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June 16, 2020

For some pediatricians, the prospect of regularly using telehealth to connect virtually with patients was a distant thought prior to the COVID-19 pandemic. However, the public health emergency created by the novel coronavirus meant an accelerated introduction to the technology that would provide a link to patients and families when social distancing demanded fewer in-person visits.

Minnesota Pediatrician asked for reflections from members around the state about their experiences with telehealth in the time of COVID-19. Here’s what we heard:

Katie Smentek, MD, FAAP; Mankato Clinic

Within 12 hours of investigating telehealth options at the Mankato Clinic, we had our first provider up and running. Within one week, every provider was trained and using the new platform. Telehealth visits were critical to our clinic in April, when 45 percent of our visits were via telemedicine. Our families are so thankful to have an additional way to see their pediatrician during this time.

 

Gretchen Karstens, MD, FAAP; St. Luke’s

Telemedicine worked well to help get us started back up seeing our kids. We worked with Doxy.me and it seemed to generally go well. It was so good to see my families, reassure them, and be reassured that they were okay. Going forward, it seemed like telemedicine might work well for some of the behavioral health visits especially with teens as they seemed very comfortable with working in this medium.

 

 

Janna Gewirtz O’Brien, MD, FAAP; Adolescent Medicine Fellow, Leadership Education in Adolescent Health Fellowship, University of Minnesota

I’m particularly excited about the use of telemedicine with adolescents. I’ve heard from them that they love being able to access their healthcare virtually from the comfort of their own homes. I’ve also had the opportunity to connect via telemedicine with youth facing homeless in shelter and they are grateful to have the opportunity to receive healthcare without having to leave the relative safety of the shelter. While we as providers may find integrating the technology to be a challenge, we can learn from young people who are savvy with technology and have adapted to this new world, even in the face of significant adversity. Even though many of us have launched telehealth as a rapid response to COVID-19, I think there is great potential to continue to use virtual care in the future as one way of expanding healthcare access for teens.

The American Academy of Pediatrics continues to offer members guidance about the increased use of telehealth during the pandemic. Most recently, Dr. Richard Oken, a member of the AAP Committee on Medical Liability and Risk Management, authored the article, “How to provide good care using telehealth and reduce medical liability risks” through AAP News.

You can find the article at https://www.aappublications.org/news/2020/05/21/law052120.

By Michael Severson, MD, FAAP

When pediatric residents from the University of Minnesota came to Brainerd to participate in my rural preceptorship, I would always make sure we took a field trip to the Brainerd Head Start Classroom for two reasons. First, because I was on the Head Start Advisory Board and could easily make the arrangements and second, because I wanted young pediatricians to observe the human fabric of these radiant, busy children’s faces woven by many threads but the single most common thread: poverty.

Poverty predicts that you are unlikely to leave the county you were born in, it predicts you are more likely to suffer from childhood obesity, heart disease, diabetes and mental health disorders, become a high school dropout or experience teen pregnancy.

Minnesota Head Start exists to help change these outcomes. Head Start oversees a program of services for pregnant women and children from birth to age 5 across 87 counties and 8 tribal nations. It assures the enrolled children will have a well child exam and perhaps find a medical home. It assures immunizations are current, that hearing and vision are normal or appropriately referred, and dental health evaluation is completed.

Head Start is a successful program and insists high-quality education and care must be available to every one of the more than 50,000 Minnesota children under the age of 5 who live in poverty.

In 2017–2018, there were 69,310 children in poverty under age 5 in Minnesota. Of those, only 46 percent of three and four-year-olds had access to Head Start. And only 9 percent of children under 3 had access to Early Head Start (EHS). EHS programs are available to families prenatally until a child turns 3 years old and is ready to transition into Head Start or another pre-K program. Most early childhood initiatives focus on preschool-age children (3-5-year-olds). Younger children (birth-3 years) who are defined as at-risk can also clearly benefit, but for many of them, Head Start at age 4 is too late. Current Minnesota funding for Early Head Start is for only 1,400 children.

For a student, Head Start could likely be the place she learns she has a last name, an address, and phone number. It could be the place one learns the pleasure of sliced apple, banana or grapes or an orange segment. Head Start is the place that improves the use of please and thank yous and sharing and perhaps how to tie your shoes.

