As we work together to navigate the impact of COVID-19, SAHM will be hosting a series of free virtual chats to discuss a variety of issues relevant to the COVID-19 response.   

Upcoming Topics: 


Virtual Chat Session Summary:

  

Upcoming Virtual Chat Sessions

 

Racial Injustice

Wednesday, August 19, 1-2 p.m. EDT

COVID-19 and police killings lay bare longstanding racial injustice, and call upon all of us to work together for a more equitable world. How do we all walk into that zone of growth that allows us to see and perceive micro- and macroaggressions to others and to us, and to give space to the teens we serve to talk about these issues, fostering awareness, critical consciousness, and resilience while protecting ourselves as much as we can?
 
This one-hour online interactive conversation led by Veronica Svetaz, Rebekah Fenton and Alison Culyba will be about creating space to share positive practices that have helped us cope during this time and to learn more about how to do this work in togetherness. We will discuss and use a healing practice from the book Mindful of Race, and use a framework based on Vicarious Resilience. This session will lay the groundwork for future discussions about how we as individuals and we as a SAHM community can further our efforts to address racism and violence. 

For information on how to register, please email [email protected]

 


Virtual Chat Session Summary

 

Wellness and Mindfulness in Challenging Times

Thursday, July 16
 A summary of this session will be posted shortly


Caring for Adolescents with Eating Disorders during the COVID-19 Pandemic

Friday, June 19

Resources shared:




Advocacy Priorities for Adolescent Health During COVID-19: A Conversation with SAHM and AAP Advocates

  Discussion of current challenges and strategies related to advocacy: 

Juvenile justice issues – cases in juvenile justice centers, staff refusal to wear masks, release versus continued detention, solitary confinement 

Putting procedures in place quickly – decreasing census, virtual court, increasing time that kids can talk with families, education of youth and staff, PPE, separate floor for COVID-positive or those under investigation, working with officials, ramping up testing. AAP policy statement has been published. SAHM working on statement.

Runaway and homeless youth – concerns for transmission

Writing a document to support homeless youth; sheltering in place, rapid testing in shelters. 

Access to reproductive health services and family planning

Telehealth – what services can be provided, and how can they be provided? For example, Mifepristone prescription. This and other meds are under REMs which the FDA had waived for other meds but has not waived in-person prescription for Mifepristone. ACOG sued FDA – AAP and SAHM will likely be asked to support that effort.

AAP, SAHM and many other organizations filed amicus briefs and issued statements regarding states’ restrictions on abortion services in response to COVID19.

ACA – what will Supreme Court decide when they hear the case and what this will mean for adolescents?

Supreme Court has agreed to hear the challenge to the ACA. Continued advocacy will be important. AAP Federal Affairs is monitoring the situation and will provide updates.

Health insurance - state Medicaid programs have been receiving many requests due to unemployment. If states do not receive federal funds, they will respond with cuts. Generally, states moving into increasingly difficult positions. Almost all states have mandatory budget balancing provisions, but what that actually means differs across states.

Need funding to shore up funding for Medicaid. Next coronavirus bill would provide state support. Current status of COVID19 bill- passed US House of Representatives, stalled in US Senate.
 
Additionally, there are concerns about ongoing payment for telehealth services.

Health promotion targeting adolescents – Why should I as an adolescent practice mask wearing and social distancing? Is there enough information on how Covid affects adolescents?

Few campaigns directed toward adolescents re: practicing PPE and social distancing. Should be done in collaboration with adolescents. More likely to be asymptomatic carriers. How could SAHM be involved? Anisha Abraham has shared materials with us. Chinwe Efuribe has noted that youth engagement SIG could be involved. Has OAH thought about doing a campaign? Re-inviting families back to preventative care: https://www.youtube.com/watch?v=B7U7iddiR9c

Resources for youth:

Mental health concerns

Virtual visits have been a silver lining. Now have better access to Telehealth.
 
But there are concerns about mental health effects of disruption of routines, social isolation, lack of peer interactions, school interruption, and sleep disruptions.

Sports PEs not required this year – concerns that this will decrease well visits

Some states, health systems and insurers have said that the AAP recommended delaying pre-participation visits. In fact, the AAP has issued no such guidance but has issued guidance on care:

Substance use disorder management – increased use

Some programs have gone virtual.

