The Kennedy Krieger Institute in Baltimore, Maryland, is a healthcare facility for children with developmental disabilities and neurologic problems. It is doing some powerful work in telemedicine with a program called START.
START stands for Screening Triage Access and Referral Team. It is a triage program (free of charge) aimed at increasing access and decreasing wait times. It was launched in February 2024 and is led by Dr. Paul Lipkin, professor of pediatrics at Kennedy Krieger Institute and Johns Hopkins School of Medicine.
THE CHALLENGE
Kennedy Krieger has had a longstanding problem with high demand for its specialty services and a very limited workforce. The result has been families calling in then having extremely long wait times to be seen – 237 days on average. The institute was looking for a solution to this problem.
PROPOSAL
The COVID-19 pandemic created an opportunity for Kennedy Krieger staff to think through the way they were delivering care.
“Prior to the pandemic, no one really took the time to think of new ways to address this challenge,” Lipkin recalled. “The pandemic not only gave us time to think through these things and discuss them in an organized and collaborative manner, it also exposed us to the possibilities of telehealth, working remotely with families.
“Before telemedicine, we always worked out of brick-and-mortar buildings and expected families to come in to be seen before anything could be done,” he continued. “But with the pandemic, we came to realize that one can connect well with individuals in other ways, and particularly in this case, through video discussions.”
MEETING THE CHALLENGE
When the institute was designing START, it wanted to take advantage of video communications with families to employ some of the expertise it had within the institution to facilitate children getting in.
“So, prior to START, families made telephone contact with an on-site trained individual who had to decipher what the child’s needs were and then put the child into queues for the different types of services they needed,” Lipkin explained. “Because we treat developmental problems, developmental disabilities and neurologic problems, it’s not usually a single service they benefit from. It’s usually multiple services.
“Families would be sent forms,” he continued. “They’d be put on different waiting lists. They could wait weeks or months before they’d hear back from anybody. The engagement and the interaction with families was disjointed and often impersonal.”
Staff thought one way to improve the process would be to have experienced physicians and nurses familiar with these medical problems meet with families upfront and figure out the problems before the child is entered into the systems of care.
“That’s the way START began, with that intent,” Lipkin said. “And it required a lot of coordination on our part upfront with all these other services to get them on board, to get them understanding ways they could facilitate children being seen, and essentially cut through a lot of the paperwork and bureaucracy that had built up over decades.
“So, we had an ad hoc team of physicians, nurses, therapeutic professionals and administrators come up with a program design, and we got buy-in from specific programs, and set up the START system, which involves interviewing a parent of a child via telemedicine soon after they contact the institute and making a determination as to what that child needs based upon what the parents’ concerns are,” he added.
There also arose the opportunity, thanks to a newly upgraded electronic health record system, to try to integrate all of this into the Epic EHR.
“Before this, families were sent paper forms,” Lipkin said. “They sat in queues and files, digital or hard copy files. And what we did as we worked together with our health IT team was to make sure everything we were doing would go directly into the EHR.
“In fact, from the beginning, when a family contacts us, every bit of information they provide is turned into part of the child’s electronic record for sharing with others,” he continued. “And in fact, we create reports that other people can provide. We designed our reports in such a way that that piece of them can be incorporated into the direct evaluation reports.”
Lipkin emphasizes Kennedy Krieger is not formally evaluating the child – it is a START. Staff decided they could get this information from the parent, as is done in pediatrics, where most of the history comes from the parent without having to see the child – knowing the limitations of seeing the child.
“From there, the child is routed to the type of specialized services they will best benefit from,” Lipkin explained. “Going directly then from that video call with the parent into these new systems for appointment setting and care. We also had essentially a design before where there was gatekeeping by people at the first appointment, often a physician.
“The family could wait months before that child was ever seen by the professional,” he continued. “From that visit, that would typically then set in motion other evaluations. So, the families could be waiting from the time they call, months, if not longer, to get the care they need.”
Now, with the START telemedicine program, staff is making determinations upfront, all because of the way they have been able to integrate video interviewing in with the electronic record and scheduling methodologies now at hand.
RESULTS
Kennedy Krieger began START in February 2024. It has taken a look back at how long it took for a child between the ages of two and three, which is START’s focus, to get into care.
Before START, it was taking 237 days on average, from the time of the first phone call to the time a child saw a physician – eight to nine months for a child to be seen.
“These are very young children with parents in distress and needing help and assistance,” Lipkin explained. “They often got in for some other appointments sooner, but even those, it would take four or five months to get seen by some other therapies or some other evaluations.
“So, families of young children had a really long wait, and we, in fact, had a bad reputation within the community for the impossibility of getting children in to be seen,” he continued. “So, in putting START together, we then cut down the time for a medical visit. Comparing the 2024 data to 2023, we cut down the wait time for a medical visit from 237 days to 117. Three to four months from the time of that first call. Much, much better.”
There still is room for improvement, he added. But cutting four months out of a wait time is a dramatic improvement.
“We cut the time in half for a child waiting for a medical appointment,” he reported. “For the nonmedical appointments, we similarly cut it in half. We went from 132 days to 70 days. And so really through this upfront video triaging system and through related collaborations with our program and health IT integration, we’ve been able to speed up the time when a child is coming in to be seen.”
ADVICE FOR OTHERS
“What we’ve learned is how much one can accomplish through delivery of telehealth,” Lipkin emphasized. “That often just talking with the individual and engaging in that history-taking piece can really be very fruitful. People in medicine were always taught this as far back as medical school, that the history is 90% of your evaluation; the physical exam, and all subsequent testing, is maybe 10%.
“We’re trying to take advantage of that 90% and use telehealth to try to get at that history,” he said. “So, in our case, we use it as a means to solve our problems with our long wait time and waitlist. And I will tell you, these START interviews take about 15 or 20 minutes on average. We could do them back-to-back. This year, we’ve done more than 500 at this point, and it’s only been limited by our staffing limitations.”
The hope is to shorten in-person visits.
“By combining what one can derive from telehealth with history with a more limited in-person visit, one might be able to deliver care much more efficiently,” he concluded. “And for organizations like us, where we have more demand than we have staffing to that demand, it hopefully can increase the number of patients being seen and cared for.”
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