Interdisciplinary feeding clinic during the coronavirus disease 2019 pandemic: Implementing telehealth and social determinants of health screening

Pediatric feeding disorders (PFD) are an impairment in oral intake that are associated with nutritional, medical, psychosocial, or feeding skills dysfunction.1 They are clinically complex and challenging due to the heterogeneous underlying etiologies and significantly impact health and social-emotional development.2 Furthermore, the burden of PFD extends beyond challenging mealtimes and medical manifestations and contributes to financial concern, caregiver/parent stress, and poor quality of life,2-5 and requires interdisciplinary team management. With the rise of the coronavirus disease 2019 (COVID-19) pandemic, it was predicted that historically marginalized populations may be at higher risk of experiencing the negative sequelae of the virus.6 However, this risk has not been evaluated in patients with PFD. Contributing to the risk in the PFD population is limited access to care.7 To date, few programs for children with PFD have systematically evaluated access to care and social risk factors during the pandemic.8-10 Telehealth for PFD has been increasing and increased dramatically during the pandemic due to healthcare policy adaptations.11 Telehealth is safe and effective at improving access, treatment, and follow-up;12, 13 studies for PFD have found telehealth interventions to be effective, result in a high level of satisfaction, and reduce no-shows.8-10 However, telehealth poses technological challenges that can overwhelm clinic staff and create disparities for patients.14, 15 The patient barriers to telehealth use include lack of technical skill and equipment, cost, and internet access all of which are further affected by age, sex, and socioeconomic status.14, 15 Given that telehealth is now a primary tool for care delivery, and the socioeconomic factors that impact access, it is important to evaluate and address disparities in families of children with PFD. Healthcare systems are incorporating social needs documentation and intervention into routine care given the strong evidence that a patient's social and economic contexts shape their health. Standardized social determinants of health (SDH) screening documentation in electronic health records (EHR) is endorsed by many professional organizations.16 Despite research demonstrating the effectiveness of SDH screening in areas such as housing, access to nutritious food, transportation, racism, education, and job opportunities, clinicians rarely screen for, or address, SDH in pediatric clinical care settings.16 To date, there are limited data available on SDH screening in specialty clinics, demonstrating the need for expanded development. In response to the potential impacts of the pandemic intensifying challenges with access to care and social risk factors,17 we initiated a quality improvement project in our interdisciplinary feeding clinic to ensure children and their families were receiving the care they required. The purpose of the quality improvement initiative was to preliminarily examine, during the pandemic, the transition from an in-person to a telehealth clinic, and the implementation of an SDH screening tool in our specialty pediatric clinic to inform clinical operations and policies. This project was completed as a Quality Improvement Initiative. The transition to telehealth and SDH screening instrument implementation was completed in the Center for Feeding and Nutrition (‘the Center’) an interdisciplinary clinic composed of gastroenterologists, speech-language pathologists, dietitians, occupational therapists, and psychologists at Massachusetts General Hospital (MGH) in Boston, Massachusetts that cares for a range of children with feeding disorders, including for example, premature infants and children with feeding tubes, avoidant/ restrictive food intake disorder, and neurological disorders.1 Prior to the COVID-19 pandemic, services were in-person which included all providers in a visit room at a time. Additionally, social risk screeners were not formally administered in The Center. The Center fully transitioned to a telehealth clinic on March 18, 2020. Parents were contacted by telephone to provide support and prepare them for the telehealth visit and to register for the patient portal to access video services, instructional materials, and information about their child's healthcare services. Telehealth visits were offered by telephone, stand-alone Zoom video-conferencing, and video services integrated into the patient portal. For telehealth visits, families met with all providers simultaneously to recreate how in-person visits were conducted. After the evaluation by each provider, the team, including the family, review the findings and collaboratively develop a treatment plan to maintain the same high-quality care that was offered in person. Data were abstracted from the EHR for all visits scheduled from January 8 to March 11, 2020, defined as the in-person clinic, and from March 18 to July 8, 2020, defined as the telehealth clinic. All visits were conducted virtually and visits that were canceled or no-shows were considered “not attended”. In October 2020, the Center implemented an SDH screening instrument adapted from a tool developed by the Centers for Medicare & Medicaid Services and focuses on food, housing, transportation, employment status, education, care of family members, and paying for medications.18 This was the first instance of utilizing screening in a pediatric subspecialty area. Prior to a visit, a patient service coordinator sent the survey to families with Medicaid via the patient portal and if not completed, followed up by phone. The survey was available in both English and Spanish. Clinicians and staff were trained prior to implementation. If a family screened positive (i.e., had one or more positive responses), their provider was notified via EHR and they were referred to MGH Accountable Care Organization (ACO) Community Resource Navigators to identify and access services/resources. Data on the SDH screenings were collected from 10-2020 to 12-2020 via EHR abstraction. Visit characteristics for telehealth visits were compared across groups by clinic status and visit attendance using a one-way analysis of variance for continuous variables, and Kruskal-Wallis or McNemar's test for categorical variables. We applied the missing indicator method to maximize statistical power. We calculated descriptive statistics regarding the characteristics of patients who participated in the SDH screenings. Statistical analyses were carried out using SAS 9.4 (Cary, NC) statistical software, with significance determined at P < 0.05. When the clinic transitioned to telehealth, 235 (68%) of visits scheduled were attended. Of the visits attended (n = 364), differences between the in-person and telehealth clinic included the age of children such that those who attended the telehealth clinic were younger (42.0 months vs. 24.0 months, P < 0.001), and an increase in patient portal activation (P = 0.003). Conversely, of visits that were not attended (n = 175), there were no differences between in-person vs. telehealth visits. During the in-person clinic period, there were no differences between visit attendance categories, except for patient sex (P = 0.04), indicating that of those patients who did not attend the visit, a