Telehealth Best Practices: Linda Hanna of Mahmee On How To Best Care For Your Patients When They Are Not Physically In Front Of You

When a client comes into a clinic setting, no one can really tell what is going on in the home without a visual in real-time. Remember, the home virtual visit actually allows for real-time interaction and allows the clinician an opportunity to provide necessary resources, if needed, based on the information obtained during the visit.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Linda Hanna, Co-Founder and Chief Nursing Officer at Mahmee.

Linda Hanna, RNC, MSN/Ed., IBCLC, is Co-Founder & Chief Nursing Officer at Mahmee, a data-driven maternal and infant health technology company that is building the digital infrastructure needed to connect the maternal health industry and prevent critical gaps in care. Linda is a veteran health care expert who pioneered world-class maternity and lactation programs at Kaiser Permanente, Cedars-Sinai Medical Center, and other health systems. She has over 40 years of clinical experience and has helped over 100,000 moms and babies.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

I am happy to share my story with you! When working at the bedside of expecting and new mothers and families, I felt my responsibility was to ensure they had the knowledge and skills necessary to care for and feed their babies with confidence. I also wanted to make sure the mothers would have support and guidance when they left our care and went home with their newborn. After starting my last company, I found myself and my team not only helping the new family but also reaching out to them long after our initial appointment to make sure they had what they needed to be successful and also maintain their health and wellness. I also wanted to make sure the primary care provider for both mother and infant was always aware of the condition of each of their patients, as well as the care plans that we provided for them to follow.

My daughter, Melissa Hanna, an activist-entrepreneur, realized that my tools to provide this care and support were not adequate and would not provide the access to care that was necessary. We set out to build a complete Electronic Medical Chart, as well as all of the components necessary to provide support for the providers, as well as the tools for the patients — and thus Mahmee was created.

Can you share the most interesting story that happened to you since you began your career?

I have too many stories to tell after four decades in this profession, but I can share that most of my experiences with families have been amazing. They don’t always feel that way when they’re happening but the after effects last a long time. The ability to learn from new parents and their own personal experiences and stories lives on within me, and I take those experiences to the next family.

Sometimes, after an appointment with a client, I have to stop and think hard about the interaction, about how I was behaving and speaking and what they needed from me. I often would leave an appointment and wonder if I met all of their needs at that time, or wondered if I could make up for what I missed or forgot to mention or show them. I have worked with very extraordinary people with privilege and families with very little personal property or provisions and I always work to provide the same type of care to each of the families. My own biases have to be left at the door when I meet a new family and this is often hard to do for people in healthcare.

Over the course of my career, I have had the opportunity to work with celebrity clients. Due to this, I very rarely attend movies, if at all, and I rarely watch television shows because I am always concerned that I will meet one of the actors on the show and have an opinion about them based on their character, rather than on them as a parent. This way, I do not know them in any other capacity other than as a new parent. Often when meeting very high-profile celebrities, they are happy that I don’tt recognize them from whatever show or movie they have been in. To me, they are just a mommy or a daddy who needed some attention and guidance. It has worked out very well for me. This way everyone is treated the same.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I’ve learned there is absolutely nothing that is absolute in this profession. We honestly can’t say one thing is for sure going to happen, since each mother-baby dyad is so unique and special. Even our clients with multiple children have a new experience with each pregnancy, so we cannot just tell them things will be the same. In fact, we know they will often be very different. We paint with a broad brush when we start care with a new family, using guidelines rather than absolutes. It works well for everyone. Then we can monitor and adjust the care to meet their special and unique needs and desires. I am often quoted saying, “follow these guidelines for now, and let’s tweak things as we go.” That way, we don’t miss anything along the way.

I also remind the families we work with, something that my dad said to us all the time, “one day does not a habit make,” meaning just because something happened today, doesn’t mean you can count on that happening again. You have to work at everything you do to get the results you want. It’s not hard, it is just part of the planning process.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

I’ve had some amazing nurse mentors throughout my career. I’ve worked under some of the top clinicians as well. The nursing leadership gave me the guidance and confidence to be an amazing bedside nurse, as well as a nurse leader in my field. The physician teachings and support allowed me to gain clinical skills that I took with me to every job I’ve ever had. I remember the young obstetricians I worked with early in my career, who took the time to show me how to care for a laboring mother and how to support her through childbirth and beyond. I wanted to be the best partner for these families and be a guiding light for them, so I trained hard and studied so that I could support them through childbirth and into their breastfeeding journey and beyond.

