA guidelines- DSME and monitoring at least every 3 months Support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team The interaction of health behaviors and related processes that patients and families engage in to care for a chronic condition (Modi et al., 2012, p.475) Family Stress Pediatric diabetes affects family QOL Increased stress, anxiety, and depression Financial strain, and family conflict Decreased self-efficacy. (Cousino and Hazen (2013) Pediatric Diabetes Complications Serious life long consequences Retinopathy Nephropathy Neurological complications Cardiovascular disease DKA -most common cause of death Psychological problems increase the difficulty of achieving glycemic control (ADA, 2014)

2 Rural Maryland Geographic isolation Fewer health care professionals Higher rates of chronic disease and mortality Large Medicaid population Poorer health behaviors and disparities Obstacles and Challenges Solutions What is Telemedicine? The use of medical information exchanged from one site to another via electronic communications to improve a patient s health status (ATA, 2014, p.4) Synchronous real time face-to-face contact (image and voice) via videoconferencing. Asynchronous remote monitoring and delivering feedback via and cell phones. Telehealth Landscape: Nationally American Telemedicine Association 2014: Est. 75 million Telehealth visits Predict +/ 50% of health care provided remotely in 5 years Telehealth offers access to specialists Chronic care management

3 Current State of Telemedicine Legislation in Maryland 2012: HB1149/SB781 -Mandating commercial Payers to reimburse providers in parity and without geographic restrictions 2013: HB1042/SB798 -Proxy Privileging for physicians 2013: HB934/SB776 -Maryland Telemedicine Task Force 2014: HB802/SB198- Mandating Medicaid to reimburse providers in parity and without geographic restrictions Literature Review Improves access to care and future research focused on patient s perspectives with telemedicine innovations (Ekeland, Bowes, & Flottorp, 2010) Improved self- management, glycemic control, and satisfaction (Guljas, Ahmed, Chang, & Whitlock, 2014) Lower HbA1c, improved quality of life, reduced calls by the school nurse, and fewer hospitalizations and emergency department visits (Izquierdo et al., 2009) Pediatric Diabetes Telehealth Project Overview Project Aim: Improve access to pediatric diabetes specialist to improve chronic disease management and prevent complications. Community coalition: diabetes specialist, pediatric hospitalists, APRNs, a certified diabetes educator, school nurses, dietician, information technology specialist and nursing administration. Pediatric Diabetes Telehealth Clinic Pediatric outpatient clinic on the Eastern Shore of Maryland in partnership with Washington Nationals Diabetes Care Complex at Children s National Medical Center. Increased Access to Pediatric Diabetes Specialist Family-centered Selfmanagement Support Telehealth Chronic Care Model Telehealth Diabetes Clinic: Increased Utilization of Services NP Coordinated Services through Telehealth in collaboration with proactive team. Improved Outcomes & Decreased Health Care Cost Wagner (1996)

4 Telemedicine Diabetes Parent/ Caregiver Satisfaction Survey Patient/Family Satisfaction Adapted from Myers, Valentine and Melzer's (2008) Parent-Reported Satisfaction Telepsychiatry Survey. Nine items, focusing on three major domains Communication quality and privacy (items 1, 2, 3) Increased access to care (items 4, 5, 6) Quality of telemedicine services (items 7, 8, 9) Advanced Practice Registered Nurses Role Master technological tools Implement telehealth protocols/practice guidelines Lead the coordination and collaboration with other healthcare providers Policy advocacy and participation State Rural Health Council and Telehealth Clinical Advisory Board State Policy: Maryland Telemedicine Task Force Improve access to care and quality of care Improve patient satisfaction Facilitate management of a surge of patients Decrease cost of care consistent with the Affordable Care Act ULTIMATELY accelerate telehealth diffusion in the State Telehealth Program Benefits and Facilitators Immediate patient access, reduced service gaps, improved quality, additional clinical support, better patient and caregiver satisfaction and improved adherence to care standards. Improved health outcomes of underserved and at risk children. Leadership team provided effective management for continuous quality improvement

5 Telehealth Program Barriers Need for community education Regional Pediatric Diabetes Symposium for school RNs, pediatricians/np/pa primary care providers, hospital ER and pediatric RNs, exercise science specialist, dieticians, social work. Need for additional space and supporting staff Leadership support Grant funding Multidisciplinary Collaborative Teamwork Dependable technology Integrated care High level of collaboration o CNMC emergency line for after hours o Certified diabetes educator and dietician consultations o Care coordination with primary care and school nurses Caregiver completes forms with child s data according to diabetes regimen Child s measurements and vital signs obtained and plotted on graphs, uploaded to EMR Child's home blood glucose meter data downloaded into electronic medical record Lab data obtained for review Arrival Telehealth Appointment Telehealth video conferencing Family and nurse practitioner review the data with diabetes specialist via live video conferencing. The NP performs the physical exam synchronously (including eye, thyroid, injection sites) The specialist reviews the lab results, glucose data, physical & history findings; adjusts medications, provides self-care instructions, transmits written copy to remote site and printed for the family. Detailed visit summary sent to PCP school RN, dietician and diabetes educator. NP manages diabetes care in between visits & serves as a consultant to primary care providers and schools. Diabetes educator and dietician visits, diabetes camp for self-management skills. High level of collaboration for acute illnesses: school RN, clinic NP, hospitalist and diabetes specialist. After & In-between Visits Future Research Clinical metrics: HbAIC Health care cost: utilization of services, hospitalizations and emergency room use Psychological considerations: caregiver burden and health-related quality of life Opportunities to Expand Telehealth in School-Based Health Centers Future Potential Telemedicine Infectious Disease Neurology Psychiatry Dermatology

6 Key Take Away Messages Telehealth can relieve caregiver burden Increase family education and monitoring Reduce access to care barriers Advanced Practice Registered Nurses have been challenged to lead this movement Improved Pediatric Health Outcomes!

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