Abstract
Background and Purpose Telehealth is defined as the delivery of health-related services and information via telecommunication technologies. The purposes of this case report are: (1) to describe the development, implementation, and evaluation of a telehealth approach for meeting physical therapist supervision requirements in a skilled nursing facility (SNF) in Washington and (2) to explore clinical and human factors of physical therapist practice in an SNF delivered via telehealth.
Case Description In 2009, Infinity Rehab conducted a pilot program to determine whether telehealth could be used to meet physical therapist supervision requirements in an SNF. In 2011, language allowing telehealth physical therapy was approved by the Washington Board of Physical Therapy (Board). In 2014–2015, telehealth outcomes were evaluated in a 51-person sample at an Infinity Rehab SNF. Cost savings of telehealth implementation from 2011 to 2015 were estimated.
Outcomes The Board deemed the telehealth pilot program a success and subsequently established telehealth practice language for physical therapy. Both human factors and clinical outcomes were required to implement a successful telehealth practice. Clinical outcomes and user satisfaction in telehealth and nontelehealth groups were equivalent. Cost savings were identified.
Discussion Human factors, such as the need for provider education in appropriate bedside manner with a telehealth session, were identified. Since 2011, more than 1,000 telehealth physical therapy sessions were conducted at Infinity Rehab SNFs in Washington State. In the future, alternative payment models focused on valued-based clinical outcomes may facilitate wider telehealth adoption in physical therapy. Future research on efficacy and cost-effectiveness is needed to promote broader adoption of telehealth physical therapy in SNFs. This experience demonstrates that telehealth implementation in an SNF for the purpose of physical therapy re-evaluation is a feasible alternative to in-person encounters.
Telehealth is the use of secure 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 for patients and clients.1 In clinical practice, telehealth services are delivered to patients and clients in a synchronous real-time manner via audio and video technology or delivered asynchronously via store-and-forward digital technology. For example, a physical therapist from a distant site may conduct a real-time telehealth session and then forward a home exercise program asynchronously to a patient at the originating site where the patient is located. Synchronous and asynchronous telehealth services improve care coordination where health disparities might exist, such as in provider shortage areas and rural settings, by overcoming access barriers to physical therapist services.
In 2014, the House of Delegates of the American Physical Therapy Association (APTA) endorsed telehealth as an appropriate service delivery model when provided in a manner consistent with the following: APTA positions, standards, guidelines, policies, and procedures; Standards of Practice for Physical Therapy2; Code of Ethics for the Physical Therapist3; Standards of Ethical Conduct for the Physical Therapist Assistant3; Guide to Physical Therapist Practice4; and telehealth definitions and guidelines.5,6 In 2015, the Federation of State Boards of Physical Therapy (FSBPT)7 released a telehealth recommendation for model regulations for physical therapist practice addressing administrative, clinical, ethical, and technical guidelines in physical therapist practice. Informed consent for telehealth service and proper security measures to safeguard patient information and data are examples of FSBPT's telehealth regulatory recommendations. Overall, recent policy actions better position physical therapists to implement telehealth services in the digital age.
According to US Census data, the older adult population in 2013 was 14.1% of the US population.8 This demographic population is expected to increase to nearly 1 in 5 US residents aged 65 years and older by 2030.9 Currently, there are more than 15,000 nursing homes serving more than 1.3 million residents.10 Of the nearly 196,000 licensed physical therapists in the United States, approximately 12,000 (6%) are employed in skilled nursing facilities (SNFs).11 Due to workforce shortages of physical therapists in SNFs, compliance with state practice regulations can be challenging in some states. For example, meeting practice requirements such as mandatory periodic re-evaluations by a physical therapist can be a challenge with a limited physical therapist workforce. The aging population is resulting in increased demands for rehabilitation in SNFs. Furthermore, the Omnibus Budget Reconciliation Act (OBRA) of 1987 mandates that nursing home residents have the right to function at their highest functional level and not lose functional ability as a resident in a nursing home.12 This law is challenging to meet at times because nursing home residents typically have multiple chronic health conditions with various deficits that require coordinated care. Therefore, SNFs are in urgent need of innovative care models that promote the highest level of function for their residents.
