Episode Transcript
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Dr. Elise Fallucco (00:21):
Welcome back
to psyched for paeds, the child
mental health podcasts forpediatric clinicians, helping
you help kids.
I'm your host, Dr.
Elise Fallucco.
Gluco child psychiatrist andmom.
Today, we're talking aboutpractical strategies for how to
incorporate telebehavioralhealth into a busy pediatric
practice, as well as how toaddress common challenges.
(00:42):
In the telehealth world.
I'm really excited about ourguests.
We have a delightfulpediatrician, Dr.
Rachel Schare, who has extensiveexperience.
Taking care of behavioral healthin the primary care pediatric
setting.
And she has been practicingtele-health since before the
pandemic.
Welcome Dr.
Rachel Schare.
Dr. Rachel Schare (01:03):
Thanks for
having me and I love your pod
and congratulations.
I think this is really a reallycool thing.
Dr. Elise Fallucco (01:08):
Thanks so
much.
So we're going to talk about thegood, the bad, and the funny
about tele-health.
So starting with the good, whichpatients do you think telehealth
works best for?
Dr. Rachel Schare (01:20):
I Would say
well established patients that
have maintained continuity withthe practice.
If you have a well establishedpatient that Is stable on their
medication or they only needmild increase or decrease in
medication.
Those would be the patients wewould want to center on the
most.
You can't have your first visitthrough telehealth, because one
(01:43):
of the limiting factors is wecan't do screening tools through
telehealth.
Dr. Elise Fallucco (01:47):
I
wholeheartedly agree that it is
very challenging to do a newpatient visit over TELA unless
you have a fantastic patientportal system and way of getting
completed screening toolsquickly and efficiently to help
with your assessment.
And I agree that telehealth canwork beautifully for follow-up
visits.
And I would say specifically forADHD, that is fairly well
(02:09):
controlled.
And even sometimes for kids whoalso have anxiety and depression
who have been stable on theirmeds for the past couple of
visits and have not requireddose changes, those are.
Ideal cases for tele-healthfollowups.
Now let's switch and talk abouthow do you incorporate
tele-health into a busypediatric practice.
(02:29):
Most pediatricians currently aredoing a majority of in-person
visits, if not a hundred percentin-person visits, but you have
experienced blending tele-healthvisits, incorporating
tele-health visits into a busypediatric schedule of in-person
visits.
Can you give some advice topediatric clinicians about how
(02:50):
to integrate these telehealthvisits in a schedule that
already has a lot of in-personvisits?
Dr. Rachel Schare (02:55):
I think most
practitioners are choosing
certain times to do theirtelehealth if they're doing it
at all.
sometimes practitioners aredoing it at lunchtime, which I
don't always recommend because Ithink we all need our own
downtime for our own mentalhealth.
You could do one virtual visitevery two hours just to give
yourself a break to sit down andget out of the practicing part
of your office.
(03:16):
It is an easy way to get anextra visit in where you may
have space or a gap or somebodythat really needs advice
quickly.
Instead of just giving telephoneadvice, which it's very
difficult to bill for, you couldactually meet with them on their
phone and see a rash or thechild or, and actually bill for
(03:37):
it so there is that concept tooof just increasing the amount of
patients per day.
In the offices that I cover, ifthey see a gap or they have a no
show, or Somebody's called andcanceled their visit.
If somebody calls in, they'llsay, do you have the ability to
do a televisit instead ofdriving all the way in, cause I
have a spot like in the next 20minutes that I could take you
Dr. Elise Fallucco (04:00):
it sounds so
smart to be able to look at your
schedule and instead of justhaving a last minute
cancellation that you're prettysure you're not going to be able
to fill, to offer that as atelehealth option for people who
urgently need to be seen anddon't want to wait till the next
day, that makes sense.
You have to have a reallybrainiac scheduler though,
Dr. Rachel Schare (04:18):
yes, yes
Dr. Elise Fallucco (04:19):
So we've
talked about the good parts
about tele-health and how itoffers accessibility, especially
for urgent patients, and we'vetalked about how it can be used
flexibly.
To fill in gaps in yourschedule.
Now let's talk about the badpart or rather the challenges of
tele-health.
Dr. Rachel Schare (04:37):
WIfi and tech
connection issues can become so
frustrating especially when youdon't have a lot of time and
you're running a busy practice.
SOmebody is trying to check yourpatient in virtually and you're
waiting for them to connect oryou start the visit and then
they lose signal.
I don't know if this hashappened to you all the time,
(04:57):
every
Dr. Elise Fallucco (04:57):
day, just
like fast forward 10, 15 minutes
of trying to figure out.
Do they need help asking yourstaff to try to troubleshoot
with them?
I feel like a miniature ITassistant at times.
It's added challenges to theday.
Dr. Rachel Schare (05:13):
Yes.
Which is why one of thetakeaways I definitely would
make in this situation is Unlessyou do this frequently like I do
on a daily basis visits shouldprobably be 30 minutes you've
got to make sure that yourconnection is good.
Sometimes, you can't give themthat 15 minute leeway that you
can in the office before youhave to cancel the visit.
(05:34):
You have to keep moving.
But that allows your Assistantin your office to hopefully get
it connected or to call them andsay, Hey, we've got to find
another way to link, pull upyour phone.
Let's try it in a differentformat.
Dr. Elise Fallucco (05:50):
So allow for
extra time when booking these
visits, anticipating thatthey're going to be technology
issues, especially when they'reconnecting for the first time
and trying to figure this out.
Dr. Rachel Schare (06:00):
I do think
that having that support system
of being able to send reminderswhether it be by text or email
or both just like with any othervisit, it makes a big
difference.
