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INTRO TO TELEHEALTH

The Future of Rehabilitation

Tracey L. Davis, MOT, OTR/L

Provider Disclaimer

• Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation.

• There was no commercial support for this presentation.

• The views expressed in this presentation are the views and opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

What is Telehealth?

Service Delivery Model - falls within current scope of practice for both OT and PT (Brennan et al., 2010)

Can include any service that uses some sort of telecommunication or technology as part of session

Synchronous - real time

Asynchronous - store and forward technology

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Occupational Therapy Definition

Identified by AOTA in 2011 as an emerging niche

Defined in 2013 position paper (latest revision 2018) as a service delivery model that uses telecommunication and technology (AOTA, 2013)

“ the application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technology (AOTA, 2018)

Physical Therapy Definition

2012 position paper Physical Therapy defined telehealth as “ the use of electronic communications to provide and deliver a host of health-related information and health care services, including, but not limited to physical therapy-related information and services, over large and small distances.” (APTA, 2012)

American Telemedicine Association

Telerehab Special Interest Group

Created Blueprint for Telerehabilitation Guidelines (Brennan et al., 2010); updated in 2017 as American Telemedicine Association’s Principles for Delivering Telerehabilitation Services (Richmond et al., 2017)

Good information on definitions and best practice across rehab disciplines, and the basis from which AOTA and APTA created their own position papers

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Center for Connected Health Policy

Telehealth regulations for all 50 states

Describes current legislation

Encompasses all of telemedicine, not only telerehab

Newly released document (Fall 2018): State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 States and District of Columbia

www.cchpca.org

Some states have additional restrictions for tele practice. Position papers have no state jurisdiction. Refer to your state of practice for details.

Start here: Calouro, Kwon, & Guttierez.(2014). An analysis of state telehealth laws and regulations for occupational and physical therapy. international journal of tele rehabilitation. 6(1), 17-23.

APTA – Telehealth Compact Live in 2016

* Currently 13 states participate

* 12 states with legislation enacted but not yet participating

* 3 states with legislation introduced

* Essentially gives a telehealth practitioner licensed in a compact state free reign to treat in any state that has also joined the compact

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What Does Telehealth Include?

ANY sort of telecommunication or technology as part of its session

must be integral to the session

synchronous (real time)

ie videoconferencing

asynchronous (store and forward)

IE Wellpepper (wellpepper.com)

Force Therapeutics (forcetherapeutics.com)

Blue Jay Engage (www.bluejayhealth.com)

Examples of Telehealth

Direct school based session using an e-learning platform

Adobe, Blackboard Collaborate, Collaborate Ultra

Teleconference consultation session with rehab team and client

Small group home exercise program using secure video connection

**Must adhere to HIPAA privacy laws

Skype is NOT secure (Simple Visit creates 3rd party HIPAA compliance)

Inexpensive and compliant alternative: VSee

Why is this important? How does it affect me?

With such promising technological advances, the use of telehealth will only become more prevalent

Many therapists will soon find themselves using it on at least a part time basis

Becoming familiar with the use of telepracticetechnology will help therapists be more marketable as well as allow for clients to have better access to therapy

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CURRENT RESEARCH

OUTCOMES MEASURES

POPULATION GROUPS

AREAS OF PRACTICE

Current Research

Bini, S., & Mahajan, J. (2016). Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study. Journal of Telemedicine and Telecare. 0(0), 1-9. doi:10.1177/1357633x16634518

Compared traditional live physical therapy vs store and forward technology

Results were not statistically different between the groups

Current Research

Boehm, N., Muehlberg, H., & Stube, J. E. (2015). Managing Poststroke Fatigue Using Telehealth: A Case Report [Abstract]. Am J Occup Ther American Journal of Occupational Therapy, 69(6), 1-7. doi:10.5014/ajot.2015.016170

single case study

COPM scores increased, fatigue decreased

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Current Research

Cason, J. (2014). Telehealth: A Rapidly Developing Service Delivery Model for Occupational Therapy. International Journal of Telerehabilitation, 6(1), 29-35. doi:10.5195/ijt.2014.6148

