How telehealth physical therapy helped a CHOC patient take his first steps

Jennifer and Justin Charles had experienced a smooth pregnancy until 27 weeks, when doctors discovered that Jennifer had lost most of the amniotic fluid around their growing baby boy.

Worried there had been a rupture in the amniotic sac, Jennifer and Justin prepared themselves for a premature birth. Further testing showed the complications were caused by a condition in the baby’s developing kidneys. But due to having little to no amniotic fluid, ultrasounds during were difficult to interpret and an official diagnosis didn’t come until the baby was born.

“We were scared, overwhelmed, confused – unaware what next steps would look like, unsure if he would be viable outside the womb at that point,” Justin says. “We prayed a lot, hoped for the best and prepared for the worst.”

Jennifer was admitted to the hospital quickly after that. She was monitored until baby Shiloh was born at 35 and a half weeks’ gestation.

“He made everyone wait to find out what was going on,” Jennifer says. “He’s had that drive since the beginning; he’s not one to go on anyone’s timeline but his own!”

Multiple diagnoses after a premature birth

Shiloh’s diagnoses include end-stage renal disease, and renal cysts and diabetes syndrome. Though still concerned about the future, Jennifer and Justin were relieved to know what was going on in Shiloh’s kidneys and to have a better picture of the journey ahead.

Shiloh’s first two years of life have included a 60-day stay in CHOC’s neonatal intensive care unit (NICU) at birth; two abdominal surgeries in his first month of life; a 90-day stay in CHOC’s Josie Y.S. Lee Pediatric Intensive Care Unit (PICU) later on; ongoing care with a variety of CHOC specialists including nephrology, gastroenterology, hematology, cardiology, endocrinology, pulmonology and rehabilitation;  nightly dialysis; monthly blood draws; weekly Epogen shots to maintain his red blood cell count; a G-tube insertion for feeding; learning to swallow; and several medications. Eventually, Shiloh will require a kidney transplant, for which he is currently on the transplant list.

Shiloh’s premature birth and medical complexities meant that he might face some developmental delays. As part of Shiloh’s care, Jennifer and Justin began taking Shiloh to regular physical therapy appointments at CHOC.

 Virtual visits during COVID-19

Once COVID-19 hit, however, they found that their rehab visits would have to look a little different than they had grown used to.

The CHOC rehab team turned to telehealth visits to ensure the health and safety of their patients. Rather than in-person appointments, the Charles family began seeing the rehab team via video chat.

Telehealth physical therapy appointment
Shiloh participates in a telehealth physical therapy visit.

“Telehealth requires participation and adjustments on both ends,” says Jennifer. “That looked like Dad holding the iPad to capture Shiloh’s movements and projecting our therapists onto our TV for Shiloh to see.”

telehealth physical therapy appointment
During telehealth physical therapy visit, Shiloh’s parents projected his physical therapist onto their TV.

The trio also had to be creative about which toys and exercises they could do from home using their own equipment, since they did not have access to CHOC’s outpatient rehab gym due to COVID-19.

For exercise, the family took walks outside, practicing on the steps in front of their house. As Easter approached, Jennifer and Justin placed plastic eggs around on the ground for Shiloh to pick up and put into a basket. They also played with a baseball, basketball and soccer ball to engage with him in a fun way.

Looking back at taking on telehealth rehab appointments at home, Jennifer acknowledges there was a learning curve, but noted how she developed an even deeper appreciation for Shiloh’s care team during this time.

“We developed so much more appreciation for how much effort the therapists put in on a daily basis, Jennifer says. “They spent time connecting with us during each session to make sure we were comfortable and adapted to what worked best for us and best helped Shiloh thrive.”

As the weeks passed, Shiloh’s parents and therapists took note of his development. Being able to work using his own toys and in his own home helped keep him comfortable.

“It gave us a chance to see even more of his personality shine through and to see him develop an even better sense of self confidence,” Jennifer says.

Despite the challenges of adjusting to a new normal in the time of COVID-19, Shiloh’s parents look back on telehealth as a great bridge for him to achieve his final physical therapy goals. He grew from crawling to assisted walking, then from unassisted walking to climbing stairs. They even caught his first steps on video, thanks to his telehealth physical therapy appointment.

Shiloh takes some of his earliest steps after learning to walk doing CHOC telehealth physical therapy appointments.