Decreases in vaccination rates

Provision of health to AYA in rural areas

Discussed challenges, especially hesitancy of payers to reimburse for telehealth services. Jesse Barondeau (South Dakota) is interested in networking with other rural providers.

Advising colleges, schools – risk of transmission (including chorus and band)

  1. How to return to campus safely
  2. How to enforce public health measures for campus students
  3. Impact on local resources, infrastructure, and health systems

Some colleges may ask students not to leave campus from beginning of school until Thanksgiving which may pose challenges. Strategy of screening/testing students when they come back to campus, as students are returning from all over. Is the public health system ready for this?

Second wave affecting more young people

Should we then be thinking what should be the mitigation public health approaches that should be adapted. Is this something the SIG could do to guide institutions? Need statements and educational materials from SAHM and AAP that we can use for local advocacy

Youth in essential jobs (MAs, grocery stores, etc.) and youth in the military

Need for messages for these groups. Sara Kinsman interested in working with us on these groups. They may be at greatest risk for not having health insurance, etc. Important to focus on these groups in addition to college kids. In January 2020, of the 2,670,000 people working in grocery stores, 329,000 were ages 16-19 (12.32%) and 412,000 (15.43%) were ages 20-24.

Immigrant youth and in detention centers

Adolescent-led families

Adolescent-led families are experiencing a period of destabilization with lack of access to childcare while trying to do online schooling for themselves, in addition to financial constraints, lack of support structure, and limited access to medical care. Many experience structural barriers including transportation and lack a full understanding of the medical system leaving them more vulnerable.

Additional Resources



Caring for Adolescents with Eating Disorders during the COVID-19 Pandemic

Friday, May 15

Dr. Jean Doak shared her own observations from her eating disorder outpatient clinic that was closed as of mid-March and transitioned to Telemedicine. Within 2 weeks, they transitioned to Epic video visits.

  • Saw a drop-off of referrals of college students, but an uptick in referrals for new visits
  • Initial challenges with the pandemic around food
  • Stockpiling food became an issue for some patients – have had to find the balance between the desire to stockpile food and what ability they had to regulate that
    Food deficits impacted meal plans, so had to call in dieticians to provide a plan B, plan C, etc.
  • Food insecurity – some patients who receive meals through school districts, and not all had the resources to deliver meals to people’s homes

Discussion of Ongoing Challenges and Strategies: 

Lack of supervision leading to restriction and hyperexercising
(conversely, perhaps new ED patients are being identified sooner with parents/family/home sheltering)    

  • Guided decision-making, mindfulness may be helpful

Crises re-ignite EDs 

Less structure and waking up late

  • Working on daily schedules with patients
  • Some do less well with structure because they are trying to get away from rigidity – strategy of putting things in a hat and pulling them out

Repertoire of strategies has decreased because there is less flexibility around what one can do outside    

  • Building a different repertoire
  • Increased availability of exercise routines online (also can be a challenge!)
  • New hobbies (e.g. needlepoint) for distraction
  • Some patients with OCD tendencies are into mask-making
  • Babbel (with a fee, unlimited language training for life)
  • Just finished listening to a webinar on Art, Creativity, and the Brain. It emphasized how developing creativity helps with decision making, self regulation, problem resolution , resilience, etc. Creating art, experiencing arts to include visual art, writing, all modalities of the arts which is very wide ranging. Particularly pertinent for everyone and the patients we are discussing.

Increased availability of exercise routines

  • On-line resources for distraction – e.g. museum tours on line
  • Your Teen Magazine

Not able to tolerate visit because they can’t tolerate seeing themselves on the screen  

  • Teach them how to minimize the image. This might even be a good technique for the visit – increasing the amount of time or size of the image

Caring for COVID positive teens with ED – facilities refusing to take them

  • Difficult to make these decisions about how to care for them in the outpatient setting

ED patients not wanting to be hospitalized or not wanting to come in for vital sign checks

  • Indicate that EDs are an essential service
  • Provide information about the safety measures in place
  • Fitbits and apple smartwatches for HR checks
  • Utilizing local providers for VS checks
  • Families doing the VS blinded or non-blinded; maybe it is not a caregiver; give parents guidance on how to get the weight (e.g. blinded, after urination, etc.)
  • pdf document we send to  parents doing blind weights etc. at home

Telehealth strategies - what is working, what do patients think of telehealth i.e. mobile apps, video chat with providers etc.