Highlights practice areas that have been researched for telehealth use

Examines challenges to tele practice

Current Research

Lindgren, S., Wacker, D., Suess, A., Schieltz, K., Pelzel, K., Kopelman, T., Lee, J., Romani, P., & Waldron, D. (2016). Telehealth and autism: Treating challenging behavior at lower cost. Pediatrics. 137(Supplement), S167-S175. http://dx.doi.org/10.1542/peds.2015-2851o

Cost is always a hot topic for insurance and other agencies

Study found cost savings and higher client satisfaction

BENEFITS OF TELEHEALTH

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Benefits of Telehealth

Provides rural populations with access to therapy

Original purpose of telehealth technology

Can also include isolation due to language or cultural barriers

True collaborative model

Adults and live assistants participate in sessions

Improves carryover

50 YO female with a diagnosis of Multiple Sclerosis. Client had a flare 3 months prior to coming to OT; neurologist recommended OT for fine motor. Worked full time and had difficulty attending therapy sessions.

Case Study

6 YO boy with a diagnosis of autism. Transferred to virtual school and placed on continuing treatment via a transfer IEP. Received 45 minutes OT 2x/wk. Issues included short attention span, decreased motor planning, sensory processing difficulties, and decreased distal control and visual motor integration.

Case Study

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Benefits of Telehealth

Can be more cost effective for tight budgets

Facilities can make use of equipment they likely already have and avoid spending valuable time and money resources sending therapists between locations

Motivating to the client

Those with limited attention spans often demonstrate improved attention with telehealth, especially in the pediatric population.

Benefits of Telehealth

Outcomes measures show effectiveness equal to or greater than live therapy (AOTA, 2018)

Improves collaboration and carryover

Develops a therapist’s verbal communication skills

A learning coach is a therapist’s hands

Directions must be provided verbally

Being able to effectively communicate improves a therapist’s creativity and problem solving ability

Challenges of Telehealth

Technology issues

Technology is great…until it doesn’t work!

Converting therapeutic activities to a virtual model

Requires constant innovation

Steep learning curve initially

Controlling the environment

Similar to early intervention or home health, controlling lights, sounds, and distractions is difficult and sometimes impossible

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Challenges of Telehealth

Intimidating for clients

Older clients and those unfamiliar with technology might be hesitant to transition to telehealth

Telehealth is hard to conceptualize until it is experienced

Licensure portability (Calouro, Kwon, & Guttierez, 2014)

Need licensure in both state of residence and state of practice

If a client goes to a third state on vacation, you CANNOT see them unless you are licensed in that location

Challenges of Telehealth

Need two sets of equipment for activities

Ethical and privacy concerns

Must comply with HIPAA regulations for all communications

Reimbursement

Medicare does not currently reimburse for virtual and occupational therapy

A few states do provide Medicaid reimbursement

Current Legislation

Tricare recognizes telehealth and uses it extensively within the VA system; VA allows treatment within the VA system across states

Medicare: legislation on floor but OT and PT not currently on the provider list (ATA TR SIG actively lobbying at this time) – Bill 2550

Medicaid: 12 states currently allow for telehealth reimbursement

Individual states have legislation with specific regulations, such as informed consent

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Billing for Telehealth

*Caveat* Because OT and PT are not on the Medicare Provider list, these codes do not mean much unless private insurance

acknowledges these same codes

Exception To The Rule

Tricare: Public policy of payment for technology based services

confirm with Tricare before offering telehealth services

**Unclear if policy extends to dependents

Private Insurance

Inconsistent but growing

May fall under out of network provider

Examples of companies who do reimburse for telehealth services: Anthem BCBS (in some states), Tricare

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MAKING THE SWITCH TO

TELEHEALTH

Who is appropriate for telehealth? And who is not?

