Telehealth in occupational therapy

Article Reviews
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Read Full Text: Telehealth in occupational therapy: An AOTA Position Paper (Available via NBCOT and ProQuest)
Journal: The American Journal of Occupational Therapy
Year Published: 2018
This week’s article was chosen in response to the coronavirus pandemic.

The world has changed drastically in a week’s time—and we are being asked to change with it.

I know this has meant long, exhausting days. And, that we have been left scrambling trying to figure out what a “new normal” will look like in the weeks ahead.

For many of you, telehealth will be part of this new normal. This is why I wanted to spend this week discussing AOTA’s Position Paper on Telehealth with you.

No matter how quickly the world changes, I believe that, together, we can stay grounded in our mission: to provide the best possible care to our patients.

Understanding the language around telehealth

Per this paper, “telehealth” is the recommended term for when OT professionals provide services by way of information and communication technology.

That being said, telehealth is technically a very broad term—and it is helpful to know some more specific language to understand all of the ways telehealth can manifest.

In the next section, I’ll break down the different types of telehealth. I will also link to the articles that the Position Paper highlights.

(I’m using way more links than usual because I want you to be able to find the study that correlates most closely to the care you are seeking to provide.)

In what situations has telehealth been studied?

Telerehabilitation: This is a phrase used to describe the delivery of rehabilitation or habilitation by way of information and communication technology. Telerehabilitation is a branch of telehealth that would encompass all of the other terms we are about to look at.

Tele-evaluation: Evaluation through information and communication technology

Tele-intervention: The provision of interventions that are preventative, habilitative, or rehabilitative in nature via information and communication technology. Of course, this is the section that we want to know most about. But, unfortunately, little guidance was given in the paper.

Tele-consultation: Tele-consultation is a term that describes virtual consultation, which may or may not have the client present, and may involve some combination of the following parties: a local provider, a remote provider, a durable medical equipment vendor, prosthetist, physician, and/or caregiver.

It seems to me that the line between intervention and consultation may be vague. And, some of the studies linked below may be helpful in guiding intervention as well as consultation.

Here are the types of tele-consultation the position paper highlighted. You can click through to see the associated study mentioned in the article.

Telemonitoring/remote patient monitoring:

Ok, first of all, I want to ask if anyone has any updates on reimbursement for remote patient monitoring. Lauren and I wrote this article which laid out our knowledge of the reimbursement situation, but it was over a year ago.

Telemonitoring is commonly used in the medical model for chronic disease management. Typically, patients’ vital signs and other health data (e.g. ADL performance, fall events) are sent to a clinician for review to ensure timely monitoring takes place.

Studies looking at how occupational therapy practitioners have used telemonitoring have looked at:

What assessments should we be using?

As therapists make the quick transition to telehealth coverage, sound clinical reasoning will keep playing a role in determining which assessments are appropriate.

Below are the assessments (as of 2018) that were studied and found to be reliable when administered through telehealth:

Personal gripe: I’m really confused why no pediatric assessments were mentioned in this paper, given that most teletherapy I’ve heard of anecdotally has been delivered in pediatric or school-based settings. Next week, we will be sure to look at a study that highlights teletherapy in pediatrics.

What do you need to know about supervision and telehealth?

When it comes to supervision of students and COTAs, the guidelines that dictate your normal practice should remain in place when delivering telehealth services. You will need to reference your state licensure laws if you are uncertain about these guidelines.

What are ethical considerations?

Right now, a common feeling among OT practitioners is that we are having to weigh ethical concerns as we navigate a very fine line. This line becomes increasingly fuzzy as we consider the need to deliver care to our patients—and whether doing so will jeopardize the safety of patients and ourselves.

The position paper highlights that occupational therapy practitioners are, of course, still called to adhere to our code of ethics.

The position paper also directs readers to the American Telemedicine Association’s “Principles in Delivering Telerehabilitation Services.”

