Guideline 19

Guideline 19: Babies First!, CaCoon, Family Connects Oregon (FCO) and Nurse-Family Partnership (NFP) Telemedicine/Telehealth Visit Guidance

Purpose

To provide guidance on the use of telemedicine/telehealth1 visits in the Babies First!, CaCoon, FCO, and NFP nurse home visiting programs to ensure consistent process for providing home visiting services via phone or video conferencing.

Background

Babies First!, CaCoon, FCO and NFP clients are assessed in the physical, mental and social drivers of health domains. The nurse and client agree upon a visit schedule, location, and content based on the client's goals and needs, the nursing assessment, and program guidelines. Most visits happen in-person, usually in the home, with the nurse or a community health worker (per program guidance).

According to the report, Virtual Home Visiting during the COVID-19 Pandemic: Lessons Learned from Research, Practice, and Policy2, "Home visiting services are inherently in-person, built on the concept that visiting families in their homes provides unique opportunities to support caregivers and children. However, some eligible families may not receive the benefits of evidence-based home visiting programs due to a variety of barriers, including scheduling, geographic distance, and family disengagement. Prior to the COVID-19 pandemic, some home visiting models and programs were using virtual methods to help connect and work with families. With the onset of the COVID-19 pandemic, the majority of home visiting programs needed to make an abrupt shift to delivering services virtually, rather than in person. There appears to be general agreement amongst those involved in home visiting that virtual service delivery will continue to be a component of home visiting programs moving forward from the COVID-19 pandemic."

Process

Before the Visit

Obtain and maintain technology used in telemedicine/telehealth communication that is compliant with privacy and security standards and approved by local implementing agency. Services provided using a telemedicine or telehealth platform shall comply with Health Insurance Portability and Accountability Act (HIPAA), https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996.The mode of telemedicine/telehealth visits for the nurse home visiting programs needs to be approved by the local implementing agency but may include audio only, video only or audio with video. The use of facsimile, electronic mail, or text messages are not approved modes for a telehealth/telemedicine visit.
Ensure policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records to unauthorized individuals.
A telemedicine/telehealth visit may be offered to clients that decline an in-person visit (see also Program Specific Requirements for Telemedicine/Telehealth Visits). Additional situations in which local agencies may approve the use of a telemedicine/telehealth visit in place of an in-person visit are:

Weather creates dangerous driving conditions
Illness of client (or someone in the client's household) or home visitor (or someone in the home visitor's household)
Identified safety concerns (from the client or home visitor)

Assess the client's capacity to engage in a telehealth/telemedicine, giving special consideration to access to necessary devices, access to private and safe location, adequate internet, digital literacy, cultural appropriateness of telemedicine, and other considerations of client readiness to use telemedicine.
Client should be oriented to a telemedicine/telehealth visit: have a conversation about how the visit will be the same as an in-person visits and what will be different. After the first telemedicine/telehealth visit, it is best practice to reflect with families on what is working and what is challenging, just as would happen for in-person visits.

During the Visit

Verify client identity at start of telemedicine/telehealth visit by confirming name and date of birth.
If using video conferencing, ensure any material with identifying information of other clients is out of view of the client receiving telehealth.
Ensure the telemedicine/telehealth visit occurs in a private area where no other person can hear the conversation with the client.
If an interpreter is needed, they should be included in the phone call or video conference.
Follow requirements for telemedicine/telehealth visits (identified below).

After the Visit

Document telemedicine/telehealth visit per local implementing agency's standard documentation rules in the client's medical records; ensure documentation includes the client's declination of the in person visit and/or the reason for the telemedicine/telehealth visit.
A nursing care plan must be documented for all telemedicine/telehealth visits conducted by a nurse.
Community Health Workers (Babies First! and CaCoon only) must document the telehealth visit per usual Community Health Worker visit documentation practices.
Enter telemedicine/telehealth visits in the state designated data collection system (e.g., FLO, THEO, the Family Connects Database (Salesforce) .
Maintain clinical and financial documentation related to telemedicine/telehealth services.

Requirements and Considerations

Requirements for telemedicine/telehealth visits

Telehealth visit must include the client (and/or client's caregiver).
The telemedicine/telehealth visit must include work on at least one screening or assessment; OR one intervention (e.g., case management, motivational interviewing, health education); OR BOTH.
In order to bill Medicaid for Targeted Case Management (TCM) provided during a telemedicine/telehealth visit, a targeted case management service must be provided, per the TCM rules (OAR 410-138-0007). The appropriate TCM documentation must be completed in the client's medical record.

Program specific requirements for telemedicine/telehealth visits

FCO clients must be offered an in-person Integrated Home Visit (comprehensive visit). If they decline an in-person visit, a telemedicine/telehealth Integrated Home Visit must be offered (OAR 333-006-0120).
NFP nurse home visitors should follow additional telehealth guidance from the NFP National Service Office.
Babies First!/CaCoon community health worker home visitors must conduct visits per a nursing care plan, and they may do so via a telemedicine/telehealth visit.

Considersations for nursing assessments provided via telehealth

Nurses in home visiting programs use a broad range of assessment skills to gather information, analyze, interpret and plan for client care. The Oregon Nurse Practice Act directs Registered Nurses to conduct comprehensive assessments by: (A) Collecting data from observations, examinations, interviews, and records in an accurate and timely manner as appropriate to the client's needs and context of care (OAR 851-045-0060). Nurses are particularly adept at using a relationship-based approach to ask questions to gather appropriate data for physical and mental health assessments.

These same skills can be utilized successfully via telehealth visits. Conducting history and physical assessments and mental health assessments via telehealth should be done much the same way as in- person.

The inability to conduct hands-on assessment – feel, listen, or look closely – will provide some limitations; however, nurse home visitors should probe for accurate description of issues through careful questioning and being curious. When discussing a specific clinical issue (e.g., rash, fever), the nurse home visitor should gather information on standard assessment components. For example, Symptoms, Characteristics, History, Onset and Duration, Location, Aggravating or associated factors and Relieving (SCHOHAR). Whenever possible, clinical best practices should be followed; when not possible due to limitation in telehealth, this should be documented in the client chart.

Guidance for ASQ assessments may be found here