“It was wonderful being able to show our therapists the progress from appointment to appointment and to share in the excitement of his first steps together,” Jennifer says. “It was almost like getting to bring our CHOC family into our home after spending so much of our time in theirs at CHOC. Telehealth is such a great tool not just in times of quarantine but overall. We are thankful for this technology and for the rehab team being able to adapt to it so quickly and without compromising the level of care that CHOC is known for.”

Although Shiloh has graduated from physical therapy, he continues to see other CHOC specialists as he awaits a kidney transplant. In the meantime, his parents are cherishing his growth and development into what Jennifer affectionately calls her “tank of a two-year-old.”

Justin is likewise appreciating this time with his son.

“This kid is my hero,” Justin says. “His resilience is second to none. He’s a full-blown toddler, make no mistakes about that. But he is so kind and brings so much joy to everyone he meets. He carries a special light within him – that is for sure.”

Ger more information on telehealth

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Respuestas a las preguntas más frecuentes sobre la telemedicina

En esta época de grandes desafíos, aquí en CHOC Children’s nuestra meta es brindar tranquilidad a los padres de familia cuando se trata del cuidado de la salud y del bienestar de sus hijos. La atención médica a los niños, ya sean exámenes físicos, vacunas o acceso a especialistas, es fundamental. Por esa razón, nuestras clínicas permanecen abiertas empleando medidas preventivas adicionales y ofreciendo citas con el uso de telemedicina, cuando resulte adecuado, para que tenga disponibilidad de nuestros expertos desde su hogar.

Comprendemos que la telemedicina es algo nuevo para muchos padres y sus familias, así que hemos preparado una guía que contiene las preguntas más frecuentes sobre esta tecnología para responder a cualquier duda que tengan y ayudarlos a prepararse para la primera cita de su hijo/a por videollamada.

¿Qué es la telemedicina?

Las citas mediante el uso de la telemedicina son consultas por video con un profesional de la salud de CHOC a través del empleo de un teléfono inteligente, tableta o computadora. Usted y su hijo/a pueden participar en ellas desde su propia casa o de cualquier otro lugar que cuente con acceso a internet y donde usted se sienta cómodo. Durante su cita, podrá ver y escuchar a su médico o especialista de siempre. También podrá interactuar con él o ella, hacerle preguntas y responder a las que le hagan.

¿Todas las citas pueden llevarse a cabo mediante la telemedicina?

Su doctor/a de cabecera o su especialista pueden proporcionar atención médica sin problemas y adecuadamente para muchos tipos de afecciones a través del uso de tecnologías como la telemedicina. Algunos tipos de consultas necesariamente deben ser en persona. Su profesional del cuidado de la salud determinará si una cita por videollamada es lo ideal para usted.

¿Es segura y confiable la tecnología que usa CHOC para la práctica de la telemedicina?

CHOC utiliza una versión especial de Zoom, un programa especial para videoconferencias, que cuenta con niveles de seguridad adicionales para garantizar la protección de nuestros pacientes y de la información sobre su salud. Nuestra plataforma de telemedicina siempre ha sido y continuará siendo segura.

¿Qué sucede una vez que mi cita por telemedicina ha sido programada?

Una vez que se apruebe su cita virtual, recibirá un mensaje por correo electrónico con instrucciones, sugerencias para resolver las dificultades que surjan y un enlace de acceso para su videollamada. Siga las indicaciones. Primero verá una “sala de espera” virtual en donde se le pedirá que espere a que el médico de su hijo/a le dé ingreso a la consulta. No se salga de esta pantalla. Cuando sea admitido, verá y escuchará a su prestador de atención a la salud y le podrán ver y escuchar a usted.  Asegúrese de que su hijo/a esté presente para que sea evaluado adecuadamente.

Vea este video en preparación para su primera cita virtual y obtenga sugerencias para que sea exitosa.

¿Quién debe estar presente?

Por favor, asegúrese de que él/la paciente esté presente para todas sus citas por telemedicina para que su profesional de servicios médicos lo/la evalúe debidamente.

¿Con quién será la cita de mi hijo/a por videollamada?

Su cita será con su médico de cabecera o su especialista.

¿De qué hablaremos durante la consulta por telemedicina?

