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10/25/21Welcome!Event MaterialsLet’s Chat!Tech SupportSelect All Panelists & Attendeesfrom the drop-down whencommenting in the chat pod.Visit the event page to downloada copy of the presentation slidesand any additional resources.Email us if you need techsupport or have questions!MilFamLN@gmail.comEvent 319/11Welcome!Recording AvailableUpcoming EventFood Allergy vs. Food IntoleranceIntuitive Eating and DiabetesManagementJanuary 26, 2022Visit Our Website:MilitaryFamiliesLearningNetwork.org/221

10/25/21Optimizing Telehealth Delivery ofNutrition TherapyEvent MaterialsVisit the event page to download acopy of the presentation slides and anyadditional resources.Continuing EducationThis webinar has been approved to offercontinuing education credit. Please staytuned for more information!Adobe Spark Free ImagesEvent 319/33Connecting military family service providersand Cooperative Extension professionals toresearch and to each other throughengaging online learning rk.orgThis m aterial is based upon work supported by the National Institute of Food and Agriculture,U.S. Departm ent of Agriculture, and the Office of M ilitary Fam ily Readiness Policy, U.S. Departm ent ofDefense under Award Num ber 2019-48770-30366.42

10/25/21Today’s PresenterErin Skinner, MS, RDN, LDNOwnerEmpowered Nutrition, LLCwww.empowerednutrition.health Military veteran with 15 years ofhealthcare experienceCo-created one of the only insurancebilled functional medicine clinicsnationallyBills most major payers for telehealthProviding MNT via telehealth since201555ObjectivesParticipants will: Understand the insurancereimbursement climate for medicalnutrition therapy (MNT) deliveredvia telehealth Learn how to ensure thattelehealth delivery of MNT isHIPAA compliant Discover how to optimize thequality and efficiency of telehealthdelivered MNTNational Cancer Institute on Unsplash663

10/25/21Respond using the poll pop-up feature.Are you currently providing telehealth services topatients? Yes, 100%SometimesNot at allNot sure77Respond using the poll pop-up feature.How do you feel like the quality of care fortelehealth MNT compares to in-person MNT? In-person is always betterIn-person is usually betterThey’re about equivalentTelehealth is usually betterTelehealth is always betterIt dependsNot sure and/or not using telehealth884

10/25/21Share your ideas with us in the chat pod!What is a top challengethat you’re having withtelehealth?99Telehealth OverviewPer The Academy of Nutrition and Dietetics (AND) 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, resources/telehealth/practicing-telehealth10105

10/25/21TelenutritionPer AND . Interactive use, by a RDN, ofelectronic information andtelecommunications technologiesto implement the Nutrition CareProcess with patients or clients ata remote location, within theprovisions of their state licensureas applicable.Adobe Stock Standard License 11Telenutrition EvidenceRDs successfully deliver MNT via telehealth for patients with Stage 3-4 CDK1Inherited metabolic disorders2Malnutrition in older adults3Liver transplant patients4Overweight children5Overweight and obese adults6Type 2 diabetes7Adobe Stock Standard License 126

10/25/21Telehealth LimitationsAround 42millionAmericans,and 1 out of4 ruralAmericansdo not havebroadbandinternetaccess.813Image: Julien et al.813Telenutrition TrajectoryIt’s Here to Stay The telehealth market is expected to become a 2.8 billion industryin the United States by 2025, up from 240 million 5 years ago.9 That was 2019!Vlada Karpovich from Pexels14147

10/25/21Telenutrition nsure/licensure-map1515Telenutrition LicensureBottom line: If your tele-patient is in ared state, you must be licensed in thatstate to provide /licensure-map16168

10/25/21Reimbursement ClimateMedicare Relaxed location and telehealth requirements duringCOVID-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 continuethrough 2021 AND supporting an effort to make these changespermanent. Get updates: tes/coronavirus-updates1717Reimbursement ClimateTricare and Private Payers 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 forDietitian Nutritionists’ Facebook group ians/18189