That said, the most influential person in my life was my director, Faith Rossman, who led our entire Education Department. She allowed me to develop programs and hire and train staff to follow along with my program designs. She trusted me and became a trusted advisor and friend. She gave me wings to fly, and when I was falling, she would scoop me up and let me try again.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

I am happy to share about our relationships with the families we help and how the pandemic has changed that role for all of us. When you sit down with a new parent and family, you learn about their physical and emotional well being, and hands on care can be provided. Sometimes, for many new parents, that is just what they need — someone to hold their hand or offer physical support. When you are together in the same space, the tone and tempo of voices fluctuate according to your and their emotional wellbeing and understanding of the topics being presented. People can understand when you have a quieter tone versus a firmer or louder voice to explain and describe things. Face-to-face care allows for visual learning about pain and feelings that the individual is experiencing and then generates a care plan that the family can follow after the visit is completed.

With the COVID-19 pandemic and the wearing of masks for all appointments, we lost a few essential parts of the visit. One being our ability to read and understand grimaces and facial expressions, and the other being our expressions in response to the patient. We take a lot of cues from the mother about how to care for her based on her expressions. Pain, joy, fear, etc. Additionally, during this time, the provider does not get to share their expressions, and so many times the patient is not sure if their provider understood them or acknowledged their feelings. When we switched to all virtual care and removed our masks, we were able to see our families and they could also get to know us. This allowed for all of the feelings and emotions to be made more clear and then allowed the practitioner to provide clear care based on the mothers needs.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

If our clients do not get the sense that we are fully with them, understanding their needs and desires, they are less likely to fully participate in the care plan we provide for them. When the team approach is used, and the provider and the family have an opportunity to discuss the “next steps,” there is a greater likelihood that positive results will occur and the end goals will be met in a more timely fashion. If there is a need for multiple visits because the expectations of the client were not met, there could be a delay in the proper care plan, allowing for other issues to arise. We have to know that the mother and the family all are in agreement with the recommendations discussed and the actions that should be taken.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)

1. When a client comes into a clinic setting, no one can really tell what is going on in the home without a visual in real-time. Remember, the home virtual visit actually allows for real-time interaction and allows the clinician an opportunity to provide necessary resources, if needed, based on the information obtained during the visit.

For example, a family came to the office for a check in and typical items were not in the baby diaper bag that might help the parents while they were away from the home. They forgot a change of clothes, they only packed two paper diapers to use if the baby peed or pooped, they also didn’t have any wipes packed and did not have a burp cloth. The dad explained that they’ve had a hard time getting organized and can’t find everything at home. I asked to do a call with them the following day, in the late afternoon, using the virtual call feature. When I started the call I asked if they could walk me around the apartment so I could see where the best place for mom to sit and nurse would be based on what they had at home. I was also able to see that the floor had clothes piled up, some clean, some ready for the laundry. There were boxes around the chairs and on the couch, mostly opened with items inside and some empty. The kitchen was clean but things were left out and not put away in the cabinets. This allows for a discussion about organization for the home, domestic help, reorganization of family duties and what to expect in the upcoming weeks and months.

2. Another wonderful feature of a virtual appointment is the opportunity to talk directly to the patient and get both body and facial expressions that allow the clinician to make considerations to the care plan based on what the patient seems to be most comfortable or motivated by.

When seeing a mother recently at an office appointment, we all had masks on, so I could not see a complete view of her face. I could tell by her voice that she was very upset and concerned about how she was going to care for the baby. Her voice was shaky and more quiet than normal for the clients that we typically see in the office. Most of the time the mothers are very excited to get to meet the consultant and get help with nursing. Noticing that something seemed off, I asked her if I could see her again and we did a follow up telehealth appointment the next day. Without a mask, I was able to see her appearance and she looked very tense, and it showed by tightening her mouth and lips. She also frowned a lot during the appointment. I would not have been able to determine this with her mask on in an office setting. Mothers are often very good at hiding their feelings. They do not want to be judged by the providers or have it look as though they do not know how to care for themselves or their baby.

3. Telehealth also allows the clinician to make a clinical diagnosis and treatment plan based on visual examination and review, and they can then use the referral network as needed to allow patients access to next-level care.

For example, when a mother has some concerns about their breasts or nipples, we can see the area they are having issues with by having them set themselves up with the camera pointing directly towards the body part they are having a problem with. This allows the provider to make a clinical diagnosis and provide a treatment plan immediately and also document it in realtime. There is also the possibility that a mother or infant might need to be referred to a specialist and that transaction will also take place while still on the call or immediately following.

4. When the patient is not physically with the provider there must be other means of communication besides just doing a virtual appointment. We know that by using our telehealth platform, we can communicate with mothers and their caregivers, as well as the other providers, by using the messaging feature. We’re also able to send treatment plans and articles to the patient as needed. Additionally, healthcare should be provided in a way that is also meaningful, while not imposing time restrictions and other considerations on the family.