An opportunity exists for physical therapists to implement a value-based practice13 that focuses on improved access to care and cost containment. Towey noted reduced costs for the MaineCare (Medicaid) program while improving access and value to recipients of speech therapy practice via telehealth.14 In Maine, telehealth speech therapy provided more than $2,367 Medicaid savings in 7 patients with vocal cord dysfunction who required a range of 1 to 4 telehealth visits compared with usual care. With emerging value-based practice,13 physical therapists need to bridge the gap between benefits and barriers in telehealth services if telehealth is to become a viable model for physical therapist practice. The purposes of this case report are: (1) to describe the development, implementation, and evaluation of a telehealth approach for meeting physical therapist supervision requirements in an SNF in Washington and (2) to explore clinical and human factors of physical therapist practice in an SNF using a telehealth approach.
Need for Telehealth in Washington SNFs
Infinity Rehab of Wilsonville, Oregon, provides clinical care services to older adults in more than 175 sites in 10 states, including Washington. In Washington, the physical therapy practice act describes the professional and legal responsibility of a physical therapist supervising assistive personnel (Tab. 1).15 In the originating site of the pilot telehealth program, the residents of the SNF in Washington had an average of more than 15 comorbidities, with an average length of stay of 39.3 days. The residents of this SNF had medically complex conditions and required the physical therapist and physical therapist assistant to have extensive experience in treating patients with multiple comorbidities and chronic conditions, as well as complicated discharge dispositions.
Washington Physical Therapy Practice Acta
Due to workforce shortage of physical therapists in the area, disruptions in the continuity of physical therapist services to the residents of this SNF frequently occurred. As a result, Infinity Rehab had to take extraordinary measures to meet the state-required periodic re-evaluations. These measures resulted in less-than-acceptable clinical outcomes and added costs to the health care system. For example, Infinity Rehab paid the itinerant physical therapist more than 30% of the salary of a regular employee, which also was less efficient due to travel and time required to become familiar with the facility, staff, and residents of the SNF. The existing physical therapy regulations required that, at minimum, a physical therapist conducting a re-evaluation lay eyes on the resident. Therefore, Infinity Rehab identified an opportunity to pilot a telehealth program as evidence for managing older adults with chronic diseases via telehealth was emerging.16
Telehealth Pilot Program
The time line of activities summarized in this case report is shown in the Figure. In summary, Infinity Rehab first proposed a telehealth pilot program to the licensing board of physical therapy in Washington (Washington Board of Physical Therapy [Board]) in November 2008. A follow-up meeting was requested by the Board with Infinity Rehab. In March 2009, after the meeting, the Board approved a pilot program at an SNF.
Time line of telehealth implementation. Board=Washington Physical Therapy Board, WAC=Washington Administrative Code.
In order to determine the success of this telehealth pilot program, the Board required that a telehealth session of supervising a physical therapy session to meet the clinical standards (Tab. 1) be video recorded and archived for review by the Board and documented in the resident's electronic medical record (EMR) as a telehealth physical therapy session. The Board also requested that if the physical therapist or physical therapist assistant determined the resident would be better served by an in-person visit, the telehealth session should not be conducted. From March 2009 through June 2009, several telehealth sessions were conducted in a single Infinity Rehab SNF in Washington.
In June 2009, Infinity Rehab presented to the Board a recorded telehealth session among the physical therapist, physical therapist assistant, and resident. At this meeting, key issues such as public safety, literature support, and proper physical therapy clinical encounter via telehealth were discussed. In October 2009, draft telehealth language was proposed by the Board. After several reiterations of draft language, a public hearing was conducted in October 2010. The final telehealth physical therapy language was approved in February 2011 (Tab. 1; WAC 246-915-187).17 Upon amendment of the practice act, telehealth sessions were expanded to 2 additional SNFs, with the same physical therapist serving as supervisor.