Usted y su hijo/a pueden hablar con su profesional de la salud de todo lo que hablan durante sus citas en persona: síntomas, el plan de cuidado médico y cualquier pregunta o inquietud que tengan. Si es necesario, su doctor/a les informará sobre los resultados de sus análisis de laboratorio o de radiografías que se le hayan realizado, tal como lo hace cuando la consulta es en persona. Quizás también le pida, por ejemplo, que le tome la temperatura a su hijo/a o que le muestre el sarpullido que le brotó.

¿Cuál es el costo de una cita a través de la telemedicina?

Las consultas por videollamada se facturan de la misma manera que las cita en persona.  Se le cobrará lo mismo que usted paga por una visita médica convencional. Contará con la participación de su doctor de cabecera o de su especialista y obtendrá la misma atención de alta calidad que recibe en cualquier otra cita en CHOC.

Mi cita, ¿debe ser por videollamada?

Aunque la telemedicina puede parecer extraña o incómoda, su doctor quizás la prefiera porque podrá atenderlo/a más pronto que lo que podría hacerlo en persona. Si usted desea una cita en persona, pídala cuando llame a la oficina de su pediatra o al Centro de Acceso al Paciente (PAC); su prestador de servicios para la atención a la salud determinará si es conveniente esperar a que haya una disponible.

Llame a su médico de cabecera para hacer su cita o al 1-888-770-2462 para consultas con su especialista.

Publicaciones pertinentes:

  • Lo que puede esperar durante una cita de telesalud
    Las citas de telesalud son consultas virtuales con un proveedor de CHOC que se realizan a través de un teléfono inteligente, tableta o computadora. Llame al consultorio de atención primaria para ...

Telehealth for ophthalmology visits: What parents should know

By Dr. Rahul Bhola, pediatric ophthalmologist and medical director of ophthalmology at CHOC Children’s

Like many physicians continuing to offer care during the COVID-19 pandemic, I have transitioned many appointments to telehealth, so patients can still get the care they need while practicing social distancing. At CHOC Children’s, we adjusted our policies and practices to maintain a safe environment for our patients and families who need in-person appointments.

For in-person appointments, we require masks and practice proper hand hygiene to protect the health of everyone we serve. Before entering our building, CHOC nurses screen all visitors and staff. Screenings include a temperature check and asking symptom and exposure-related questions. In line with CHOC’s limited visitor policy during the COVID-19 pandemic, only one parent/guardian may accompany the child for their appointment. Our clinic is taking other necessary precautions such as thoroughly disinfecting clinical areas and rearranging seating in our lobby to ensure social distancing.

Since March, my office has successfully completed over 900 telehealth visits, on top of non-elective in-person appointments.

dr-bhola-choc
Dr. Rahul Bhola, pediatric ophthalmologist and medical director of ophthalmology at CHOC Children’s

Since telehealth is new to many families, here’s an overview of what parents can expect at their first virtual appointment, plus answers to parents’ most common questions on telehealth for ophthalmology.

A synchronous (live audio-video) CHOC ophthalmology telehealth appointment is divided into four components. I call them the four C’s: Contact, Connect, Consult and Care.

  1. Contact
    Our front desk reaches out to the family to confirm their contact information. We send a Zoom link to the family, along with information about how to connect to Zoom and download a Visual Acuity app that we use during appointments to check vision.

 

  1. Connect
    As the appointment day approaches, our technician connects with the family to resolve any technical issues before the physician consultation. The technician also goes over the at-home visual acuity check and evaluates basic medical history.

 

  1. Consult
    On the actual day of the telehealth appointment, the physician connects with the family to go over the relevant medical history and visual acuity and performs focused examination including external and ocular motility exam. If needed, pictures and videos from the family can be sent to the physician for further evaluation. This enables us to diagnose a majority of anterior segment ocular issues, visual acuity concerns like amblyopia, refractive errors and ocular motility disorders.

 

  1. Care
    During the telehealth appointment, we discuss the treatment care plan and review any medical issues or concerns the patient is experiencing. Throughout this process, we can fulfill their needs ranging from prescription refills or broken glasses, without them having to step outside the comfort of their home.

Our office will then schedule a follow-up visit depending on the medical necessity.

How do your patients and families feel about telehealth?

I have found that many patients love telehealth! Our families feel supported and secure, since there was no interruption in their child’s care plan. I’ve also found that our families feel grateful that during this time of uncertainty, their physician was able to connect with them and address any urgent issues, and then follow them in clinic as needed.

