Depression in children and adolescents is on the rise nationwide, and the first place many families seek care is their pediatrician’s office. Unfortunately, many pediatricians receive little to no formal training to treat mental health conditions. Which might explain why a depression management course offered in cooperation with the Center for Telehealth at Cincinnati Children’s is attracting pediatricians from throughout Greater Cincinnati.

The course is an opportunity for providers to engage with one another in a unique learning community. Last year, 18 providers completed the course, and another 24 are participating in its second cohort, which began in May.

The course takes place one weeknight a month for six months, using the Zoom video conferencing platform. Participants log on to the live meeting and spend an hour with Cincinnati Children’s faculty and staff from multiple subspecialties, including some from the Division of Child and Adolescent Psychiatry and the Division of Behavioral Medicine and Clinical Psychology.

The format includes a 15-minute lecture, case presentation, discussion and time for questions, focusing on topics such as how to manage complications of treating children with depression, prescribe medication and know when it is time to make a referral.

The course uses methodology from Project ECHO, a virtual learning network process developed by the University of New Mexico. Project ECHO (Extension for Community Healthcare Outcomes) began in 2003 to help community providers learn how to manage common, yet sometimes complex, diseases. The Center for Telehealth uses the Project ECHO model for courses about depression, hypertension and seizures/epilepsy.

A team of experts at Cincinnati Children’s led by Emily Harris, MD, MPH, FAAP, a pediatrician and child and adolescent psychiatrist at Cincinnati Children’s, created the depression management course curriculum on behalf of the Center for Telehealth. Dr. Harris teaches the course, along with child and adolescent psychiatrist Courtney Cinko, MD, and clinical psychologist Jessica McClure, PsyD, both of whom are on faculty at Cincinnati Children’s.

“The lectures are the seeds of content knowledge, but the case discussions are deep and instructive, and are the richest part of the learning. Project ECHO creates a network of learners who make connections across participant practices and provides a platform to follow cases over time, ” says Dr. Harris.

Paul Korn, MD, a pediatrician who practices in Mason, Ohio, completed the depression management course in October 2018.

“About one-third of visits to pediatricians are for mental health concerns, so this kind of training is invaluable,” he says.

“The course gave me insights into things I might change in caring for patients with depression, and a greater comfort level with certain approaches and medical management. The training I received could allow me to make fewer referrals for specialty care, which means patients will receive the treatment they need more quickly," says Dr. Korn.

Since taking the course, Dr. Korn says he has shared his new knowledge with the other pediatricians in his practice to enhance the care they provide patients as well.

Provider feedback is making Project ECHO courses even better, Dr. Harris says. “We hope to develop additional mental health courses on topics such as anxiety, trauma and behavioral health practice transformation.”

The Center for Telehealth at Cincinnati Children’s launched five years ago with a commitment to improving patient access through innovation. Here, Senior Director Jennifer Ruschman reflects on the center’s growth, impact and future plans in an excerpted interview.

How would you characterize the Center for Telehealth’s growth?

In our first five years, we grew 30 to 35% annually in terms of patient volume, and today we are steadily adding new subspecialties, new providers and new programs. In 2014, only nine different clinical areas at Cincinnati Children’s had at least one telehealth visit. Last year, that number was 39.

However, telehealth still does not represent a large percentage of the medical center’s total number of outpatient encounters. For example, Cincinnati Children’s has about 2,000 outpatient encounters every day, and in the first 10 months of this fiscal year the Center for Telehealth did about 2,000 video visits total.

The Center for Telehealth has accomplished a lot in the last five years, but I feel that in many ways we are just getting started.

The center is known for developing and trialing new ideas. Where do these ideas come from?

We receive a lot of ideas from doctors and nurses who see a way for telehealth to solve a clinical problem. Sometimes one of our team members approaches a clinical partner with an idea we’ve been developing or seen work at a different hospital. We use a database to track ideas through every phase of development.

How are video visits changing?

Initially our video visits were for patients who were physically located at another hospital or an outpatient clinic. Last fiscal year, almost half of our video visits (648) were with patients at home. These types of visits have a big impact on patients and families. I talked to one mom whose son receives care from the palliative care team at Cincinnati Children’s. Video visits mean she doesn’t have to pack him up in the van for a clinic appointment, or hold a phone up to his ear for a phone conference. The two of them can sit together and participate in the video call with ease, using private video conferencing software.

What is a new initiative you’re excited about?

We are working with a software company called Teladoc to develop the first pediatric direct-to-consumer telehealth platform. This will make it possible for families to contact us directly for telehealth services. Our goal over time is to work with payers to have this service covered, so that all patients and families can access healthcare from Cincinnati Children’s when they need it —even in their homes, if appropriate. We want to provide everyone with the best access to high-quality care.

Peritoneal dialysis often makes it possible for children to remain at home while they wait for a kidney transplant. But it also can be a source of stress and frustration for families. 

Four RPM nurses at the Center for Telehealth are supporting patients on peritoneal dialysis remotely so the family can stay at home. Subspecialty nurses helped develop RPM protocols, and the RPM team can customize each patient’s care plan depending on their needs and situation.

When a child is being discharged from the hospital on peritoneal dialysis, the care team explains RPM to the family. If the family is interested, one of our RPM nurses comes to the inpatient unit to explain how the program works.

Once at home, parents use their smartphone or a tablet to log on to our app twice a day. They respond to a series of questions about their child’s health status, and enter readings from the dialysis machine. They measure their child’s body weight and certain vital signs; Bluetooth-enabled devices automatically submit biometric data to us securely.

The RPM nursing team receives everything in real time and can take action as needed.

Here are some examples of what is possible:

• Monitor for complications after the nephrologist adjusts  medication

• Send parents links to educational videos about constipation or catheter blockage, which are common problems for children on peritoneal dialysis

• Send an email alert to the Kidney Clinic nurse if a child misses multiple medication doses or if more dialysis supplies are needed

• Notify the Kidney Clinic nurse when the parent notices early signs of infection

Before RPM, the kidney care team might not be aware of a problem until a child’s follow-up appointment in the clinic. Now, they are alerted by the RPM nurses when biometric data or other vital information starts to show a concerning trend. As a team they can respond quickly when problems arise or when parents have concerns or questions.

Kidney failure is a chronic and complicated condition that affects many body systems, and children on peritoneal dialysis sometimes need to be hospitalized. Our early data show that patients on peritoneal dialysis who participate in our RPM  program are being hospitalized an average of 5.6 inpatient days a year, compared to an average of 8.4 days a year for patients the year prior to Cincinnati Children's starting to use RPM. Lower healthcare utilization can translate into a significant cost savings, less stress for families and improved health for children awaiting a kidney transplant.