  • Obtaining blind weights from other visits (e.g. dietician)
  • Telehealth visit for the assessment and RN visit for VS/labs etc (with one nurse) to minimize touch – multiple programs are using this method of a virtual visit and brief in-person if needed
  • Maudsley Method could be taught remotely
  • Next stage considering 4 patients in person and 4 on-line, and then switching the next day
  • Refusing to turn video camera on seems to be associated with the patient doing worse and needing an in person visit
  • Telehealth especially beneficial for rural patients or others who travel far to the visit

Group therapy

  • Groups and meal support have been virtual
  • Planning to continue virtual groups; this is especially helpful for programs that care for patients who live far from the program

Masks make sensitive discussions more difficult

  • Start online without a mask vs. in person with a mask to build rapport

Re: effects of malnutrition on the immune system, do you discuss it with families? If so, how do you communicate with families on this topic?

Virtual care not working as well, and patients not thriving

  • May need to bring these patients in

Because patients often eat or are observed together, COVID test all incoming patients nd they are allowed only one, consistent visitor and both patient and visitor must be masked during visits    

  • Others are working with limits on visits as well. Compromises may need to be made to maximize safety while providing the family support and training that is needed.

Challenges keeping masks on all day

  • Made an exception for the pediatric patients in one program not to use masks due to the challenges

Experience of virtual IOP and PHP – effectiveness, engagement of patients, concern about them seeing themselves on screen

  • Some kids seem to be used to the online interface so perhaps not as odd to them; moving forward, talking about a virtual platform for those who have nothing else
 

Planning for Recovery of Clinical, Research, and Educational Efforts after the COVID-19 Surge

Friday, May 8

Introduction 
At UW, Central command centers have been very helpful. Deputized to make decisions and communicate out. These have shifted to “Business Rassumption Centers” to drive the recovery. The major question is how we are going to do things differently moving forward.

How are others managing the recovery? 

UCSF: cognitive-based specialties that have been able to provide Telehealth may have been less affected than others. In the recovery phase, it will be important to incorporate Telehealth to improve access. Division is back to full operation and seeing 5-10% more patients than a year ago with no change in staff. Inpatient service is unchanged. Educationally, everything is done through Zoom. Will not resume classes until July 2021. All salaries frozen until 2021 and there is a hiring freeze.

UW: Telehealth is now 80% of visits. Psychiatry is the only service that has been able to transition fully to Telehealth. All children who enter facility are tested. UW will soon provide serology testing to all employees, after testing everyone working with COVID-19 patients. Trying to align across the organization in terms of testing/screening etc. Still many questions about resuming research. 

IU: Riley Children’s is part of IU Health; incident command centers have been working well together. Able to leverage supply chain resources because part of a state-wide incidence. Testing those who have symptoms only; in the adult practices, testing before elective surgeries. Expanding testing sites in the next week or two. Adolescent Medicine took the lead in terms of Telehealth visits. This month they will incorporate residents; medical students still not incorporated. Salary freeze and hiring freeze except for clinical providers. Inpatient services have been transitioned so they are taking care of some of the hospitalist patients so that hospitalists can take care of COVID-19 patients.

Challenges

Integrating learners

  • At UW, med student rotations will be reduced from 6 to 4 weeks. 
  • How do we ensure virtual learning in adolescent medicine? Kate Greenberg is leading an effort to create additional on-line learning opportunities for residents, to complement the SAHM resident curriculum. 
  • How can we extend our reach in terms of adolescent medicine training? Consider amplifying online learning by providing online access to a broader audience, which is more feasible now that we are using more virtual learning methods. Consider online journal clubs.

Telehealth

  • Incorporating equitable access to Telehealth when not everyone has the technology.
  • Advocacy for reimbursement; Steve North and Abigail English will be working on an advocacy effort as an outcome of the virtual chat on Telehealth; contact them if you are interested. 
  • Telehealth for out of state patients – many states have loosened requirements for Telehealth. Guidelines and reciprocal agreements are state by state. 
  • Continue to see college students but have had no new patient referrals for them x6-8 weeks since campus services were closed.
  • Advocating for Telehealth when there is resistance at our institutions. May be helpful to get patients’ and parents’ feedback about the convenience and demonstrating who you are able to reach. At UAB, had to use academic staff to take over Telehealth scheduling. 
  • Zoom-health has been a good platform for to run virtual clinics - it allows faculty, fellows, residents and other team members to move in and out of breakout rooms with the patients in them, and patients stay in the room. 
  • Don't think patients will let us walk away from telehealth now that they've experienced it, and the time savings.