greater proportion of the patients were male (Table 1). During the telehealth clinic period, where the majority of visits used a video platform (six phone visits only) differences between visits attended and not attended included fewer days from the appointment was made until the visit (P < 0.001). Additionally, a greater proportion of patients who did not attend the telehealth visits did not have the patient portal activated (P < 0.001). Greater exploration of the patient population who did not activate the patient portal during the telehealth clinic showed that 45.2% had private insurance and 54.8% have public insurance. Upon completion of the SDH instrument pilot study, we identified 74 patients were eligible for screening, 48 completed the survey, and of those, 16 screened positive for at least one domain, with one patient who declined resources after survey completion. Of the patients who screened positive, the majority were male, and the primary language reported was English (Table 2). Greater than 50% of patients identified ‘childcare’, ‘education’, ‘paying utilities’, and ‘food’ as SDH domains requiring support. Of the remaining domains, less than 32% of patients selected ‘transportation’, ‘housing’, and ‘job search/training’. No patients selected ‘paying for medications’ or ‘support for the care of family members’. Examples of community resources that were offered to families include the Supplemental Nutrition Assistance Program, Women, Infants, and Children Nutrition Program, local food pantries, fuel assistance, Head Start, Early Intervention, and the Department of Early Education and Care. This quality improvement project describes the transition from an interdisciplinary pediatric feeding disorder clinic to telehealth and the implementation of an SDH screener. The findings support current literature demonstrating that the interdisciplinary approach can be delivered in a virtual format.8-10, 19 Successful telehealth visit attendance was driven by less time between scheduling a visit and visit date, and patient portal activation improving continuity of care and care quality. Additionally, patient portal activation increased during COVID-19, a reflection of substantial staff support to onboard patients. Patient portal activation is a critical component of telehealth; however, it is not without limitations. More specifically, health literacy, language, internet/broadband access, and socioeconomic status will impact a patient's ability to gain access to the various telehealth platforms and ultimately access to care and needs to be an important consideration when providing telehealth services. In the Center, there were no differences in visit attendance by language or insurance type, which we postulate were driven by staff and clinic protocols to onboard patients to telehealth platforms and provide the same high-quality care as in-person.20 Future efforts to continue to utilize telehealth even as more in-person visits are offered will be critical to maximizing clinic efficiency including cost-savings, and family-centeredness by offering families choices.21 As we move towards a hybrid system, training providers and service coordinators will be essential to ensure the same high-quality care is offered in-person and virtually. The benefits of a hybrid system include decreasing the time between initial and follow-up visits, reducing late arrivals, decongestion the clinic and waiting areas, improving clinic space limits, limiting patient/family travel, and flexible offerings for this heterogenous population to meet their needs. However, there are limits to telehealth including the inability for physical examinations. The pandemic has greatly impacted the well-being of children and families due to the challenges associated with the social shutdown resulting in unemployment, financial insecurity, and a caregiving burden, which will most likely contribute to a substantial increase in poverty over the coming years.22 The consequences of these difficulties are exacerbated in a patient population of PFD, given the additional stress of caring for a child with PFD.3, 23 Additionally, these challenges will further impact food, nutrition, and health security of already at-risk populations including those with low socioeconomic status. As a result of the quality improvement project, a majority of families identified ‘childcare’, ‘education’, ‘paying utilities’, and ‘food’ as domains requiring additional support. Evidence suggests that these are areas that families of children with PFD struggled with prior to the pandemic3-5 and our findings demonstrate that during the pandemic families continued to face these challenges. Because we only implemented the screeners with children with public insurance, it remains unknown if the pandemic magnified existing disparities and disproportionately affected low-income households that already struggle to meet basic needs in addition to managing a child with PFD. The findings are also consistent with the literature demonstrating that caregiver burden, food, health, and socioeconomic outcomes are intimately interlinked.24 Thus, it is essential to continue to adapt and reconfigure current systems to provide better intersectoral coordination among food, healthcare, and social organizations. Study limitations include the quality improvement design, such that randomization to clinic type or to receive SDH screening support was not possible, abstracting additional patient characteristics, including additional time periods, or measurement of any primary outcomes. We also used EHR data resulting in missing data. Additionally, the SDH screening instrument was executed only in Mass General Brigham ACO patients with public insurance and was not available to patients with private insurance. Finally, our SDH screening instrument was an adaptation of a tool from the Centers for Medicare & Medicaid Services, limiting the number of SDH domains screened and the depth of screening.18 The pandemic has exacerbated existing social inequalities and social determinants of health. Continued use of telehealth and SDH screening tools will improve access to care and resources for families of patients with PFD with moderate to low socioeconomic status, although the effectiveness of these approaches needs to be further studied. The findings from both the transition to telehealth and the implementation of an SDH screening tool will help inform specialty providers when undertaking telehealth and adapting SDH-related efforts and health policies. This project was completed as a Quality Improvement Initiative and therefore not formally supervised by the Mass General Brigham institutional review board. We would like to acknowledge Kriston Ganguli and Esther Israel for their help with data acquisition, Quantresa Goods and Kimberlee Perlera for patient coordination and implementation of the SDH screening tool, and the staff and clinicians of the Center for Feeding and Nutrition. This study was supported by a grant from the MDRT Foundation awarded to MS. SGH is supported by grant number F32MH118824 from the National Institute of Mental Health. LF is supported by grant number K23HD090222 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. MS is supported by grant number K23HL161447 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of any of the sponsors. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. None declared.