The document outlines administrative, clinical, and technical principles, as well as the ethical principles which I am listing below:

  • Organizations and professionals shall incorporate organizational values and ethics into policy and procedures related to telerehabilitation.
  • Organizations and professionals shall be aware of and comply with any applicable laws, regulations, statutes, and/or telerehabilitation-related policies and adhere to professional codes of ethics.
  • Organizations and/or professionals shall inform clients of their rights and responsibilities when receiving rehabilitation and habilitation services through telerehabilitation, including their right to refuse or discontinue services.
  • Organizations and professionals should have in place a formal process for resolving ethical issues as well as policies that identify, eliminate, and reduce conflict of interest associated with the provision of telerehabilitation services.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1. When it comes to adopting telehealth, COVID-19 may be speeding the inevitable

From everything I’ve read this week, it seems that the consistent prediction was that telehealth was going to eventually become a major component of therapy delivery, but that the biggest barrier was legislation that was moving far more slowly than the rapidly advancing technology solutions.

But, in just one week, we have seen many of the legislative barriers across the country begin to crumble. Now, it seems like our main focus needs to be ensuring that the reimbursement we receive reflects the value we are able to provide!

2. Of course, we always wish there was more research out there—but, honestly, there is more out there than I expected to find.

Just from looking at evidence each week, we already know that we rarely find perfect answers in research.

But, we all see that research often provides a helpful jumping off point for your clinical reasoning. And, this seems to be the case in telehealth. I was pleasantly surprised by the number of articles cited in this position paper.

My goal over this week is to gather the resources found in this paper, as well as others, into a helpful telehealth research resource page for you.

3. There are SO MANY details to flesh out…that’s why we have a forum.

Of course, you may finish reading the position paper and find yourself with even more questions than before. I have been more thankful this week than ever for our forums, where we can dive deep into specifics. But, I also just appreciate the community we have built, where we can share stories and encourage each other. I will be really curious to hear where you are with telehealth. This is a unique time because we have several active threads going, so please weigh in below with reactions to this paper and general questions about best practices in the comments below.

Or, check out one of our associated threads:

Listen to my takeaways in podcast form:

Find platforms for listening to the OT Potential Podcast here.

(Possibly) Earn CEUs/PDUs for reading this article.

Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.

And, here’s the full APA citation you many need:

Cason, Jana, DHS,O.T.R./L.F., A.O.T.A., Hartmann, Kim, PhD,O.T.R./L., F.A.O.T.A., Jacobs, Karen, EdD, CPE,O.T.R./L., F.A.O.T.A., & Richmond, Tammy, MS,O.T.R./L., F.A.O.T.A. (2018). Telehealth in occupational therapy. The American Journal of Occupational Therapy, 72, 1-18. Retrieved from https://search.proquest.com/docview/2193509193?accountid=143111

What questions/thoughts does this article raise for you?

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Even in the midst of the pandemic, I am so proud of our profession for being flexible and innovative to meet the needs of our patients. If you have a place for it, I have some research articles that might be helpful to put on our list highlighting the efficacy of teletherapy versus in-person intervention. I am working on my doctorate currently, and I compiled a small list when working on an advocacy paper to reach rural families in pediatrics. Thank you for the work on this!

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I know! I am so proud all of the therapists I’ve interacted with for how they are navigating this.

I would love to see your list of research articles, and hopefully can get the articles added to a bibliography of sorts to share mid-week. (Also, that’s so awesome you are pursuing your doctorate!!)

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Hello Sarah, thank you so much for this article ! I am working in pediatrics (private clinic in France) and because of the current state I am looking for information about telehealth.

I think telehealth is interesting more than ever because: (In France)

  • OT clinics are closed, but during this time patients are in needs of our care.
  • When the quarantine will be over, I believe, the economical consequences will change our societies organization (for the better, I am sure) and telehealth will be an essential tool.

As you said in your article, “No matter how quickly the world changes, I believe that, together, we can stay grounded in our mission: to provide the best possible care to our patients.”
Thank you for this inspiring sentence and all the informations. I am so glad to be a part of this community. It’s amazing to see how OT are able to adapt so fast! Let’s continue to help and evolve together in our beautiful profession.
Marine

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Hi Sarah,
Very timely article. I have my first class online today in an hour and one of my student groups is presenting on Telehealth via Zoom. Will share some things with them and will let you all know how it goes.
Yes, I am very proud of all the OT practitioners who are trying to learn new technologies and being so flexible for their patients and students. Together , we can do it.