Most clients who can follow

instructions can benefit from

telehealth.

Ideal Telehealth Clients

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Contraindications

Getting Started as a Telehealth Therapist

Switch current clients to a part time or full time telehealth model

Pick up side clients

Contract with staffing service

Ask current employer to consider adding telehealth

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Platform Options

Vsee: Barebones, Uses half the bandwidth of Skype (ideal for those with slower internet speeds)

Zoom: Free or low cost, Highly capable and intuitive

Adobe Connect: More capability, higher cost, some companies have built customized platforms from this base

Blackboard and Blackboard Ultra: High cost, but mainstream in videoconferencing world

Doxy.me: basic option with just video, subscription based that includes HIPAA secure screen sharing and messaging

Blue Jay Engage: Hybrid between synchronous and asynchronous technology

Luxury Items

Second Monitor: Improves productivity, high value for the money

Organization System: Worthwhile if practicing independently full time

Dedicated work space: Quiet, uncluttered space is necessary, separate office is useful

Therapy and evaluation materials: Can use household materials but will want a few specialty items

Virtual Evaluations

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Best Practice Language When Conducting Virtual Evaluations

“These assessments have not been standardized for telehealth; however results are thought to be

representative of client’s current level of function.”

“Client was evaluated via a telehealth service delivery model using a secure and compliant

video connection. Informed consent was obtained prior to the evaluation.”

Adapting to the Telehealth Model

■ Hurdle the mental barrier!

■ Trust your instincts.

■ Be the same therapist, but better.

■ Problem solve like a champ!

■ Improve your verbal skills.

■ Use your learning coach.

■ Maximize your client’s potential.

Same Therapy, New Format

BUT HOW???

Great question! There is no one right way to adapt your activities to the

telehealth model. There are, however, easy places to start to smoothly

transition to the telehealth model.

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Adapting to the Telehealth Model

Area to be Addressed

1) Balance

2) Midline Crossing

3) Therex

4) Proprioception

5) Visual Perception

6) Distal Control

7) Home Safety

Telehealth Model1) Yoga via webcam

2) Dancing to YouTube video

3) Therapy Band or weights

4) Simon Says using body weight activities

5) Hidden picture presented on screen

6) Clay, craft, origami

7) Use a tablet or moveable webcam

Gross Motor Resources

Gross Motor Resources

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Gross Motor Resources

Fine Motor Resources

BLIZZARD

BLIZZARD

BLIZZARD

BLIZZARD

BLIZZARD

BLIZZARD

© Your Therapy Source Inc www.YourTherapySource.com

BLIZZARD CARD GAME Directions: Cut apart the cards below . Using your first two fingers and thumb, roll up

each card into a small “snowball”. Place all the cards into a winter hat. Player one takes a turn by reaching into the hat to pull out a “snowball”. Open up the ball, if it is a snowflake keep it. If it is a blizzard card, you must put all your cards back into the hat. First player with 4 snowflakes is the winner!

Go to for the complete downloadwww.YourTherapySource.com/fmwinter

Fine Motor Resources

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Fine Motor Resources

Visual Perceptual Resources

Visual Perceptual Resources

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Visual Perceptual Resources

Websites and Resources

www.yourtherapysource.com

www.youtube.com

www.pinterest.com

www.teacherspayteachers.com

www.hep2go.com

Think Outside the Box (or the discipline)

Look for resources in unlikely locations

Ask your clients to give you a virtual tour so you know what you have to work with

Use the home health mindset – try to use common household objects whenever possible

Create a virtual toolkit (aka file folder) of fun worksheets or games that can be adapted

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VIDEO

When is a learning coach not necessary?

Sports injury

Adult with typical cognition

Middle/High School students

Five year old girl with mild cerebral palsy has entered kindergarten and qualifies for both OT and PT school based services. Her parents have opted for a virtual school program due to the fact that they live in a rural area. They live far from the nearest clinic, but mom stays home with her daughter and acts as her learning coach.