Due to the positive response we have received from our families, we plan to continue offering telehealth appointments in the future.

Does telehealth compromise quality of care?

No. We carefully scrutinize the kind of visits that can safely be performed via telehealth without compromising on quality of care. If your ophthalmologist decides your child’s visit can safely be conducted via telehealth, rest assured your child will still receive the high level of care you’re used to receiving in person. After the telehealth appointment if we feel the need for an in-person appointment, we will work with our families to schedule that appointment promptly and safely.

Sometimes, an exam conducted via telehealth reveals something requiring an in-person appointment. In those cases, we work with our families to schedule appointments promptly and safely.

Ger more information on telehealth

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Lo que puede esperar durante una cita de telesalud

Las citas de telesalud son consultas virtuales con un proveedor de CHOC que se realizan a través de un teléfono inteligente, tableta o computadora.

Llame al consultorio de atención primaria para programar una consulta con el pediatra de CHOC.

Llame al Centro de Acceso al Paciente de CHOC al 888-770-2462 para que lo atienda un especialista de CHOC.

El proveedor de su hijo o hija decidirá si una consulta de telesalud es ideal para usted.

Después de que se programe su cita, recibirá un correo electrónico de CHOC con instrucciones.

Cuando llegue la hora de su consulta, usted y su hijo o hija pueden estar en casa o en cualquier lugar privado que tenga acceso a Internet.

También sería bueno que disponga de un termómetro, una fuente de luz y una báscula para ayudar en el examen. Además, debería conocer su laboratorio y farmacia preferidos.

Aproximadamente 15 minutos antes de la cita, usted recibirá una llamada de CHOC preguntándole si necesitara ayuda adicional para la consulta.

Para empezar, encuentre el correo electrónico de CHOC y siga las instrucciones.

Para las citas de telesalud, CHOC utiliza un software especial que cuenta con varios niveles de protección. El video de la consulta no se guardará ni se almacenará.

Durante la cita, podrá ver y escuchar a su médico o especialista. También podrá dialogar, hacer preguntas y responder las preguntas de su proveedor.

Durante la cita, podrá ver y escuchar a su médica o especialista. También podrá dialogar, hacer preguntas y responder las preguntas de su proveedora.

No se preocupe si la consulta “se siente” diferente al principio. No hay problema, eso suele ocurrir.

A los padres se les podría pedir que ayuden en el examen. Por ejemplo, es posible que usted necesite tomar la temperatura de su hijo o hija, y ayude a mostrar lo bien que él o ella puede mover sus extremidades. El proveedor lo guiará en este proceso.

Al final de su consulta, el proveedor le explicará los siguientes pasos, incluyendo el pedido de cualquier prueba de laboratorio o receta necesaria.

Este breve video describirá lo que puede esperar durante una cita de telesalud con un proveedor de CHOC Children’s.

Tips for making the most of your first mental health telehealth appointment

By Dr. Sabrina Stutz, pediatric psychologist at CHOC Children’s

Mental health services don’t always need to be carried out in person. Services can be delivered via a smartphone, tablet or computer. You and your child can engage in mental health services for telehealth from any private location with internet access.

If you are new to mental health telehealth services, here’s a guide for how you can prepare for your visit virtual appointment and what to expect, plus benefits of telehealth for mental health and answers to some commonly asked questions.

What happens before my first visit?

  • CHOC’s psychology team will email you a secure link for your virtual appointment. It is recommended that you practice signing onto the teleconference link prior to your visit.
  • We will also email a link to consent to mental health evaluation and treatment, for you to review and sign prior to your appointment.
  • We recommend that you find a place with stable internet service and good lighting in which you and/or your child can speak openly and freely with privacy.
  • Please ensure that a parent or adult caregiver will be physically present in the same location as the child at all times during telehealth mental health visits in case of emergency.

Who needs to be at the first telehealth mental health session?

Both a legal guardian and the child should be present at the beginning of the first session to go through the consenting process. It is recommended that the primary caregiver and the child be in the same physical location for the first appointment.

What will we talk about?

Your clinician will introduce themselves and confirm that a legal caregiver and child are present. They will review and confirm your contact information in the event of technology disruption or an emergency. Then, your clinician will review the consent process and answer any questions about using the teleconferencing software.