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In a world of unknowns and occupational deprivation, OT is more important than ever for our patients. I see so many benefits to telehealth, and have a relatively clear picture of how it can be used in mental health and pediatric settings.
However, my struggle is with patients who need splint adjustments, tactile cues, or hand over hand assist, to name just a few. Additionally, even the assessments that have been shown to be reliable over telehealth would need to be brought to the individual.
Does anyone have comments on how they are helping in these cases right now?

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Hi @Marine! It is so good to hear from someone in France. I know, I keep looking at world maps and wondering how other countries are faring.

It is truly amazing that as a global OT community we are collectively facing the same issues. I agree that this virus will certainly change the way our societies are organized.

I think that is why it so critical that we join together right now, and are pro-active about what we want that change to look like for our profession, and that we set ourselves up for success to continue to provide high long-term value to our patients. Please keep us posted on how you are doing.

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I totally agree about the assessments! I will have to look more closely at the studies to see how they were actually carried out, but I was like “Why are they studying the efficacy of a dynamometer in telehealth? That seems so impractical!”

If you haven’t seen this example yet, you can see how this practitioner handled administering assessments and the corresponding documentation in a pediatric case:

https://club.otpotential.com/t/telehealth-school-ot-eval-example-diagnosis-trisomy-21/349

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As you noted, I too am most interested in the intervention strategies that I can use as I start EI teletherapy. I am spending this week training and planning with the families I work with so that these sessions can be productive and as low stress as possible. Working with 0-3y, we have been really focusing on using a coaching model with the families with the teletherapy platform. All of my experience is in Early Intervention, but I see a strong coaching focus being our basis for all OT teletherapy practice right now.

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Jessica,
Which state do you practice in? My friend and co-instructor is an EI practitioner. She told me that though Medicaid is allowing all states to provide OT telehealth services, our state (NC) has still not approved it. Different states are implementing it differently.

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I am in Indiana. Indiana First Steps (their EI program) has approved telehealth for a limited period at this point, to be re-evaluated as needed. The support and understanding from the state and our local agencies has been great. Families too! So far, I’ve heard lots of great feedback for using the teletherapy platform. Its great to read this article and others that also show research support. Maybe sending some of these articles to your state representative or EI office would help tip the scale in that direction?

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Sorry one more question, @jessica14! Is there a link you can send us about First Steps approving telehealth for a limited time? I think that in addition to research, our state officials are also swayed by seeing other states in their region take steps (like Indiana has) to ensure continuity of care.

(Also, I’m working on getting a documentation example of telehealth in EI. I always think it is helpful to see what actual sessions are looking like.)

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This is a link to the First Steps Covid-19 policies. The First link outlines the changes, including the approval of telehealth and the wording on “until when”. The others are supporting documents.

https://www.in.gov/fssa/ddrs/3399.htm

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Super curious to hear your feedback from class @sanchala!

Thank you for all the great information here. I sent in my signed petition today!! A curiosity I have is if we are losing opportunities to use the old school phone right now to help bridge the gap. Has anyone else been using the phone more for telehealth?

I am doing my best (in home health) to a) pre-screen for s/s of C19 and if at all possible go out to do the onsite evaluation (with appropriate use of PPE and following all other precautions). Then I am doing moving to do massive coaching and care coordination over the phone. It actually helps with reimbursement overall in home health (if other disciplines are going out to use the other visits) and I am watching it be massively valuable already to lean into phone calls. But what I am finding to be also worth noting is HOW we use this equipment not just THAT we get to use it (beyond assessments bc that’s still beyond me with how we’d do that in home health). I am excited to dig in more to those resources @SarahLyon. Wow. What an incredible trunk of treasures to dig thru.

It’s one thing to “call” someone. It’s another to ask myself, What can we talk about in this conversation, such that by addressing it and talking about it I/OT can help keep this patient out of the hospital and off the floor (especially right now). I am watching a tremendous amount of rapport and buy-in be built. It’s worth noting that we are able to “track” these at “Teletriage visits” and though I am not reimbursed per visit, I am hoping (humbling aiming) that these calls are actually making a bigger difference in weaving the big picture together (which is where I feel like OTs thrive esp on the home health team).

