ROUGH EDITED COPY

UTAH STATE UNIVERSITY – CASEY JUDD

EHDI 2019 – TOPICAL SESSION 6, 7, & 8 – INTERNATIONAL F
MARCH 5, 2018
2:15 P.M. ET

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	(Writer standing by.) 
>> SPEAKER:  Welcome.  I'm Karen.  I'm the moderator.  If you need anything, let me know, and we'll be ending on time, and please, um, give your evaluations to me at the end.
>> SPEAKER:  Thank you all for sticking with us through to the very end, like the very end.
(Laughing.)
>> SPEAKER:  Um, so, today, we're going to talk about our experience in South Dakota setting up and specifically focusing on the training for spoke sites in our tele‑audiology system.  So, we all know this, and I'm not going to spend a lot of time here on this one‑three‑six, but I want to provide that as a framework for the work that we have been doing in South Dakota over the past few years.  We have been working with the funds available through HRSA for programmatic improvement for about four years now.  Prior to that as a state, we didn't receive those funds, and, so, over the last few years, we've really focused on the steps about one‑three‑six, trying to develop some programmatic improvement and reduce our loss to follow‑up percentages, and when we first started, we started kind of at the beginning and at that screening phase, and in South Dakota, we do pretty well with the screening phase.  
We are screening almost about 99 percent of babies, which is actually saying something, because as a state, we do not have any type of legislation requiring reporting of the screening results or any of the testing results or even that the screening is performed.  So, all of the birthing facilities in South Dakota are doing so willingly, which, again, I think is quite amazing.  In our state, where we struggle is after that.  That initial screening, although we're performing that at really high rates, we really struggle with getting infants to an audiologist for diagnostic testing, and then we have an even greater drop‑off at that stage moving to early intervention, and in the last data that I report here, which was from 2015, we had about a 62 percentage loss to follow‑up rate.  So, a good chunk of our babies, we lost them after that initial screening, and so we spent a lot of time reflecting on that, going to different stakeholders, doing some different data collection, trying to identify what was contributing to that, and we really started at the beginning with the one, and we started with doing some training and inter, excuse me, interviews with NICU staff and birthing facility staff, providing scripts and different types of trainings for them, and then moving forward, each step of the way, trying to, one, collect information, two, provide some type of programmatic improvement.  
That has got us to our most recent step, which is the tele‑audiology, specifically focusing on tele‑diagnostics, the ABR portion of that.  That tele‑audiology piece grew out of parent focus groups that we conducted in the state, where we learned from parents that one of the biggest challenges they were facing was that act of actually making it to an audiologist, and that's largely because of the geography of our state, and I know these are fairly small here, this is available to you as a handout so that you can zoom in on this, but in South Dakota, we're very rural.  We are truly, by definition, a frontier state.  Our population density is small enough that we qualify as a frontier state.  In South Dakota, our population is under 800,000 total for the entire state, right?  And in terms of live births per year, we're around 13,000 live births per year.  So, our entire state is smaller than many cities in the United States, but we are spread across this pretty large geographic area, and kind of, I think it goes in line with this, we also have really low income, household income in the state.  
That's what the top figure is up there, is income based upon county in the United States, where blue, the darker blue is higher income per household, or income in the household, where the darker orange brown is lower household income, and South Dakota, we have outlined up in there, and as you can see, we are mostly dark orange.  In South Dakota, we have six of the ten poorest counties in the country.  So, we live in a state where families face travel limitations, getting to pediatric audiologists, financial limitations, getting to an audiologist, and, because it's winter, winter travel in South Dakota is not easy at all.  So, really, we had a lot of things to overcome that really suited us well for tele‑audiology.  We really had kind of an ideal setting where we could really try to have a pretty significant impact in the outcomes in our state in terms of reporting through a relatively minor action, and so we looked at our data, and we identified by county those counties in South Dakota that had the highest loss to follow‑up rate, which is demonstrated here.  So, again, the darker blue, those are the counties with higher loss to follow‑up rates.  