Research

  • COVID-19 related research – one topic might be the link between adolescent population’s use of vaping products and COVID-19 illness. There are a great deal of opportunities available.
  • Phased plan for ramp-up of research at Cincinnati Children’s – being ramped up phase by phase, the timing of which is driven by the epidemiology of COVID-19 in the hospital and in the community.
  • Social distancing will be a key factor in bringing researchers back
  • Extension of reappointment and tenure clocks 
  • Could be a great time to write at this time

What will be different moving forward – what do we need to think about and plan for?

  • The ability to expand access through Telehealth
  • Disruptions to medical education – how will we attract learners to our field if they have less exposure to us?
  • Virtual recruitment and ensuring diversity when we cannot bring people in for visits. With fellows, will be bringing fellows for interviews for different disciplines virtually – there will be group interviews. Working on a virtual tours. Maybe first phase is a virtual tour and second one in person. On some levels, it’s easier for us to participate in interviews outside of our department, on other levels, it's much more difficult to anticipate the person beyond the camera.
  • What visits need to be in person; finding a balance between in-person and Telehealth visits.
  • Funding streams for research; research on the mental health aspects of Telehealth
  • Challenges in terms of academic productivity while children are at home and online schooling
  • Continuing to communicate through SAHM about innovations occurring across the country and learn from each other


Strategies for Optimizing Virtual Patient Care - Thursday, April 30

A summary of this session will be posted shortly
 

Optimizing Education for Residents and Fellows During the COVID-19 Response - April 23, 2020

A summary of this session will be posted shortly

 

Telemedicine - April 16, 2020


Introductions:
  • Most people on the call are rapidly ramping up Telehealth but others are still in the queue or have access to audio but not video telehealth
  • Enthusiasm expressed about the opportunity to start Telehealth, but would prefer it wasn’t on such a rapid timeline
Challenges and Strategies:

Maintaining confidentiality 
  • Ask parent to step out of the room when discussing confidential topics
  • Ask patient to step outside the house when discussing confidential topics
  • Ask patient to use headphones
  • Call back at another time when it is more feasible to have a confidential visit
  • Ask yes/no questions if they don’t have privacy
  • Catch them when they are on their way to and from work (unless they are driving)
  • Create MyChart accounts for those younger than 18 years, if possible
  • Ask yes/no questions if they don’t have privacy
  • For reaching marginalized populations, using Doxy.me can be helpful (free)
Conducting video visits through the EMR (e.g. in Epic) 
  • Some have used Epic, but may be advantageous to use another platform because it can take so long to make changes through Epic and the portal enrollment is challenging
  • Using a system in which a link can be sent to the patient is very helpful
Conducting well visits
  • AAP came out with guidance yesterday
  • Billing regulations are state by state – Center for Connected Health Policy
  • Some are seeing patients for urgent issue by Telehealth and doing the physical component at a later date
Providing vaccinations
  • Some practices are doing drive-through vaccinations after doing a virtual well visit, and scheduling the actual physical exam for later
  • Person receiving the vaccine cannot be the driver (given possibility of syncope or allergic reactions)
  • Others are creating vaccine clinics – well visit done virtually, then bring them in for a nurse-only visit
Doing screenings virtually
  • Only use the tool when you have the opportunity to intervene; if you do a GAD7 or PHQ9 through a portal and don’t see the results for 24 hours, it can be unsafe
  • MA or LPN can administer the forms via the Telehealth platform
  • Some read the questions out loud to patients
  • Some are emailing the forms or sending through MyChart – asking them not to fill out until the day of the visit
  • Guidance from Child and Adolescent Psych Guidelines on Telehealth 
  • One more resource for managing suicide risk (question that came up earlier): Essentially, confirm contact info for "Patient support person"/safety person if suicidality arises - Practice Guidelines for Video-Based Online Mental Health Services 
Incorporating learners into Telehealth
  • Use a platform that allows for multiple providers: InTouch, Google duo (works for live time watching a resident do the interview and precepting, and interfaces with visual both android and iphone), Microsoft Teams, Zoom
Involveming multiple providers
  • As above; for example, there are platforms such as Zoom in which there can be warm handoffs between providers. They are in the same “virtual” room. Providers can come and go in virtual clinic and they get placed in a virtual waiting room until the next step.
  • Epic MyChart portal allows up to 5 people on a visit (combination of providers and family members)
Maintaining social distancing
  • Conduct well visits in morning, ill in the afternoon
  • Limit staff who are physically present in clinic
Managing suicidality screening
  • Make sure you know local resources
  • Make sure you have their contact info and address if you need to send someone (police, ambulance)
  • Confirm a safety plan during the visit
Conducting a physical exam by Telehealth
  • Ask patient to take their own pulse – there are apps to obtain a pulse, or can use data from Fitbit or apple watch
  • USB stethoscopes or otoscope on iPhone for patients who need them
  • Bring camera close to the patient
  • Have them take off relevant clothing if needed; e.g. to do a skin exam
  • To assess for acute abdomen – have them bounce up and down on the balls of their feet
Conducting new visits by Telehealth
  • egulations differ state by stateShould be able to do new visits, if state allows
Evaluating patients with dysuria or vaginitis
  • Do they have a prior hx? If yes, more likely to treat empirically (e.g. for UTI).
  • May be able to have patient go to test referral to drop off labs.
  • Shipping of STI screening tests directly to patient – however, may lead to issues around confidentiality
  • Routine screening questions and then drop in to provide labs
  • Drop off home pregnancy tests in school clinic
  • Self-collection of Affirm vaginitis swabs
Managing inconsistencies in what visits are being done in person or by telehealth
  • Provide guidance to triage nurses about who could see in person vs. telehealth – create standards across practice
Supervising residents and fellows
  • Assign SAHM resident education modules and go through the cases and videos
  • Teaching sessions virtually; virtual curriculum
  • Google duo
  • 3-way phone call – resident conducts visit with attending on the phone – then staffs afterwards
  • With Telemedicine, opportunity to be in the “room” at the same time then patient goes back to the virtual waiting room while they staff
  • For new eating disorder patients: resident sees the patient first then they get on “team meetings” at the same time, and resident presents the case to the team.
Conducting inpatient consultations
  • In some organizations, all consults done virtually – have technology in rooms to allow for more complete exams
Collecting our individual experiences so that we can advocate for adolescent telehealth
  • We may be able to collect data that would be useful in advocacy; e.g. improved show rates for visits
  • Will set up another time to discuss
Ensuring reimbursement
  • If seeing patients from other states, may have to follow the regulations of the state of residence rather than the state you practice in. Some states have lifted those restrictions during this time
  • Resource - Listing of states waiving medical licensing requirements  





SAHM Virtual Chat - April 8, 2020


Because we were unable to meet in San Diego and the COVID-19 pandemic has been disruptive and challenging, we brought SAHM members together for a SAHM virtual chat on April 8 to:
  • reflect on our experiences of the past few weeks
  • discuss major challenges and stressors
  • provide support for one another by being together and by sharing strategies and resources that have been helpful 
  • discuss what resources SAHM can put into place to address challenges 
Almost 60 SAHM members participated in this warm, energetic and supportive virtual chat, and below I’ve summarized for you the discussion and a description of resources that we are planning to put into place in response to the challenges raised.

We asked participants to provide one word describing how they came into the call at the beginning, and one word describing how they were leaving the call at the end. A review of some of the words offered demonstrates the powerful impact of connecting SAHM colleagues with each other:
  • How participants came into the call: unsure, stretched, confused, nervous, sad, frustrated, alive, disoriented, still, stressed, hopeful, anxious, helpless, unorganized, lonely, restless, zoomed-out
  • How participants left the call: hopeful, good, supported, optimistic, recharged, connected, uplifted, reinvigorated, interested, not alone, energized, motivated, grateful, optimistic
Discussion Summary:

