10/25/21

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Welcome!

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Event Materials

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Event Page: MilitaryFamiliesLearningNetwork.org/event/101319/

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Welcome!

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Recording AvailableFood Allergy vs. Food Intolerance

Upcoming EventIntuitive Eating and Diabetes ManagementJanuary 26, 2022

Visit Our Website: MilitaryFamiliesLearningNetwork.org/

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10/25/21

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Optimizing Telehealth Delivery of Nutrition Therapy

Event MaterialsVisit the event page to download a copy of the presentation slides and any additional resources.

This webinar has been approved to offer continuing education credit. Please stay tuned for more information!

Continuing Education

Event Page: MilitaryFamiliesLearningNetwork.org/event/101319/

Adobe Spark Free Images

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Connecting military family service providers and Cooperative Extension professionals to

research and to each other through engaging online learning opportunities

https://militaryfamilieslearningnetwork.org

This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of

Defense under Award Number 2019-48770-30366.

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Erin Skinner, MS, RDN, LDN

Today’s Presenter

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OwnerEmpowered Nutrition, LLCwww.empowerednutrition.health

• Military veteran with 15 years of healthcare experience

• Co-created one of the only insurance-billed functional medicine clinics nationally

• Bills most major payers for telehealth• Providing MNT via telehealth since

2015

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Participants will:

Objectives

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• Understand the insurance reimbursement climate for medical nutrition therapy (MNT) delivered via telehealth

• Learn how to ensure that telehealth delivery of MNT is HIPAA compliant

• Discover how to optimize the quality and efficiency of telehealth-delivered MNT National Cancer Institute on Unsplash

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Are you currently providing telehealth services to patients?

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• Yes, 100%• Sometimes• Not at all• Not sure

Respond using the poll pop-up feature.

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How do you feel like the quality of care for telehealth MNT compares to in-person MNT?

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• In-person is always better• In-person is usually better• They’re about equivalent• Telehealth is usually better• Telehealth is always better• It depends• Not sure and/or not using telehealth

Respond using the poll pop-up feature.

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What is a top challenge that you’re having with

telehealth?

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Share your ideas with us in the chat pod!

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Per The Academy of Nutrition and Dietetics (AND)…

Telehealth Overview

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• Use of technology to deliver long-distance…• Healthcare• Health-related education• Public health• Health administration

• Includes interactive technology (i.e. video conference)• Includes passive technology (i.e. email, fax)

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

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Per AND….

Telenutrition

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• Interactive use, by a RDN, of electronic information and telecommunications technologies to implement the Nutrition Care Process with patients or clients at a remote location, within the provisions of their state licensure as applicable.

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

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RDs successfully deliver MNT via telehealth for patients with…

Telenutrition Evidence

12https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

• Stage 3-4 CDK1

• Inherited metabolic disorders2

• Malnutrition in older adults3

• Liver transplant patients4

• Overweight children5

• Overweight and obese adults6

• Type 2 diabetes7

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Around 42 million Americans, and 1 out of 4 rural Americans do not have broadband internet access.8

Telehealth Limitations

13Image: Julien et al.8

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It’s Here to Stay

Telenutrition Trajectory

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• The telehealth market is expected to become a $2.8 billion industry in the United States by 2025, up from $240 million 5 years ago.9

• That was 2019!

Vlada Karpovich from Pexels

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Telenutrition + Licensure

15https://www.eatrightpro.org/advocacy/licensure/licensure-map

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Telenutrition + Licensure

16https://www.eatrightpro.org/advocacy/licensure/licensure-map

Bottom line: If your tele-patient is in a red state, you must be licensed in that state to provide MNT!

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Medicare

Reimbursement Climate

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• Relaxed location and telehealth requirements during COVID-19 emergency

• Improved MNT access for Medicare part B participants (97802-4 added to approved telehealth list)

• 2% increase in MNT reimbursement• Renewed at 3-month intervals, expected to continue

through 2021• AND supporting an effort to make these changes

permanent.• Get updates: https://www.eatrightpro.org/news-

center/member-updates/coronavirus-updates

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Tricare and Private Payers

Reimbursement Climate

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• Most still allowing MNT via telehealth• Tricare Select• BCBS• Aetna• UHC• Cigna

• Changes can be abrupt and state/region-specific. • New to network: contact for clarification/direction• Ongoing resource: ‘Insurance Credentialing and Billing for

Dietitian Nutritionists’ Facebook group• https://www.facebook.com/groups/InsuranceForDietitians/

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Don’t Let the Complexity Overwhelm You!

Telehealth Billing

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• You quickly get used to the specific payers that you bill• The payers do have support for billing

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Get reimbursed!