Send the link as much as youcan, as every place you can.
make sure you have working phonenumbers to connect.
Dr. Elise Fallucco (06:17):
So in
addition to the tech challenges
inherent in doing tele-health,there are also unique situations
that come up while you're doingtele-health that you have to
navigate.
Do you know what I'm talkingabout?
Dr. Rachel Schare (06:29):
We get people
all the time that are driving
and our guideline is we cut offthe visit.
We just say, I'll wait till youpull over, but you cannot be
driving during this encounter.
We definitely have people eatingdinner.
They're watching TV and they'renot paying attention to you.
Dr. Elise Fallucco (06:50):
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 thebackseat
Dr. Rachel Schare (06:58):
We don't see
people when they're driving
their car.
We will not give you advice ifyour child is not with you.
Cause you have to see thepatient and you have to have a
parent or your guardian presentwith you.
Dr. Elise Fallucco (07:13):
I know a lot
of our listeners appreciate
scripts.
in theory, the boundaries makesense.
We can't see you while you'redriving.
We can't see you without yourchild.
So when you encounter either ofthese situations where there's a
family who's driving or Patientwithout guardian or guardian
without patient.
What are the words you use in away that, maintains a
therapeutic relationship thatalso sets up your boundary?
Dr. Rachel Schare (07:35):
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 waivethis visit.
We are happy to see your childwhen you get to a stationary
position or you are back at homeand that's that.
Or if we have a patient that thefamily is not with them, we Just
(07:57):
tell them that per ourcorporation's guidelines, the
child has to be present with theguardian in order to be seen for
a visit.
There are those boundaries thatyou have to set with parents
just like if they were cominginto your office There are
boundaries.
Dr. Elise Fallucco (08:13):
I'd like the
positive phrasing that you had
to, if you want to pull over toa safe place, I can see you.
Otherwise we need to disconnect.
It's just very simple and nojudgment, now you have a choice.
Here's what the boundary is andhere are your choices.
Dr. Rachel Schare (08:27):
Or if you
make it very clear in the email
that you send
Dr. Elise Fallucco (08:30):
These are
all really helpful pieces of
advice about setting boundariesand over communicating and
making sure that you've gotcommunication backup in the form
of accessible phone numbers Anyother strategies to keep
telehealth visits runningsmoothly?
Dr. Rachel Schare (08:47):
It really is
about making sure nothing is
distracting in the house that wewouldn't normally have in our
patient rooms.
There aren't TVs in our patientrooms in our offices.
There aren't 16 children runningaround.
It is you and the parent and thepatient.
Thank goodness the phone isusually not a distractor.
most of the time when you'redoing telehealth, most of these
(09:09):
people are on their phones, asopposed to a laptop.
And in our situation, you can't.
Go out of our screen or you maydisconnect.
So it's not like they can beplaying a video game, because it
will disconnect the visit.
Dr. Elise Fallucco (09:24):
Oh my gosh.
We have different experiences.
I'll go to want to speak one onone with the child and I can
tell that the child is notlooking at me and I'm like, wait
a minute.
You have another phone you'replaying 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 withour school age kids to be able
(09:46):
to engage them and connect withthem.
I use the little reactionbuttons and the stickers or
change my background to try tokeep their attention or to try
to engage them.
We cannot compete with they'rewhatever Nintendo
Dr. Rachel Schare (09:59):
you're
absolutely right.
But I do find that when we dothe younger kids for regular
visits, they're really stillvery interested in the phone,
because again, that's all whatthey're about is technology at
this point, they want to look atme and they want to talk to me,
they want to comply becausethey're more comfortable in
their own space at home thansitting up on a table in an
(10:20):
office.
Dr. Elise Fallucco (10:21):
so far we've
talked about the good parts of
tele-health the bad orchallenges of tele-health and
how to navigate them.
So now let's shift and talkabout the funny.
Can you share one of your funnyexperiences from doing
tele-health?
Dr. Rachel Schare (10:35):
Oh, okay.
When you're in a home settingthis is your time when you can
really Look in the backgroundand you can get an idea of, is
there chaos in the home?
All kinds of things.
Can't tell you how many timesmom or dad have walked behind
whoever's on the film and just.
(10:56):
They're undies or naked, andthere's just nothing you can do
except for, honestly can, I justneed you to check your
surroundings.
And let's continue with thevisit 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 carepediatricians if they're about
to start trying to incorporatemore 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 justto see how you feel interacting
with families and how the justhow 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
(11:49):
and the staff to support youwith that.
Dr. Elise Fallucco (11:52):
Oh my
goodness.
Dr.
Schare, this is amazing to talkwith you.
Thank you so much.
I'm still cracking up thinkingabout 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 reallyhelpful tools and tips.
And and this is very topicalbecause so many of us are trying
to figure out how do younavigate this in person versus
virtual and.
How can you take advantage ofthe benefits of being able to
see people virtually for theirsake, and then also for your own
sake and flexibility but in away that doesn't drive you
(12:26):
crazy.
So I like the start small andbuild approach to just start
with a couple appointments, workout some of the kinks before you
overload yourself with too many.
And then think about, strategicscheduling throughout the day to
give yourself a break from inperson or just, block scheduling
a certain time of day or acertain day, half day of the
(12:47):
week or a couple of hours aweek.
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 keytakeaway points and scripts and
tips.
Check out our website and clickon the tabs, scripts and tips.
Thanks again for joining us.
If you liked this episode, feelfree to share it with a friend
and look forward to seeing younext time on psyched for paeds.