In the past five years, telehealth — using the telephone, telecommunications technology or both to conduct visits with a patient or client — has become more widely adopted in many disciplines, including nutrition and dietetics. The COVID-19 public health emergency has further catapulted adoption by providers and patients. Switching delivery of nutrition care from in-person to telehealth encounters can be relatively seamless for practitioners who understand the benefits, follow essential steps to get started and incorporate best practices before, during and after sessions.
Practitioners who use telehealth to deliver care to their patients or clients can enjoy the convenience of working remotely, decrease the time spent commuting and save on costs associated with owning or renting physical office space. Insurance companies are increasingly covering telehealth services, a benefit to the practitioner and patient or client alike.
Accessing care via telehealth can offer a significant convenience, saving patients and clients time and money on travel and allowing home-bound individuals or those living in rural areas to receive care that might not otherwise be available to them. For example, patients or clients may not need to take time off from work or school, incur childcare costs or have to rely on public transportation as they would for in-person appointments. Telehealth meetings also can enhance services, since practitioners can observe the patient or client in their home environment — for example, to see inside the refrigerator or pantry and provide more personalized advice.
“Because it is so easy to hop on your computer or your phone, the patient is more likely to continue their relationship with the dietitian on a more regular basis,” says Divya Aggarwal, MS, RDN, LD, a telehealth dietitian in Cleveland, Ohio, and a supervisor with GemCare Wellness.
When preparing to use telehealth to deliver services, compliance with the Health Insurance Portability and Accountability Act of 1996 regulations should be a foremost concern. Practitioners should consider using only telehealth platforms, electronic medical records, video conferencing, email or messaging platforms and any other services that are HIPAA-compliant. Confirm that each platform or service will enter into a Business Associate Agreement that ensures protected health information is secure and that the platform remains HIPAA-compliant.
Practitioners should obtain professional liability insurance that covers care delivered via telehealth. Additionally, many states require licensure for registered dietitian nutritionists.
It is illegal to provide medical nutrition therapy in a state that requires licensure if the RDN does not have a license to practice in that state. Obtain a license for each state in which you want to practice MNT, meaning where the patient or client is located.
Similar to providing in-person services, you should confirm payer coverage and payment policies for telehealth services for each patient or client before seeing the person via telehealth. Some states require health insurance companies to pay the same rate for services delivered via telehealth as for an in-person visit. In states without such laws, you may find that telehealth services are paid at a lower rate. For patients and clients not using insurance, consider gathering payment information beforehand to avoid a missed payment. Clearly communicate billing practices and fees to avoid any miscommunications or misunderstandings.
Start a website and use social media platforms to explain and advertise your services. Practitioners seeing in-person clients or patients can communicate the benefits of telehealth services to them and ask about their interest in switching to receiving services via telehealth.
Best Practices and Etiquette
A key to a successful telehealth practice and good customer service is proper etiquette. Before a session, test your equipment to make sure it works properly. For technical assistance, it may be helpful to contract a professional or find a tech-savvy friend. Set specific time frames so patients and clients know what to expect; for instance, designate one hour for an initial consultation or 30 minutes for a follow-up session. Before the meeting, try to obtain relevant information such as anthropometric data, labs, medications or eating habits and behaviors.
A second computer screen may be helpful for you to quickly search or pull up information without needing to exit out of the meeting window on your main monitor. To minimize distraction, use a quiet keyboard or keep a notebook nearby. Ensure your surrounding area is free of clutter and distractions. Host sessions in a quiet area where children or pets cannot enter. Keep your room’s background simple and professional. Test the lighting to make sure the room is not too dark or too bright. Wear neutral solid colors, since bright colors and patterns can be distracting.
Look directly into the camera, not your computer screen, so it doesn’t appear as if you are looking down, rather than at the patient or client. Fill as much of the screen as possible with your body. At the beginning of a session, ask the patient or client if they can see and hear you well.
At the end of a session, schedule a follow-up meeting if needed. Allow the patient or client to end the call so they don’t feel as if you hung up on them. Immediately following the session, document the meeting and submit billing codes.
Potential Barriers to Access
While telehealth can be a convenience, barriers to access exist. For instance, in 2018, only about 70 percent of people in rural areas and 65 percent in tribal areas had access to high-speed broadband internet.
“When it comes to barriers to telehealth, there are three main areas I see: technology, policy and personal comfort,” says Aggarwal. In addition to access to a computer, telephone and internet, barriers may include a lack of education on how to use technology in general or a lack of understanding or experience using certain technologies. Patients also may be concerned about privacy or quality of care.
Medicare, Medicaid and individual state regulations can create policy-related barriers; for instance, limiting reimbursement for certain modalities of telehealth or certain providers. Interestingly, the COVID-19 pandemic has helped in this area. “The pandemic offered opportunities to expand telehealth care, which is a positive that’s come out of it,” says Aggarwal.
Hear how three RDNs successfully implemented telehealth into their practice and how you can, too. Listen to the FNCE® 2018 session “Expert Panel: Advance Your Practice Through Telehealth,” plus access the Academy’s telehealth information to view an interactive licensure map and more detailed tips on getting started, billing and payment, and more.
Another policy barrier is inconsistent licensure regulations. “We can advocate for more consistent licensure laws for dietitians, advocate for all types of MNT services to be reimbursed and really push health care insurers and governments to invest in telemedicine,” says Aggarwal.
You can help reduce barriers to access by using technology your patient or client already has access to such as a phone rather than computer (if allowed under state or federal laws and regulations and payer policies). Take extra time to build trust and rapport, and provide education on how to use the technology, if needed.
126. Expert Panel: Advance Your Practice Through Telehealth. FNCE® 2018. Academy of Nutrition and Dietetics. Accessed May 27, 2020.
Telehealth Etiquette Checklist. Telehealth Resource Center website. Accessed May 27, 2020.