For example, after an initial visit with a mother, I felt that she couldn’t take in any more information during the appointment, as I felt she was still in need of more support and guidance. By engaging with her later via the Mahmee website, she was able to communicate with our entire team, asking questions, as well as reading material suited to her immediate needs. The messaging feature allows us to be in constant communication with her and manage her needs when she needs our help.

5. The providers have a responsibility to understand more than just when their clients need support. The other family members may need some guidance and questions answered as well. Additionally, the client’s other providers also need to know that the primary care provider is following along with their care plan, and that they will pay attention to their needs as well. It’s essential that there is a time to discuss a patient’s care in between the visits with all of the providers. This can be done through secure messaging.

For example, after doing an appointment with a new mom who had a very “sore nipple,” I could see that it had the appearance of a plugged Montgomery gland on the areola area, fairly close to the nipple. The mother was describing a pain score of 8–9 and looked very uncomfortable while attempting to nurse on that breast. Additionally, when we attempted to pump, the mother was in tears from the pain. After a more careful look at the skin and area around the nipple/areola complex, it was more apparent that this was indeed an abscess that needed to be evaluated. I reached out to the breast surgeon through the platform and set up an appointment for the morning. She was evaluated and treated for a breast infection and abscess and seen again in 48 hours by the physician. At that time she needed to have a drainage tube placed and then a medication change as well. The information was passed along to the Obstetrician caring for her, as well as the pediatrician caring for the baby, who were then able to watch her progress. I worked with the mom again after six days of pumping and reintroduced the baby to the breast. With the small dressing in place and a cover over that area, she was able to continue on with full nursing for another six months. The care model we use allows for all members of the team to collaborate with each other and ensure the mother is getting the best care and support she needs and wants from her providers to meet her goals.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Telehealth can support practices by allowing the follow-up check-in to have eyes on mother and baby, not excluding any body part or any medical / nursing concern. In many past experiences, nurses would have to make additional home visits or use the telephone to get follow-up data from the mothers on how the treatment plans were working. Now, this very close contact, in real-time that allows for dialogue to continue with parents and providers feeling connected without being in-person directly, yet being close enough to be part of the conversation. Many times a nurse would like to check on healing or conditions that are being treated and with the visual viewpoint, using telehealth, we can document what we see rather than what is reported. Then, we can provide accurate and up to date information to the physician and other healthcare team providers responsible for the care of these patients. Even more, costs are significantly reduced when a telehealth lactation consultation is performed and nurses, as well as other ancillary care providers, provide direct patient care this way. Additionally, time to see more clients is made easier because the provider does not have to drive from one location to another. Time saved on gas and other costs is also reduced significantly when using telehealth.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

At Mahmee, our IT team has built secure video feature technology that we use to conduct our appointments, as well as run classes and support groups.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

Through the creation of Mahmee, we feel that we have built the best telehealth platform for both providers and patients — with access to their medical chart, pregnancy history, birth history and baby details included. The best features are our messaging and care plan / treatment plan creator. We can send “just in time” information, education and personalized care plans that mothers and family members can begin to use immediately to start the healing and recovery process, as well as plan their next few weeks and months.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

One of the essential takeaways of a visit with a nurse, lactation consultant, or other clinical care provider is that the family / client feels that they were able to express their concerns and get their needs met during the visit. We want parents to know that they can take advantage of the supplies in their homes that they might not have at an in-person office visit. For example, when it comes to breastfeeding, this might include hands-on practice and special techniques such as pumping skills, positioning, and understanding of normal feeding patterns. Patients need to know that a good clinician can use descriptions and particular language to guide, direct and explain most aspects of normal feeding patterns, pumping techniques, and other related pregnancy and postpartum recovery practices.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

We hope to one day soon be able to do more with language and integrations with other existing platforms and EHR’s.

Is there a part of this future vision that concerns you? Can you explain?

I am not concerned about the future now, anymore than I have even been, as the medical community is always updating and changing practices to meet the needs of the patient and family types they provide care for. I know there will continue to be changes to charting tools, making things even more accessible than they are currently — especially by adding in new features including AI and VR as well. These are exciting things to look forward to. I see how much I have been able to adapt myself as a clinician throughout the years and I cannot imagine working without these tools in the future.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

I believe that the way I inspire people is by doing my best work and that’s what I wish to motivate in others.

For me, as a member of a team that has the opportunity to “do good,” I always strive for my best work by providing patients with what they need in real time. If that means a phone call or a visit, then that is what we would do. If we meet our mommies where they are, not where we think they should be, and provide “just in time” connected care, then we will help by allowing things to go more smoothly for them.

How can our readers further follow your work online?

Website: https://www.mahmee.com/

LinkedIn: https://www.linkedin.com/in/linda-hanna/

Twitter: https://twitter.com/getmahmee

Facebook: https://www.facebook.com/getmahmee/

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.