Although the pandemic has impacted everyone, it has not been uniform. Dramatic differences emerge when comparing geography, race, socio-economic status, occupation, and even political views. One upside has been the greater appreciation of health equity, and the myriad of factors that influence it. One downside is that we have been confronted with a series of difficult dilemmas.
This has certainly been the case with one especially vulnerable demographic: children.
Prolonged school closures and other measures limited COVID-19 spread, while distance learning inhibited social interaction and exacerbated educational gaps. Despite the (thankfully) reduced incidence of serious illness among kids, their emotional development, education, and overall health has been significantly disrupted. The longer-term impact on psychosocial development is still to be determined.
Importantly, it was not just about “schools open or closed.” Whether in-person or not, children faced emotional and behavioral challenges from the disruption of their normal routine, family stress, and economic hardships. Their health was adversely affected in many other ways, including reduced physical activity and deteriorating diet; delays in preventive care, routine immunizations, and chronic disease management; and access to watchful eyes over children at risk in their homes.
Yet, children’s hospitals have continually adapted to meet the needs of patients and their families.
I recently spoke with my colleague Leonard G. Feld, MD, PhD, a pediatric subspecialist and physician leader, who has seen many hospitals and practices through difficult times. One of his biggest concerns during the pandemic has been maintaining access for kids to the care they need.
A solution embraced by children’s hospitals has been to expand telehealth services. In 2014, as the chief medical officer at a leading children’s health system, Dr. Feld assisted in the implementation of telehealth for selected pediatric hospital-based services. Fast forward to today, telehealth uptake is forecasted to increase by 64% nationwide in 2021, with sevenfold growth by 2025.
Virtual care has increased access, allowing patients to get to physicians promptly and more conveniently. Dr. Feld cites that in pediatrics, when a parent is told their child needs to see a specialist, “The clock starts ticking.”
With enhanced telehealth services, this can now happen within hours or days rather than weeks or months, especially for underserved communities. It’s also allowed for greater communication among specialists, primary care providers, and patients/families.
Questions remain over how telehealth plays out in the long term for pediatric care delivery.
Several issues need to be addressed before telehealth can become a mainstay in pediatric care. Most importantly, can children’s hospitals support the interventions necessary to get kids back on track?
Regulatory and reimbursement barriers to telehealth that were removed early in the pandemic are progressively being reinstated. However, with additional federal support for telehealth in rural communities, pediatric hospitals can leverage their broad expertise as an ideal candidate to receive funding for new strategies.
Another obstacle is access and the digital divide, which is becoming a social determinant of health in its own right, especially in rural America, where nearly 40 million children live 80 miles or more from pediatric subspecialty care. When families are forced to travel long distances for care, aspects of their day-to-day lives, such as work and school, are impacted. While virtual care would seem tailor-made to help address this issue, a recent study suggests affluent Americans in urban areas are using telehealth significantly more than those in rural areas.
However, balancing the convenience of virtual vs. in-person care is also essential for providers as an increasing number of patients and families expect virtual access. Regardless of compensation, clinicians cannot be expected to increase telehealth visits, maintain in-person volume, manage hospitalized patients and consultations to other hospital-based services, and travel to off-site clinics— all while sustaining some semblance of work-life balance.
3 Opportunities to Improve Virtual Pediatric Care
Discussions with Dr. Feld have pointed to three clear opportunities where virtual pediatric care can be enhanced.
1. Establish criteria for rural pediatric telehealth services to accommodate primary care providers and specialists and families during office hours as well as before or after school/work. The latter has the advantage for all caretakers to be involved in discussion with providers without significant disruptions to their daily routine. Virtual patient-centered tools like Ask Me 3 and Teach-Back can help support these efforts by improving communication, efficiency, and compliance.
2.Accelerate training (with federal funding) of advanced practice providers or retrain a cohort of employed primary care providers with “mini-fellowship” training (behavioral health, endocrinology, nephrology, pulmonology, gastroenterology, genetics, cardiology, etc.). This approach can help drive telehealth expansion while allowing specialists to concentrate on tertiary and quaternary patients.
A mini- fellowship is an approximately 12-month program focused on less complex specialty diseases. The pediatrician is embedded within a pediatric specialty practice (ex: hematology/ sickle cell disease). General pediatric board certification would be a prerequisite. This approach may also bridge any specialty provider shortages.
3. Secure a new or expanded pediatric regional referral network. With the advent of value-based care, adding scale without increasing costs requires pediatric institutions to increase the size of their “village” through geographical expansion and partnerships for new models of care which should include focused rural pediatric telehealth protocols.
Leveraging their telehealth expertise is essential to thrive, but children’s providers— especially those in rural areas— must maximize new federal funding, accelerate training, and design market-sensitive regional models that deliver the right care at the right time and place.