Telehealth Program Evaluation
Data on clinical outcomes and patient satisfaction were collected from consecutive residents admitted to the SNF for physical therapy rehabilitation between September 2014 and March 2015. Patients were alternately assigned to either a telehealth group or an in-person group. A secondary analysis of data from these patients was conducted, excluding those with incomplete data in the medical record. The analytic sample included 25 people in the telehealth group and 26 people in the nontelehealth group. Clinical outcome measures included the Short Physical Performance Battery (SPPB) and Six-Minute Walk Test (6MWT). The satisfaction survey is shown in the Appendix. The elements of the SPPB18 were designed to assess gait, balance, lower extremity strength, and endurance, and the 6MWT19 is a measure of submaximal aerobic capacity. A validated patient satisfaction survey20 was designed to assess level of satisfaction with telehealth experience and technology in health care services. In addition, feedback from physical therapists and physical therapist assistants was collected informally and evaluated.
Since 2011, more than 1,000 telehealth physical therapist re-evaluations have been conducted successfully. Cost savings from telehealth treatments were estimated for these 1,000 visits.
Telehealth System
In 2009, after several consultations with telehealth vendors, Infinity Rehab chose a real-time, synchronous telehealth platform system (GlobalMed LLC, Scottsdale, Arizona)21 to conduct the pilot program. This telehealth platform required multiple hardware configurations at both telehealth sites. Next, a digital camera capable of 340 degrees of wide-range pan and 120 degrees of tilt with a high-zoom ratio autofocus lens for excellent light sensitivity was selected. In addition, the customized preset function with fully remote control capability allowed for movement and gait analysis. At the start of the telehealth pilot program, a stationary setup location where a resident was able to travel to the telehealth equipment was used at the originating site. However, the drawback to this arrangement was the inability to bring the telehealth system to a resident's room, as the setup was stationary. As the program progressed, a laptop and a tablet computer were utilized for a telehealth session to allow for portability for all users to interact accordingly. Due to the bidirectional flow of video streaming, high-quality bandwidths with upload speed of 10 MB/s and download speed of 50 MB/s were required for proper Internet connectivity. At the distant site, fiber optics were used in order for a physical therapist to supervise the telehealth session. In addition, at the originating site where the residents were located, cable and digital subscriber lines were utilized as a backup in case of an Internet connectivity failure. Eventually, a business-grade wireless remote access point for multiple connections allowing for laptop and tablet use were deployed at the originating site. After the pilot program in 2011, a clinical setting with designated space and scheduled time for telehealth sessions was invaluable for a successful telehealth service, as periodic maintenance and updates to technology were needed.
The initial administrative telehealth cost was $1,500 for hardware and a monthly subscription fee of approximately $150. This fee included use of a secured platform for audio and video conferencing. The rationale for using a synchronous platform was based on a Medicare telehealth standard requiring a real-time audio and video session through a secured and private transmission.5
Considerations for Telehealth Implementation
The application of the telehealth service involved human factors (clinical, ethical, and technical aspects addressed by users). For example, Infinity Rehab provided additional education and training to the practitioners (physical therapist and physical therapist assistant) to promote acceptance of the telehealth pilot program. Residents of the SNF had to be oriented to the telehealth model as well. Regarding human factors, telehealth education was provided for a different type of “bedside manner” between practitioners and a resident. For example, it was easy for the practitioners (physical therapist and physical therapist assistant) to engage in a dialogue during the telehealth encounter but to exclude the resident. Therefore, a time-out session to inform a resident about what was being discussed between the practitioners through the telehealth platform alleviated potential miscommunication. Mindful consideration of eye contact between a resident and practitioners was critical. Moreover, it was important that the health care team discuss the telehealth service delivery model in general. By presenting a telehealth educational session about the evidence supporting the efficacy of telehealth services,22 it garnered support from practitioners in order to conduct a pilot telehealth program.
All residents admitted to the SNF signed a consenting document to all care during their SNF stay, including physical therapy. In addition, the physical therapist received consent from the resident to proceed with the established physical therapy plan of care. A physical therapist documented this verbal consent in the EMR. Next, residents were given a description of how the telehealth encounter would occur, how it compared with in-person care, privacy and data security concerns, and how those concerns would be addressed. The residents could choose to forgo the telehealth visit and be provided with an in-person visit. Finally, the physical therapist could deem the telehealth service inappropriate at any time before or during the telehealth session if the resident's medical condition called for an in-person visit.