We identified two locations in our state to setup as spoke sites for tele‑audiology, and we specifically identified sites that were in those counties with higher loss to follow‑up rates, but yet had a birthing facility, which limited us to the two sites that are identified with the red dot.  So, both of those communities have a larger hospital, and that hospital is part of the state, of one of the two state‑wide hospital networks.  In South Dakota, we have Avera system and Sanford system, and, so, we have each of those systems represented in our two sites.  For the northern site, although it is in one of the lighter blue counties, the reason it is there is it's adjacent to several dark blue counties.  Those dark blue counties are Native lands, excuse me, reservation lands, and it can be quite cumbersome and difficult to get permission to have a spoke site setup in a reservation community and to have consistent access to that, both in terms of Internet access, Internet connectivity, as well as just having access to the personnel at that facility.  So, that southern location that we chose kind of got us as close to those reservation lands as we could without actually crossing over into them.  The star in the lower left‑hand corner then, that's where we are, that's our hub site out of the University of South Dakota, so we are conducting all of our testing out of USD, and we are streaming in to those two centers.  
So, that's how we identified the two centers, but I want to spend most of our time in how we trained those two facilities.  Being in that remote location, with such a small number of births per year for a state, that means each of those facilities, those two facilities, we, maybe, our hypothesis was we may see ten babies per year at each of those facilities, which meant we faced a really interesting conundrum of how do we train the staff at that remote facility to do this task that they're only going to do, maybe, once a month, on average.  That's not adequate to really develop a really solid skill set in that.  So, we had to develop a training mechanism that they could return to, that they could come back to when they need it, kind of that at‑needed time of delivery, and, so, we identified a few different things to implement.  We did on‑site training with these facilities, we developed training videos that we'll show later on, and these training videos provide that staff member at that remote end a video model of exactly what they're expected to do in digestible pieces.  The videos are all purposefully edited down to about 30 seconds to 2 minutes, so that they can watch the video for the specific skill or the specific action that they need to be providing, and in both of the facilities that we are working with, they actually upload these videos to their online continuing education platform, so that any staff in those facilities could actually get on and watch those videos and step in, if needed, on that remote end.  
We then also created some pretty awesome quick‑reference guides, and we brought a sample of this that we're going to hand around later, and Ashley will talk more about that, but some people aren't visual learners, some people prefer to have this thing in their hand, so we created some quick‑reference guides that they could pull out to have in front of them to utilize during that setup as well, to just remind them of what it is that they needed to be doing, and I think then the final thing that I want to point out on this slide is that in the beginning, after we did the on‑site training, one thing that we viewed as really important was that between the time of the training and when we started seeing our first baby, we wanted to do some test connections, and, so, we purposefully scheduled babies who just, any baby, it didn't matter whether they passed their newborn hearing screening or not, we scheduled at least one appointment per month with each of those two sites, just to go through the routine, just to do it, so that that on‑site training that we provided wasn't for nothing, so that they had this repeated exposure and this repeated motor action that they were doing, until we started getting this stream of babies, and we found that really beneficial, because, for us, it was really nice to see, for one of the sites, we just did two before we had a baby there who didn't pass their initial screening, but when we got to that infant, we were like a well‑oiled machine, they knew what they were doing, they were comfortable with it, and you could really just tell in that nursing staff on that end, they didn't have the anxiety about putting the otoscope in the infant's ear as they would have if we wouldn't have been doing the practice on a low‑stakes situation.  So, for us, that was probably one of the most beneficial trainings that we implemented.
>> SPEAKER:  So, as she said, we completed on‑site trainings for each of our remote facilities, and as you can recall, we selected our remote site facilities based on the areas in our state that had the highest loss to follow‑up between our screening and diagnostic testing.  We trained the primary facilitator in each of the locations, as well as the supplementary nursing staff and their respective units.  On‑site, we blocked off approximately four hours for our trainings, and this allowed time to setup the equipment, test the equipment to ensure functionality, and then also train the remote site staff in their role of our diagnostic protocol.  We developed a site‑specific resource binder, and we will pass that around for everybody to look at, and this is at both sites for our remote staff to use during the appointments and as a reference during the appointments.  It includes prior appointment instructions to ensure that the baby arrives tired and hungry, so this nursing staff can provide this information to the family, and then it also, um, includes a setup guide for the appointment, so that the nursing staff has a step‑by‑step guide on what to do, and then it has our appropriate clinic forms, as well as a consent for tele‑health services provided remotely.  
