Meeting Adolescents Where They Are: Hybrid Virtual-in-Person Visits for Routine Preventive Care

Brian P. Jenssen; Janani Ramachandran; Gabrielle DiFiore; Maura Powell; Kate M. Fuller; Anthony Luberti; Alexander G. Fiks

doi:10.1370/afm.2996

Key words:

THE INNOVATION

Only 50% of adolescents have had a health supervision visit in the past year, missing a critical opportunity for clinicians to influence health, development, screening, and counseling. Telehealth allows an opportunity to meet the needs of hard-to-reach adolescents and redefine what it means to support patients wherever they are. Despite professional organization endorsement,^1,2 a hybrid care model for adolescent preventive care—starting a visit virtually with an in-person follow-up visit as needed—has not been well explored. We designed and tested a hybrid well-visit pilot for hard-to-reach adolescents lost to follow-up.

WHO AND WHERE

Our pilot focused on patients with Medicaid insurance aged 18 years at an urban primary care clinic who were lost to follow-up; they had not attended a well visit in >2 years with a history of no-shows for previous well visits. Our project team consisted of physicians, researchers, and experts in innovation, quality improvement, and data analytics.

HOW

In January 2022 we created an eligible patient cohort of 50 patients based on the characteristics described above. We contacted patients (or their caregivers) to gauge interest in a virtual well visit with a goal to fill 5 telehealth slots in 1 evening block with 1 clinician. Due to high patient interest and demand, we expanded to 15 slots over 3 evenings, filling the slots after contacting just 24 patients. Before the video visit, telehealth navigators contacted patients for a reminder, and to assist with patient portal activation and completion of pre-visit questionnaires that screened for depression and adolescent health risks. During the visit, the clinician set visit expectations, addressed questions, reviewed the questionnaire responses, and counseled and referred to additional follow-up as needed. Patients needing in-person follow-up were scheduled for an expedited visit. Telehealth visits were billed as preventive visits, and in-person follow-up visits were billed as no-charge nurse visits, endorsed by our Medicaid payors. After visits, we administered a satisfaction survey via telephone. We measured patient acceptability (willingness to schedule a telehealth preventive care visit), feasibility (patient telehealth visit show rate), patient satisfaction (via telephone outreach survey), clinician feedback, and clinical impact.

LEARNING

This small pilot shows that a hybrid care model may offer a feasible and acceptable approach across care settings to engage hard-to-reach adolescents in preventive care, for whom the alternative is likely no visit. Of 15 patients scheduled for the telehealth visit, 11 attended the visit (73% show rate), 9 needed in-person follow-up, and 5 completed follow-up. The prior average well-visit show rate for this patient cohort was 33%. One patient screened positive for depression and was connected to services. Clinicians counseled all patients regarding substance use and safe sex practices and started 2 patients on birth control. For the in-person follow-up, all patients received vaccinations (influenza, meningococcal, and/or COVID-19) and sexual transmitted infection screening. Eight patients completed the satisfaction survey, and all stated they liked the convenience of the video visit. The clinician noted adolescents attended the visit on-time with pre-visit questionnaires completed, allowing more time for conversations around health needs. To expand this model to all age groups and across primary care settings, further work is needed to manage pre-visit outreach to explain visit details and goals, integrate pre-visit questionnaires to support clinical conversations, and support expedited visits for in-person follow-up. Visits that don’t require vaccination or laboratory evaluation will be ideal for this model.