10/25/21Telehealth BillingDon’t Let the Complexity Overwhelm You! You quickly get used to the specific payers that you bill The payers do have support for billingRODNAE Productions from Pexels1919Telehealth BillingGet reimbursed! 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 - office202010

10/25/21Staying HIPAA CompliantNew Privacy Concerns “With regards to telehealth, at minimum, there remain thesame liability and privacy concerns, but there are additionalones as well,” said Pepin A. Tuma, senior director ofgovernment and regulatory affairs, Academy of Nutritionand Dietetics, Washington, DC.9Kevin Paster from aying HIPAA CompliantAct in Good Faith “The Department of Health and Human Services Officefor Civil Rights will temporarily waive penalties forHIPAA violations against health care providers thatserve patients in good faith through everyday nonpublic facing remote communications technologiesduring the emergency.”9 Text and email still 22211

10/25/21Staying HIPAA CompliantMedicare has relaxed their rules but Allowing any non-public facing Apple FaceTimeFacebook Messenger video chatGoogle Hangouts videoWhatsapp video chatZoomSkype 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, ing HIPAA CompliantHIPAA Compliant Platforms 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, resources/telehealth/practicing-telehealth242412

10/25/21Best PracticesPatient Communication 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, videovs not) No-shows: call at 3-5 min. No-show at 15 min.2525Best PracticesPrivacy Policies Check your current policy! Revise for telehealth or make a telehealth version HIPAA violation fines have been relaxed during theCOVID-19 emergency (inherent increased risk)9 Be clear about how you can and cannot protect theirdata 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)9262613

10/25/21Best PracticesConsent Describe telehealth (don’t assume they know)Be specific about the platform and processShare inherent limitations and privacy risks 9Get signed consent 9Cytonn Photography / Pexels2727Best PracticesClinician Environment 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 connectionand micMauldin et al.Adobe Stock Standard License #115104498282814

10/25/21Best PracticesGetting Ready Rooming vs. not rooming Try to join starting at least 5 minutes prior (last-minute Zoomupdates, anyone?) Phone and computer in ‘do not disturb’/silent mode Others in house: make them aware2929Best PracticesGetting Started Confirm they can see and hear youLook at the camera!Get verbal consent for telehealth and document 9Discuss contingency planMauldin et al.303015

10/25/21Best PracticesScreen Sharing Super helpful! Prioritize in platform selection.Know your file organization wellShow: 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 patient3131Best PracticesDocument Sharing Think about what the files that you’re sending are sayingabout 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 link323216

10/25/21Best PracticesCharting Must be complete and prompt 9 Ok to chart during the encounter – ideally, take notes andthen 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 seeour plan in black and white.Mauldin et al.3333Best PracticesFollow-Up 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-consult343417

10/25/21Best PracticesChildren 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 theminor and the guardian will get the link. Some allow you to say if child has separateemail/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 partof the encounter3535Best PracticesBonus Round: Groups Have extremely clear policies about privacy/sharingEnsure you get consent – HIPAA/group settingDemo the hand-raiseBe ready to protectively mute them (!)Moderate the dynamicExplain chat rulesIdeal: video is on for all363618

10/25/21TroubleshootingTech issues Clinic practices: email and all phones in chart3-5 minutes late: call to see if they need helpKnow how to access and re-send link to emailUnplug Bluetooth devicesUnplug added headphones/microphonesTurn off video for better bandwidthUsually better to jump to phone than to cancel3737TroubleshootingLow Tech Knowledge/Resources 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!383819

10/25/21TroubleshootingAnthropometrics/NFPE Detailed ‘MSQ’ intake: i.e., nail lines, tongue color, thinningoutside of eyebrows, hair loss, weight history, etc.10 Some cases: show pictures of scale and/or BIA scale – not rightfor all!10 Self-reported weight inaccurate, but still ask and chart what theysaid as ‘subjective’ Other data: wearables, food images, diet trackers/logs10 Focus on behaviors, diet recall, symptoms10Mauldin et al.3939Anthropometrics/NFPE40Mauldin et al. 104020