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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
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