That was new to our clinic, that we had to include as part of our consent for, on top of traditional consent, and then we also have the, our quick‑reference guides that supplement those videos, so we have, again, more words attached to them, as well as pictures on‑site, so they don't have to pull up the videos while the baby is there, and these setup guides and remote guides, they're just for the purposes and the role of the remote site staff, it does not include any instruction or information that the audiologist is doing.
>> SPEAKER:  This is our winter regional healthcare center.  This was our testing day.  At both of our training days, we did have a live baby for our trainings.  This is our cart that we use at Winters, and they call their room the tele‑health room.  This is Avera, and they use theirs and the e‑consult unit, and like I said before, it looks similar, our setup is a little bit different, and they do have all of the same equipment, and the binders, although they're parallel to each other, they are specifically written for the different sites, because both of our sites differ in not only the healthcare systems that they're apart of, we use the two major healthcare systems in the state of South Dakota and picked a site in each one, but they also differ in the type of video conference units that we use.  In Winter, we use Skype for business, and we'll discuss this later, and in Aberdeen, we use Cisco, so the wording is a little bit different in a lot of our appointment setup guides, because the staff is going to be doing different steps.  
So, you have the links to all of these videos on the handouts that you're provided, so I'm not going to show all of them today, I'm just going to show a snippet of a couple.  All of the videos are available on YouTube for anybody to use, and that was one of our goals when we made them, is that anywhere, where anyone is, they could open up these videos and utilize them for training, they're not specific just to our site, and this was one of the places where Bill was amazing to work with.  Bill Campbell worked with us to develop these training videos, where we recorded video with a baby in our clinic, developed a script that accompanied that video, and then Bill did a voice‑over of that, and we spliced the video and the audio components together, and it's really just a cell phone video, we recorded the video on an iPad, so that it really, we thought made it more accessible to people.  So, again, I'm just going to show a couple of clips here. 
>> SPEAKER:  Scrubbing the electrode sites is one of the most important steps in the assessment preparation.  The electrode site must be clean and dry for the electrode to adhere to the skin and provide good contact.  Using a dab of new prep gel on a cotton pad, gently scrub each electrode site prior to placing the electrodes.  Scrub high on the forehead, as close to the hair line as possible, as well as lower on the forehead, about an inch or so below the high forehead site.  Scrub thoroughly in a circular motion, not leaving any of the new prep residue behind.  Scrub the bony area behind the ears, not too low, where there is no bone right under the skin.  Scrub behind both ears.
>> SPEAKER:  So, that is a portion of the scrubbing video, and then I'll show a portion of the electrode placement video as well.
>> SPEAKER:  You're pointing the tip in the right direction.  The adhesive electrodes are attached to the electrode leads with a snap.  The electrode leads are color‑coded for placement.  The infant's skin will have been gently scrubbed and cleaned.  The electrodes will have a bit of gel in the center and adhesive around the outer edge.  Place the electrode with the white lead on the high forehead, in the center and as close to the hair line as you can.  Gently press on the outer edge of the electrode, not in the center.
>> SPEAKER:  So, again, that just gives you an idea of what those videos are, and we made a video for each aspect of this tele‑audiology session that that nurse on the remote end would be conducting.  So, we're pretty proud of those videos, we think that they turned out really well.
>> SPEAKER:  I do want to make one note, if you don't want to type in all these links, at the bottom of the screen in our handout of our slides, you can just go straight to our YouTube channel, which is titled at the bottom.  So, as I discussed earlier with our on‑site trainings, we decided to use two different video model, or video conference platforms, Skype for business and a Cisco system.  Why did we decide to do this?  Um, we decided to use the two different systems to gain experience in different platforms, to know what will work best in the state that we are working in, and it identifies pros and cons for when we move out of our pilot phase, to give all the information to future providers that we hope will use our tele‑audiology system.  We identified these two specific platforms due to the ease of use and possibly more widespread availability, as well as maintaining HIPAA and privacy compliance.  Skype for business is not the same as Skype.  Skype alone is not HIPAA‑compliant, but Skype for business is HIPAA‑compliant, and Skype for business actually provided us a HIPAA certification.  