Telehealth Billing

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• CPT codes: 97802-4

• ICD-10 code: • Z71.3 - Dietary counseling and surveillance• Others: can bill if documented by provider

• Overweight, obesity, diabetes, renal disease, hypertension, dyslipidemia, metabolic syndrome, eating disorders…

• Modifiers (!)• 95 – telehealth• 33 – preventative/screening

• Location (POS): • 2 – telehealth• 11 - office

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New Privacy Concerns

Staying HIPAA Compliant

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• “With regards to telehealth, at minimum, there remain the same liability and privacy concerns, but there are additional ones as well,” said Pepin A. Tuma, senior director of government and regulatory affairs, Academy of Nutrition and Dietetics, Washington, DC.9

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

Kevin Paster from Pexels

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Act in Good Faith

Staying HIPAA Compliant

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• “The Department of Health and Human Services Office for Civil Rights will temporarily waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday non-public facing remote communications technologiesduring the emergency.”9

• Text and email still prohibited.

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

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Medicare has relaxed their rules but…

Staying HIPAA Compliant

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• Allowing any non-public facing• Apple FaceTime• Facebook Messenger video chat• Google Hangouts video• Whatsapp video chat• Zoom• Skype

• Also allowing messaging via text, Google hangouts, Facebook messenger, others

• Private payers and/or states may not be as relaxed• Disclose privacy risks and optimize settings• Do NOT use public-facing: FB live, TicToc, Slack, etc.

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

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HIPAA Compliant Platforms

Staying HIPAA Compliant

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• Skype for Business / Microsoft Teams• Updox• VSee• Zoom for Healthcare• Doxy.me• Google G Suite Hangouts Meet• Cisco Webex Meetings / Webex Teams• Amazon Chime• GoToMeeting• Spruce Health Care Messenger• EHRs: Kalix, Simple Practice, Healthie, Practice Better, etc.

https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth

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Patient Communication

Best Practices

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• Link sent at scheduling and in reminders• Explain the technology (repeat)• Patients feel a little casual!

• Include a clear cancellation policy• Lay out expectations (i.e. place, connection, timing, video

vs not)• No-shows: call at 3-5 min. No-show at 15 min.

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Privacy Policies

Best Practices

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• Check your current policy!• Revise for telehealth or make a telehealth version• HIPAA violation fines have been relaxed during the

COVID-19 emergency (inherent increased risk)9

• Be clear about how you can and cannot protect their data in a telehealth setting.9

• Describe how to send you message/comms• Share what is secure vs not (i.e. email, fax, EHR,

telehealth platform)9

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Consent

Best Practices

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• Describe telehealth (don’t assume they know)• Be specific about the platform and process• Share inherent limitations and privacy risks 9

• Get signed consent 9

Cytonn Photography / Pexels

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Clinician Environment

Best Practices

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• Treat like an encounter!• No adults or children in the room • Door closed• No loud sounds or other voices• Avoid distracting backgrounds• Pets – be careful• Camera on is ideal

• Ensure good internet connection and mic

Mauldin et al.

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Getting Ready

Best Practices

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• Rooming vs. not rooming• Try to join starting at least 5 minutes prior (last-minute Zoom

updates, anyone?)• Phone and computer in ‘do not disturb’/silent mode• Others in house: make them aware

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Getting Started

Best Practices

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• Confirm they can see and hear you• Look at the camera!• Get verbal consent for telehealth and document 9

• Discuss contingency plan

Mauldin et al.

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Screen Sharing

Best Practices

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• Super helpful! Prioritize in platform selection.• Know your file organization well• Show: labs, guides, meal plans, tech solutions, apps, etc.• Be EXTREMELY careful about open tabs/files

• Close out other charts• Close out other labs• Close out other drafted notes/documents• Ensure your EHR is only showing that patient

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Document Sharing

Best Practices

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• Think about what the files that you’re sending are saying about that patient’s case.

• Example: low FODMAP meal plan for IBS• Would you send this over email (not HIPAA protected)?• Labs are a more obvious example• Prioritize an EHR that allows you to send files via secure link

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Charting

Best Practices

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• Must be complete and prompt 9

• Ok to chart during the encounter – ideally, take notes and then finish after the appointment (focus on them)

• Hint: they can hear you typing. ;)• Auto-text if able (otherwise cut/paste template)• Sometimes I will screen share my draft! I like for them to see

our plan in black and white.

Mauldin et al.

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Follow-Up

Best Practices

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• Step 1: have a feedback system• Step 2: make sure you add telehealth questions!

• Was the process clear?• Was there any frustration with the technology?• Did they feel comfortable from a privacy perspective?

• Make sure they understand next steps/scheduling• Pro tip: automated email sequence post-consult

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Children

Best Practices

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• What age do you require they join? Clear policy.• What age do you want parent to join vs. not? Policy.• Ideally your EHR will allow you to create a guardian for the

minor and the guardian will get the link.• Some allow you to say if child has separate

email/notifications or not.• Otherwise, the parent has the email in the child’s chart,

and the parent gets the info• Young children: let parent know if they can join for only part

of the encounter

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Bonus Round: Groups

Best Practices

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• Have extremely clear policies about privacy/sharing• Ensure you get consent – HIPAA/group setting• Demo the hand-raise• Be ready to protectively mute them (!)• Moderate the dynamic• Explain chat rules• Ideal: video is on for all

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Tech issues

Troubleshooting

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• Clinic practices: email and all phones in chart• 3-5 minutes late: call to see if they need help• Know how to access and re-send link to email• Unplug Bluetooth devices• Unplug added headphones/microphones• Turn off video for better bandwidth• Usually better to jump to phone than to cancel

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Low Tech Knowledge/Resources

Troubleshooting

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• CMS: phone counts (private payers: may not!)• Be flexible

• Location might be less than ideal• Might not get video• Might not have the best sound

• Email can be a continuation: send videos, handouts, guides, recipes, meal plans, food lists, etc.