Case Study #1

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18 year old boy sustained a sports injury that required knee surgery. He also received a concussion and has some residual eye hand coordination issues. He is recovering at home and his parents work full time, so they opted for telehealth rehab. He no longer has movement restrictions but has ROM limitations and decreased strength.

Case Study #2

60 year old male suffered a moderate stroke. He has made good progress during his rehab stay and is being discharged to home. He will have a caregiver during the day and would like to continue therapy using telehealth.

Case Study #3

Client living in rural area with limited mobility requires an evaluation. Choose adult or child and reason for eval. Learning coach is present. How will you communicate your needs to the LC? How will the session work? Will you include standardized testing, and if so, how? How can you make sure you get enough information to make a recommendation?

Case Study #4

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References

Brennan, D., Tindall, L., Theodoros, D., Brown, J., Campbell, M., Christiana, D., … Lee, A. (2010). A blueprint for telerehabilitation guidelines. International Journal of

Telerehabilitation, 2(2), 1-10. https://dx.doi.org/10.5195/ijt.2010.6063

Cason, J. (2014, Spring). Telehealth: A rapidly developing service delivery model for occupational therapy. International Journal of Telerehabilitation. 6(1), 29-35. doi:10.5195/ijt.2014.6148

Galiano-Castillo, N., Cantarero-Villanueva, I., Fernández-Lao, C., Ariza-García, A., Díaz-Rodríguez, L., Del-Moral-Ávila, R., & Arroyo-Morales, M. (2016). Telehealth system: A randomized controlled trial evaluating the impact of an internet-based exercise intervention on quality of life, pain, muscle strength, and fatigue in breast cancer survivors [Abstract]. Cancer. 22(20), 3166-3174. doi:10.1002/cncr.30172

Gardner, K., Bundy, A., & Dew, A. (2016). Perspectives of rural carers on benefits and barriers of receiving occupational therapy via Information and Communication Technologies [Abstract]. Australian Occupational Therapy Journal Aust Occup Ther J,

63(2), 117-122. doi:10.1111/1440-1630.12256Lee, A. C., & Billings, M. (2015). Telehealth implementation in a skilled nursing facility: Case report for physical therapist practice in Washington [Abstract]. Physical Therapy,

96(2), 252-259. doi:10.2522/ptj.20150079

Lee, A. C., & Billings, M. (2015). Telehealth implementation in a skilled nursing facility: Case report for physical therapist practice in Washington [Abstract]. Physical Therapy, 96(2), 252-259. doi:10.2522/ptj.20150079

Linder, S. M., Rosenfeldt, A. B., Bay, R. C., Sahu, K., Wolf, S. L., & Alberts, J. L. (2015). Improving quality of life and depression after stroke through telerehabilitation [Abstract]. American Journal of Occupational Therapy, 69(2), 1-10. doi:10.5014/ajot.2015.014498

Lindgren, S., Wacker, D., Suess, A., Schieltz, K., Pelzel, K., Kopelman, T., . . . Waldron, D. (2016, February 01). Telehealth and autism: Treating challenging behavior at lower cost [Abstract]. Pediatrics, 137(Supplement), 167-175. doi:10.1542/peds.2015-2851o

Powell, J. M., Fraser, R., Brockway, J. A., Temkin, N., & Bell, K. R. (2016, June). A telehealth approach to caregiver self-management following traumatic brain injury [Abstract]. Journal of Head Trauma Rehabilitation, 31(3), 180-190. doi:10.1097/htr.0000000000000167

Stillerova, T., Liddle, J., Gustafsson, L., Lamont, R., & Silburn, P. (2016). Could everyday technology improve access to assessments? A pilot study on the feasibility of screening cognition in people with Parkinson's disease using the Montreal Cognitive Assessment via internet videoconferencing [Abstract]. Australian Occupational Therapy Journal, 63(6), 373-380. doi10.1111/1440-1630.12288