It is available to anybody who utilizes Office 365, which most employers can provide that type of an account, thus Skype for business has a video conference platform with no additional cost, which is great for our future providers.  The Cisco system was utilized at the second spoke site, so in Aberdeen, and that was a facility that was more experienced with the provision of tele‑health and had an up and running e‑consult unit that was using the Cisco system.  The benefits of the Cisco system provides a more intimate experience with the family and the patient, because the clarity and the audio of the Cisco system is improved and better with that.  However, the large downside with the Cisco system is that it costs a lot more upfront, if those facilities, for our future providers, don't already have one in place.
>> SPEAKER:  All right, so I'll just close us out here and talk about what we, as a state, decided would happen after the diagnosis.  So, when you are doing the diagnostic testing with infants remotely, you have a decision to make of whether you're going to provide the results at the time of that remote testing or if you're going to have the infant come to an audiologist to receive those results.  For our state, we really spent a lot of time discussing that, and we felt that, for South Dakota, we thought that the benefits were there to discuss the results of the testing at the time of the diagnostic assessment.  As I said, really difficult for our families to get to an audiologist, so for us, we really wanted to provide those results when the family was there, and also then, if we provide the results, then those referrals that we're making can actually go into action.  So, one of the best support networks we have in South Dakota is our School for the Deaf, the South Dakota School for the Deaf.  It's an outreach‑based system, and they have outreach consultants who are deaf educators placed throughout the state, and as soon as a child is identified with hearing loss, they're assigned an outreach consultant in their area, and that outreach consultant then can really serve as a specific point of contact, a specific point of support for them and can help the audiologist to try to encourage that family to get to follow‑up appointments, and, really, it can be someone in that family's immediate area to provide that support.  
So, we wanted to provide the results to the family so that that connection to the School for the Deaf can be made and that support system and support structure could then be put into place.  The next steps we're going with this is looking at payment for these services.  Right now, we're just in the pilot phase, where all of the testing is being conducted out of the University of South Dakota.  We hope to expand that and open it up to other pediatric audiologists in the state to use, but payment is limited.  In South Dakota, Medicaid does pay for tele‑health services for physicians, but audiologists are currently specifically excluded from Medicaid rules for reimbursement, so we are collecting data on our work that we're doing to present to state Medicaid to try to encourage them to provide payment.  We have been successful in getting our state medical association to be in support of us, and they have been lobbying on our behalf, and, so, I think that is a really great benefit, I think that that will help us, maybe, to move that needle and get over that line, so that's where we're going next.  I feel like we have been successful with our tele‑audiology initiative.  As I said, we're a small state, with a small number of births, but already, since we just started doing the remote testing this fall, we've already had eight babies scheduled, and we've already diagnosed two with hearing loss, and both of those were within the three‑month timeline.  One, honestly, was two weeks old at the time of diagnosis.  So, I will say that I, this, to me, is really promising, and I think that we have a long way to go, but I'm very happy with how far we've come.  Questions?
>> SPEAKER:  Um, you guys talked about how it's not mandated for these babies to essentially be followed or get that diagnosis before 3 months.  How did you get those two sites and those nurses to buy into this program?
>> SPEAKER:  Good question.  It took a lot of conversations, and it made us firm believers in the idea of having a champion.  Like, our Winter site, that site is rocking and rolling, and it is because one of the physicians in that area, who's a family practice physician, has totally bought into this, and that physician is referring every baby, and not just the babies who don't pass their screening, babies who the parents have concerns about their hearing.  We've even tested babies who passed their hearing screening, but the parents had concerns, and that physician is referring them.  So, it really just solidified in us this idea, you have to have that one person, you have to have that champion who's going to really promote it.
(Off mic.)
(Laughing.) 
>> SPEAKER:  Three years, I think.
>> SPEAKER:  Okay, that's time.  Thank you.
(Applause.) 
>> SPEAKER:  Thank you all.
(Applause.) 

This is being provided in a rough-draft format. Communication Access Realtime Translation(CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.