Indeed, all of the above is remarkable but it doesn’t begin to address the Head Start mission of school readiness preparation and engaging parents’ involvement.

Head Start takes a comprehensive approach to meeting the needs of the whole child and family. This two-generation approach supports stability and long-term success for families experiencing economic hardships. Thanks to Head Start’s comprehensive services, most had access to family services including crisis intervention, job training, and parenting education.

Head Start sets academic goals and tests and evaluates outcomes. A prediction model has been developed to determine the children who are most at risk of not meeting the kindergarten benchmarks based on their fall or winter assessment scores. The prediction model considers a child’s literacy and math scores in the fall or winter given their age, gender, race, and English-language status. Teachers are given the names of children in their classrooms whose scores put them at risk of lower developmental growth so they can plan to offer more individualized supports for these children.

Pediatricians must actively support Head Start and Early Head Start. Do not let it be underfunded, it is wonderful and correct way to move children towards academic success and away from poverty.

Reopening Head Start During COVID-19

With the goal of re-opening services, the Head Start leadership association worked with the Minnesota Department of Health to develop a detailed, 44-page, “COVID -19 Preparedness Plan” offering background information, protocols and procedures to resume meeting the needs of this key segment of our community. Seeking a perspective on child health and safety, the Head Start Association approached MNAAP for a physician who could review the proposed plan and meet with program directors and health managers. Tim Zager, MD, a recently retired pediatrician from Duluth, represented MNAAP in this role during a web-based planning meeting on May 20 in preparation for establishing face-to-face summer services for 4-year- olds starting kindergarten and children with IEPS. Dr. Zager reviewed the re-opening plans, offered some suggestions, and prepared an information sheet on pediatric coronavirus infections. It is anticipated that about half the programs in Minnesota will open this summer to offer services.

 

By Eric Dick, MNAAP Lobbyist

All legislative sessions have their own ‘feel’ for the legislators, lobbyists, and advocates who live in the Capitol during each legislative session. Some sessions are dominated by partisan sniping and fighting, while others see more bipartisan cooperation. A few years ago, it was unusual in that the Capitol was closed for major renovations, and another recent session saw a Republican member of the Senate elevated to serve as the lieutenant governor under a DFL governor. But nothing compares to the 2020 session.

Legislative leaders entered the session in early January with a projected surplus of over $1 billion, with the House DFL intent on investing in early education, while the Senate GOP hoped to pass tax relief.  Governor Tim Walz, as well as both the House and Senate, spoke of passing a robust bonding bill. The best-laid plans were quickly scrambled in early March as the COVID-19 pandemic arrived in Minnesota. It quickly become clear that ‘business as usual’ wasn’t going to work in 2020.

With several staff members diagnosed with COVID-19 in early March, legislative leaders quickly extended the Easter/Passover break by a week to clear the Capitol as they discussed plans on how to continue or even end the session. Ultimately, the House and Senate returned to the Capitol, albeit in a very different setting. All committee hearings were conducted remotely, and both the House and Senate strictly followed the social distancing guidelines from the Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health (MDH). Some legislators voted remotely, while others were spread throughout the Capitol and would come to the floor in shifts to register their vote. Routine roll call votes that normally take mere minutes took 15 minutes or longer. Much of the debate focused upon legislation to address the pandemic’s impact.

Unfortunately, the pandemic did affect the MNAAP’s legislative priority agenda at the Capitol. While we always knew we faced an uphill battle to pass meaningful measures to reduce firearm death and injury and strengthen Minnesota’s weak vaccine laws, it was our goal to educate legislators and prepare to move these important issues forward in 2021. Most notably, our annual Pediatricians’ Day at the Capitol had to be cancelled. With a dramatically smaller field of issues being considered as the pandemic changed the dynamics at the Capitol, pursuing these controversial issues become impossible. Our legislative allies simply didn’t have the bandwidth to raise these issues given the enormity of the pandemic.

The MNAAP did have a big, important win. Our third legislative priority for the session – increasing the age to purchase tobacco from 18 to 21 – is now law. While the federal government increased the age late last winter, the MNAAP and other tobacco control advocates sought passage of a state law to ensure effective enforcement and compliance. This was an important win for the chapter.