• Even consider mail!

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Anthropometrics/NFPE

Troubleshooting

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• Detailed ‘MSQ’ intake: i.e., nail lines, tongue color, thinning outside of eyebrows, hair loss, weight history, etc.10

• Some cases: show pictures of scale and/or BIA scale – not right for all!10

• Self-reported weight inaccurate, but still ask and chart what they said as ‘subjective’

• Other data: wearables, food images, diet trackers/logs10

• Focus on behaviors, diet recall, symptoms10

Mauldin et al.

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Anthropometrics/NFPE

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Mauldin et al. 10

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Telenutrition is here to stay!

Conclusion

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• Big picture: improved MNT access is good for patients AND Dietitians

• Build a system that’s telehealth-specific• Communicate before and after• Have a growth mindset (progress vs. perfection)

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This situation is fluid!

Resources

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• AND Telehealth page: https://www.eatrightpro.org/practice/practice-resources/telehealth

• AND COVID-19 updates page: https://www.eatrightpro.org/news-center/member-updates/coronavirus-updates

• AND Telehealth Discussion Board: https://www.eatrightpro.org/practice/practice-resources/telehealth/telehealth-discussion-board

• ‘Insurance Credentialing and Billing for Dietitian Nutritionists’ Facebook grouphttps://www.facebook.com/groups/InsuranceForDietitians/

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References

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1. Warner MM, Tong A, Campbell KL, Kelly JT. Patients' Experiences and Perspectives of Telehealth Coaching with a Dietitian to Improve Diet Quality in Chronic Kidney Disease: A Qualitative Interview Study. J Acad Nutr Diet. 2019;119(8):1362-1374.

2. Singh RH, Pringle T, Kenneson A. The Use of Telemedicine and Other Strategies by Registered Dietitians for the Medical Nutrition Therapy of Patients With Inherited Metabolic Disorders During the COVID-19 Pandemic. Front Nutr. 2021;8:637868.

3. Marx W, Kelly JT, Crichton M, et al. Is telehealth effective in managing malnutrition in community-dwelling older adults? A systematic review and meta-analysis. Maturitas. 2018;111:31-46.

4. Barnett A, Campbell KL, Mayr HL, Keating SE, Macdonald GA, Hickman IJ. Liver transplant recipients' experiences and perspectives of a telehealth-delivered lifestyle programme: A qualitative study. J Telemed Telecare. 2020:1357633X19900459.

5. Hammersley ML, Okely AD, Batterham MJ, Jones RA. An Internet-Based Childhood Obesity Prevention Program (Time2bHealthy) for Parents of Preschool-Aged Children: Randomized Controlled Trial. J Med Internet Res. 2019;21(2):e11964.

6. Haas K, Hayoz S, Maurer-Wiesner S. Effectiveness and Feasibility of a Remote Lifestyle Intervention by Dietitians for Overweight and Obese Adults: Pilot Study. JMIR Mhealth Uhealth. 2019;7(4):e12289.

7. Benson GA, Sidebottom A, Hayes J, et al. Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes. J AcadNutr Diet. 2019;119(4):585-598.

8. Julien HM, Eberly LA, Adusumalli S. Telemedicine and the Forgotten America. Circulation. 2020;142(4):312-314.9. Peregrin T. Telehealth Is Transforming Health Care: What You Need to Know to Practice Telenutrition. J Acad Nutr Diet.

2019;119(11):1916-1920.10. Mauldin K, Gieng J, Saarony D, Hu C. Performing nutrition assessment remotely via telehealth. Nutr Clin Pract.

2021;36(4):751-768.

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Questions?

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Upcoming Event

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Wednesday, January 26, 202211:00 a.m. – 12:00 p.m. ET

Event Page: MilitaryFamiliesLearningNetwork.org/event/107323

This presentation explores and introduces the topic of intuitive eating and a weight-neutral approach to diabetes management.

Continuing education credit will be available for this webinar!

Intuitive Eating & Diabetes Management

For archived and upcoming webinars visit: MilitaryFamiliesLearningNetwork.org/AllEvents/

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Evaluation & Continuing Education

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This webinar has been approved for the following continuing education (CE) credits:

• 1.0 CPEU for RDNs and NDTRs

• A certificate of completion

Go to the event page for evaluation and post-test link.

Evaluation Link

Questions?Email Kristen DiFilippo: kdifilip@Illinois.edu

Event Page: MilitaryFamiliesLearningNetwork.org/event/101319/

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