After the family consents to services, the clinician may wish to speak to the parent(s) and child separately. Your provider will review your concerns and your child’s history, and will offer feedback and recommendations/resources at the end of your visit. They will also answer any questions or concerns you may have about your child’s symptoms.

Is telehealth therapy as effective as in-person therapy?

Yes! Telehealth-delivered therapy techniques have been studied for over a decade. Many evidence-based therapies have research to prove that they are just as, if not more effective when delivered via telehealth. Cognitive behavior therapy (CBT), trauma-focused interventions, and parent-coaching models all have research to support their effectiveness when delivered online by a trained, licensed provider. Some minor adaptations can be made to ensure appropriate delivery of most evidence-based outpatient therapeutic interventions online.

What are the benefits of receiving mental health therapy via telehealth?

Telehealththerapy is a great way to access mental health services from the safety, comfort and convenience of your own home. Here are some of the other benefits of telehealth delivered therapy that families and clinicians have shared:

  • Families find it easier to attend sessions.
  • Families have flexibility in their schedule when cutting out commute time.
  • There are reduced childcare costs for untreated siblings.
  • Families save time, especially during high-traffic appointment times or when living far away.
  • Therapy is still accessible when on vacation within the state of California.
  • Children who might be nervous to do therapy feel more at ease using telehealth for a first session. Then, they are more likely to follow-up with telehealth mental health sessions afterwards.
  • Family members in separate locations can both attend a therapy session without having to be in the same location.
  • Parents at work can call in on their breaks to participate in family sessions.
  • Children and families are better able to remember and use coping skills when they have learned and practiced them in their own home environment.
  • Clinicians can see and live-coach families through difficult home-based situations like picky eating at mealtimes, setting behavioral limits such as a time out, or supporting a child in accepting a medical intervention such as  injections, pill-swallowing or nebulizers.
  • Clinicians have a richer and more nuanced understanding of families when they can see them in their home environment.
  • Clinicians can make more personalized and immediate recommendations. For example, “That looks like a great spot to put a reminder to check your blood sugar! Let’s create a reminder together and put it up during our session today.”

My child has trouble keeping their attention on the screen. What can you do for them?

The mental health community has created inventive and engaging ways to keep a child engaged over telehealth! Your clinician will talk with you and observe your child to assess their capacities for sustained attention, and can adapt interventions to fit their needs. For some children, we may ask parents to print out or set up certain activities before the therapy session to help facilitate. Other engagement strategies include share-screen therapeutic drawing and games such as Pictionary or Heads Up, gratitude scavenger hunts, “show and tell” topics, and parent-assisted relaxation exercises. If a child is unable to interact over telehealth, parent training models in which the therapist helps coach the parent to interact therapeutically with their child, are available.

How can I ensure my privacy?

 CHOC clinicians hold your confidentiality and privacy rights during telehealth sessions as seriously as they do when you come to the office. During a mental health telehealth appointment, your clinician will be in a private space where no one can see or hear them, and will be using secure, encrypted video conferencing software. We recommend that you access any mental health telehalthe services through your own password protected device on a password protected internet network to maximize your privacy. You may also wish to use headphones in order to have a more private conversation when sharing a home with others. For some very sensitive conversations, some families have chosen to step out to their cars or another more private location.

I have to work, but my child is home with another adult. Can we do a mental health visit via telehealth?

 For the first session, it is best if a legal guardian and their child can be together in the same location. Please contact your clinician for questions about special circumstances. For follow-up sessions, it will be up to you and your clinician to determine whether it is appropriate for the parent to call in from work while the child is at home with another trusted adult caregiver. Please talk to your clinician in advance of any adjustments that might need to be made for the supervision of your child during scheduled therapy sessions.

What if my child has very serious mental health symptoms?

If your clinician feels that your child’s mental health symptoms are too severe to manage over telehealth, they will review their recommendations and alternative options with you.

If you are concerned your child may be having a mental health emergency, do not wait for a telehealth mental health appointment. Instead, contact one of the crisis lines below, go to your nearest emergency department, or call 911.

  • National Suicide Prevention Lifeline: 1-800-273-8255
  • Crisis Text Line: Text HOME to 741-741
  • Orange County Crisis Assessment Team: 866-830-6011

If it becomes clear to a mental health clinician during the course of a telehealth session that your child is having a mental health emergency, the clinician will advise you to go to the nearest emergency room or call 911.

Learn more about mental health services at CHOC

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