What are your personal reflections on the events of the past few weeks?
  • Widespread anxiety and fear
  • Priorities and perspectives are changing
  • Observations of solidarity and selflessness, with people coming together and connecting deeply 
  • The seismic shift to telemedicine
What are your major challenges and stressors right now? 
  • Concerns about colleagues and families
    • Concerns about family’s health
    • Concerns about the health of colleagues who care for adults
    • Managing colleagues’ concerns and emotions
  • Personal challenges
    • Serving behind the front lines instead of on the front lines
    • Pressure to stay productive
    • Balancing work, homeschooling, housework
  • Concerns about patients and youth
    • Concerns about quality of patient care with Telehealth and not seeing patients face-to-face; that patients will not be seen who have urgent issues; youth with unmet sexual/reproductive health care needs
    • Increasing conflict between patients and their families now that they are in closer contact
    • Youth in a public university with insecure housing, food, unmet mental health needs, and families who cannot support them
    • Fear that youth are being blamed for transmission
    • Youth are missing major milestones such as graduation
    • Youth will miss out on employment and internships
    • Youth are losing parents/loved ones without being able to say goodbye
    • Concern that after the COVID-19 pandemic will emerge a pandemic of mental health among youth
    • Disparities in youth outcomes during and after the epidemic
  • Concerns about trainees
    • Education of trainees, such as residents; appreciate SAHM resident curriculum but trainees are missing face-to-face care
  • Other concerns about the epidemic
    • Anxiety that social distancing will be lifted too soon and that university administrators are not being cautious enough
    • Profound disappointment in U.S. lack of preparation for the pandemic
    • Emotional shock over the scope of the pandemic
    • Urgent need for policy; concern about abortion rights
How are you managing the changes that are occurring in your personal and professional life? What are the strategies and resources you have found helpful? 
  • Provide education
    • Presentations, webinars, and podcasts about COVID19 to community, juvenile justice center, patients/families, staff
    • Providing learners opportunity to do virtual visits and learn Telemedicine
  • Clinical innovations
    • Zoom health clinics with breakout rooms for individual patients and team room for fellows
    • Mail-in STI screening, home pregnancy tests, Sub-Q depo, home testosterone injections
    • Considering how to maintain Telemedicine gains – e.g. seeing patients in their homes offers a new perspective, observing patient JUULing during the visit led to an extra SBIRT session
  • Support for and from peers
    • Daily leadership huddles, weekly meetings
    • SAHM committee calls
    • Check in on peers
    • Provide mental health resources for peers, group coaching
  • Self-care
    • Virtual happy hours and zoom calls
    • Prayer
    • Exercise (running, yoga, biking) and being outside (taking work-related calls from outside)
    • Hobbies – photography, painting, gardening, music
    • Mindfulness
    • Movies
    • Taking courses; podcasts
    • Disconnecting from media
    • Retail therapy
    • Thinking of ways to help and cheer others; sidewalk appreciative messages
    • Humor – sharing memes and cartoons, making funny videos, lip-sync challenges
    • Focusing on silver linings – gift of family dinners, college kids being home
    • Recognizing our privilege
    • Recovering after COVID-19 – regaining strength, stamina
    • Recognizing the innate drive to be ultra-productive and that COVID-19 is asking us to be more reflective, focused and flexible
What resources can SAHM put into place to help address challenges?
  • Share information on annual meeting online content
  • Organize SIG and Committee meetings by Zoom
  • Schedule regular virtual support sessions – topics could include Telemedicine, creative strategies for caring for patients virtually, educational strategies (SAHM Education Committee?), ramping back up after social distancing
  • Share resources
Here is how SAHM is planning to address the resources requested:
  1. Virtual support sessions on telemedicine, strategies for virtual patient care, educational strategies, ramping back up after social distancing
    • We will be planning these sessions - stay tuned for the schedule, and let us know if you would like to facilitate one!
  2. Annual meeting online content and virtual SIG and Committee meetings
    • Online content – SAHM is putting together a package of virtual content previously planned for presentation at the 2020 SAHM Annual Meeting. Additional details to be announced soon.  
    • SIG leaders and Committee chairs will be reaching out to set up these meetings over the coming weeks if they have not already
  3. Resources


Telemedicine - April 16, 2020

A summary of this session will be posted shortly


Optimizing Education for Residents and Fellows During the COVID-19 Response - April 23, 2020

A summary of this session will be posted shortly



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