The MNAAP saw another big win in the passage of prior authorization (PA) reform. Under the bill, health plans will be required to more quickly respond to PA requests, timelines for appeals are accelerated, “peer to peer” reviews must involve a Minnesota-licensed physicians in the same or similar specialty, and plans must post written clinical criteria for the PA policies. Other provisions protect patients when they change health plans or when their health plan changes PA criteria in the middle of the individual’s contract year. MNAAP President-elect Sheldon Berkowitz, MD, FAAP, offered testimony in support of the legislation in the House.

As of press time for this newsletter, it appears increasingly likely that a special session will be necessary on or around June 12. State law requires the Legislature to be in session should the governor wish to make or extend a peacetime emergency declaration. The current declaration expires on June 12, and most observers believe another extension is likely. The extra time for negotiations between legislative leaders and the governor may make passage of a bonding bill more likely, and there could be further actions related to the pandemic to be considered. Complicating plans is the fact that the 2020 budget surplus has morphed into a projected $2.4 billion deficit in the next biennium.

Given the extraordinary circumstances for the session, passage of Tobacco 21 and prior authorization are no small feats. But our work has just begun.

The safety and health of children is a pediatrician’s first concern, and has never been more so than now. I know many of you, like me, watched recent explosive events unfold knowing that they will shape the children of today and the adults of tomorrow. As pediatricians, we recognize that racism is a social determinant of health which impacts the long-term outcomes of health, education and economic stability of our communities of color. And in the days following the tragic death of George Floyd, we have seen the immediate outcomes of the effects of racism, accelerated and brought in to sharp focus. Children across Minnesota are being affected by violence and upheaval. Families that already live in precarious situations were left without reliable access to food or formula, medicine or first aid. Children and adolescents are traumatized from the sights and sounds in their worlds, whether it be the sirens and fires in their communities, or the video images of a man’s agonizing last moments as he pleads for help. 

Our children were already experiencing an imbalance in their sense of physical safety as a global pandemic uprooted their lives, and this trauma has been compounded by the abhorrent act of racism that resulted in the death of Mr. Floyd and the subsequent violence that has erupted. The disparate consequences of racism are laid bare for all to see during this outcry in our communities and we need to reassure families that pediatricians are here to support all children and help create safe environments for all families. 

In times of crisis and uncertainty, children and adolescents look to their grown-ups for a road map on how to travel through the experience. We need to encourage parents across our state and nation to see their child’s doctor as an ally in addressing the systemic disease of racism. Having an age-appropriate conversation with children or adolescents about racism is a crucial part to preventing a future generation that enables inequity and human suffering. It can feel like a daunting task, but it is imperative. MNAAP has collected resources and guides that can be helpful in approaching and facilitating these conversations. You can find them at www.mnaap.org/racism-and-violence-undermine-childrens-safety/.

The members of the Minnesota Chapter of the American Academy of Pediatrics stand firm in our collective mission to recognize the challenges that our children are facing, identify implicit bias and advocate for equity in all areas of our social structure that will allow them to grow up to be healthy and strong. 

Take care,

Lori DeFrance, MD, FAAP

MNAAP President

Alone we can do so little; together we can do so much.   

– Helen Keller

June 15, 2020

Childhood vaccinations plummeted in mid-March after COVID-19 was declared a national emergency. In February, there was a 71 percent decrease in MMR doses administered compared to the year before. Although vaccine rates are slowly climbing back up, they are still far below normal levels. According to the latest information from the Minnesota Department of Health:

  • Doses administered in the second year of life seem to be more impacted than doses administered in the first year of life. Comparing March 2019 to March 2020, most health systems saw a much larger drop in PCV shot administration in 12 to 15-month-olds compared to 2-month-olds.
  • Geographically, gaps exist in all regions. However, some of the regions in greater MN are seeing the biggest drop (northeast, north central, and south central).
  • The metro region saw a drop in April of 29 percent in the total number of PCV doses given when comparing 2019 to 2020.

Pediatricians should identify children who have missed well child visits and/or recommended vaccinations and contact them to schedule in person appointments inclusive of newborns, infants, children, and adolescents. MIIC and electronic health records may be able to support any catch-up immunizations. Consider using these sample social media posts or patient and families messages to communicate the importance of well child visits.

Vaccinate at every opportunity, even sick visits. And remind parents about Minnesota’s Vaccines for Children program since many parents have been laid off.

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