An in-home telehealth model implemented at the Comprehensive Epilepsy Center of Children’s Mercy Kansas City showed high rates of satisfaction among advanced practice registered nurses (APRNs) and other clinicians, according to preliminary data presented by Erin Fecske, DNP, APRN, CNRN, CPNP-PC, FAES, at AES2020.1

The telehealth model was initiated in March 2020 in response to the coronavirus 19 disease (COVID-19) pandemic. At 3 months after implementation of the intervention, Dr Fecske and colleagues sent surveys to 36 clinicians at the epilepsy center to assess satisfaction with the model. A total of 24 providers responded, including 12 attending physicians, 11 advanced practice registered nurses (APRNs), and 1 resident physician.

Nearly all respondents (96%) said that in-home telehealth provided them with an adequate evaluation of patients with epilepsy. Of the 2901 patients with epilepsy seen via in-home telehealth visits within the 3-month period, 66 patients (2%) required an in-person visit within 2 weeks of the virtual visit.


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Unfacilitated and Facilitated Telemedicine Visits for Epilepsy

Clinicians at the Comprehensive Epilepsy Center are using telehealth in various ways and settings for epilepsy visits. The first modality is in-home telehealth model for new or follow-up visits, Dr Fecske said in an interview. These visits are unfacilitated, meaning that a clinician is not at the patient location to assist with the visit. Although in-home follow-up visits typically do not involve use of ancillary devices (eg, stethoscope, handheld camera), new patient visits conducted in-home are somewhat limited as they require camera use by families to allow for a visual examination.

The second modality is facilitated telehealth at an offsite location with telehealth-trained registered nurses and ancillary equipment assisting the patient, said Dr Fecske. “These visits are utilized by new and follow-up patients as we would utilize a traditional clinic visit since the examination is not limited,” she noted.

“Alternatively, facilitated visits may occur at one of our regional primary care partners offices,” Dr Fecske explained. “The telemedicine visit [using Microsoft Teams] occurs in the patient’s primary care office. This facilitated visit includes a staff member from the primary care office, which we hope will improve engagement of the primary care provider in the care of patients with epilepsy.”

Remote Epilepsy Consult Services

“In all of these modalities, we can engage with our consult services such as dietitians and social workers to provide the same support we would provide for a traditional in-person visit, Dr Fecske said. “In situations where I would have a joint visit with an epileptologist [such as presurgical planning], the epileptologist can attend the telehealth appointment with the epilepsy APRN.”

“We have an APRN run a multidisciplinary ketogenic diet screening clinic that preCOVID required a 2+ hour in-person clinic visit from families,” Dr Fecske said. “With the use of telemedicine, we created videos for families to watch ahead of time and the actual time in ‘clinic’ is reduced to about an hour during an in-home telemedicine visit. During that time we are able to have an occupational therapist, dietitian, social worker, chef educator, pharmacist, and epilepsy APRN meet with the family and complete appropriate assessments for ketogenic diet readiness.”

Other members of the care team also can be added at the request of the patient, Dr Fecske said. “I’ve had children in group home settings, and we are able to include care team members as identified by the family, which has been very beneficial.”

The decision to use telehealth over an in-person visit is at the discretion of the provider, who selects the modality when placing an order for follow-up. In-person visits may be preferred for infants or patients with epileptic spasms, Dr Fecske explained. Additionally, most new patients seen via in-home telehealth for their first visit will be seen in-person for their next visit to allow for a complete neurologic examination to be conducted, she said.

Before the COVID-19 pandemic, telehealth at the epilepsy center was limited to facilitated visits where patients presented to off-site locations and ancillary devices were required. At that time, only a small number of providers were credentialed for telemedicine, according to Dr Fecske.

“With the original stay-at-home orders for our states we had to pivot to a more inclusive telemedicine model quickly,” Dr Fecske explained. “Now all of our neurology providers are credentialed to provide telemedicine. As we work to provide more in-person visits, we also are monitoring spacing in the clinic to ensure that we can follow Centers for Disease Control and Prevention recommendations. Therefore, we’ve continued to utilize our telemedicine offerings to ensure that patients continue to be seen regularly and monitored appropriately.”

Limitations and Benefits of Telehealth Visits for Epilepsy

Technology limitations were one of the most commonly cited issues by the survey respondents. Families may not have a camera with a high enough resolution, may have poor internet connectivity or no internet access, or may have difficulties using video applications, Dr. Fecske noted. Additionally, while some caregivers may be able to assist in obtaining portions of the examination, other components — such as reflexes — are difficult to obtain.

Thus, “although we may consider telemedicine a great way to improve access, we also need to consider how it can be another barrier to access for our patients and families,” Dr Fecske said.

“One of the biggest benefits of shifting to this telemedicine model is that it allowed us to continue to provide care to patients in a safe manner during an unusual situation,” Dr Fecske said. “I have patients that continue to request in-home visits as they feel that is the safest option for them at this time. In addition, epilepsy involves so much history taking that much of our visits are spent talking to families and patients and getting accurate descriptions, all of which we can accomplish during an in-home telemedicine model.”

Additionally, telehealth for epilepsy may reduce the number of missed work hours for adult patients and parents as well as missed school time for children with epilepsy, Dr Feckse noted. She advised clinicians who practice telehealth for epilepsy visits to recognize what aspects of care they are and are not comfortable using the technology for.

“If you need an in-person visit to get a better assessment, advocate for what you feel is going to be safest for your patient,” Dr Feckse said.

Reference

1. Fecske E, Le Pichon JB, Wellman C, Waller M, Abdelmoity A. Transition to telemedicine: being nimble during COVID-19. Poster presented at: AES2020; December 4-8, 2020.