Has anyone else ventured in the last two weeks to using the phone to help especially to fill in the blanks (vs drop all care amidst a lot of fear–which I understand)? If so, what’s been helpful in regards to structuring the conversation? (At this point, I am mostly guided by use of Motivational Interviewing questions linked to behaviors and I always tie in and document to a goal in the plan of care, hospitalization prevention and/or resources, and moving forward the established plan of care. A unique hurdle will be the cases that involve functional cognitive impairment…which were the tricky situation PRE-Covid. Ahh. One day at a time.)

Thank you. Each and every one of you for bringin’ the light and resources. Truly. Thank you.

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Hi Monika,

Thanks for asking. I completed my second class on Zoom today. Yesterday, students presented in groups of two. They made it very interactive asking questions of their peers which were typed in the chats and answered. Switching between presenters and slides
went very well, was seamless.

Today, I had a 3 hour class on Zoom where it was mostly lecture. I had a co-instructor with me who monitored the chats. We muted all microphones unless someone wanted to ask a question. We checked for understanding frequently. Overall, both classes went well.
Most of my students today had stopped their videos so I couldn’t see them. It is a little odd for me to look at blank screens
and just names and talk into the microphone. I think it will get better slowly when we get used to it.

I would like to hear from other educators for ideas. Hang in there, everyone.

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Hello Sarah,

I particularly took interest in your takeaways for OT practitioners section. The third point in particular is what I think most practitioners will be interested for the weeks to come. My biggest concern in this area is the accessibility to telehealth for out patient or clients. I know that there are people who would struggle to get high-speed internet that would enable telehealth communications to occur well. Helseth states that “only 69.3% of rural areas and 64.6% of tribal areas had access to high-speed broadband internet met the minimum benchmark set by the Federal Communications Commission”. If we were able to, as a community, to come up with possible solutions to help these people who struggle to get transportation or access to high-speed internet, it would be beneficial to those who do not have these options readily. I hope that as Covid-19 develops, we will be able to problem solve and find solutions for those in need.

Respectfully,
Josephine, OTAS

Reference

Helseth, C. (2013, August). Barriers to Telehealth in Rural Areas - RHIhub Toolkit. Retrieved from https://www.ruralhealthinfo.org/toolkits/telehealth/1/barriers

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@SarahLyon

Thank you for sharing this article that is so relevant to the time we are in now. I am curious what area you believe will really benefit from telehealth in the future that we have not seen much of yet. An article by Hayes, Jaegers, Conners, and Barney (2019) discussed the use of telehealth for individuals coming out of jail who are reintegrating into the community. It was fascinating to see how this service delivery model is being used in areas that are not as commonly heard! Thank you again.

Respectfully,
Kristen Borntreger, OTAS

Hayes, C., Jaegers, L., Conners, B., & Barney, K. (2019). Telehealth technologies support participation in community-based OT (CBOT) services during postjail transition and integration. The American Journal of Occupational Therapy, 73 , https://doi.org/10.5014/ajot.2019.73S1-PO6035

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Sarah,
Thank you for sharing this post, it is extremely beneficial and shares a lot of knowledge. One question that I thought of while reading this article and your post, is how are those patients who use telehealth assessed for adaptive equipment. Remote therapy and assistive technology over phone calls can help patients using telehealth (Schmeler, Schein, McCue, & Betz). This article helped me with that part, but I am still curious as to how patients are fit for splints and and other devices that are specific for the patient.
Respectfully,
Rozlynn Everhart, OTAS

Schmeler, M., Schein, R., McCue, M., & Betz, K. (n.d.). Telerehabilitation Clinical and Vocational Applications for Assistive Technology: Research, Opportunities, and Challenges. Retrieved March 25, 2020, from https://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6014/6192

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OTs are still not on the list for telehealth with CMS. OTs are able to do e-visits via CMS. Although the reimbursement rate is decided less for e-visits vs. telehealth, can I use a live video? It would be a much better patient encounter than a phone call or email.

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