Older adults with physical and sensory impairments required unique considerations for telehealth sessions.23 For example, audio communication was improved with the use of headphones for users with hearing difficulty. In addition, several residents with low vision had difficulty seeing a physical therapist on the computer monitor from a distance. In these cases, a larger computer monitor with improved lighting was utilized. As mentioned, preserving a resident's privacy and data security in telehealth delivery was an ethical responsibility. Strict adherence to telehealth privacy and security guidelines5,6 was followed by all practitioners. For example, because the originating site was where the residents were located with a physical therapist assistant as the presenter, the physical therapist at the distant location had to identify a resident using additional demographic information, such as the resident's date of birth and medical history. In addition, the distant physical therapist identified himself to both resident and physical therapist assistant with an Infinity Rehab identification badge. Also, potential site distractions, including background noise and lighting at each location, needed to be controlled for a successful telehealth session. Therefore, having to address 2 separate physical locations added ethical and technical complexity to the delivery of the telehealth program.
In the pilot program and wider telehealth implementation, key clinical factors were addressed by Infinity Rehab. All initial evaluations were completed by an in-person physical therapist to set the plan of care for physical therapist services. Subsequent re-evaluations with re-examination were completed via telehealth by the distant physical therapist. The distant physical therapist reviewed patient data in the EMR prior to the telehealth session. It was at this point that the physical therapist at the distant site made an initial assessment as to the appropriateness of a telehealth re-evaluation. For example, a resident with a severe cognitive impairment was excluded because he or she was unable to consent to the telehealth session. Furthermore, specific clinical re-examinations were potentially difficult during a telehealth session alone (Tab. 2). These clinical barriers were overcome with a competent physical therapist assistant with more than 10 years of clinical experience assisting a resident as a telepresenter during the telehealth session. Overall, all telehealth re-evaluations were completed in a collaborative manner.
Telehealth Re-examination/Re-evaluation Strategiesa
Telehealth Outcomes
Clinical Outcomes
The residents supervised via telehealth scored at least as well as residents seen in person for both the SPPB and 6MWT. The analysis of variance of mean change scores by group were not significantly different for the SPPB (P=.249) or the 6MWT (P=.874) at the initial evaluation and time of discharge.
User Satisfaction
Positive feedback with telehealth implementation was reported. In the sample of 25 residents supervised via telehealth, 81.2% rated overall satisfaction with telehealth at least 5 on a 7-point Likert scale (1=“very unsatisfied,” 7=“very satisfied”). Equally important, the practitioners (physical therapist and physical therapist assistant) were very satisfied with the telehealth delivery model of care. Feedback from practitioners indicated the communication between practitioners had improved. Real-time audio and video conferencing provided an opportunity for the physical therapist assistant to seek feedback from the physical therapist on case management of residents. For example, the physical therapist and physical therapist assistant discussed occasional desire to have an in-person visit when physical contact was deemed advantageous for the resident. Interestingly, the telehealth sessions provided a perception of a higher level of care from these practitioners. This assumption may have affected job satisfaction, as no turnover had occurred in the SNFs. Most importantly, the supervising physical therapist observed improved documentation after the telehealth sessions from practitioners.
Cost Savings
Between 2011 and 2015, we estimate that the direct cost savings from use of itinerant physical therapists and travel-related expenses was approximately $5,000. Through telehealth, Infinity Rehab was able to replace the itinerant physical therapist hours, which made up about 20% of the 1,000 re-evaluation visits since 2011. Each visit was about 1 hour in duration. Therefore, Infinity Rehab replaced 200 itinerant physical therapist visits. An itinerant physical therapist costs $20 per hour more than an employed physical therapist at Infinity Rehab. Therefore, the total $5,000 savings was calculated from the 200 hours at $20 per visit, or $4,000 combined with $1,000 reduction of travel time and mileage savings, by utilizing telehealth sessions. This total savings amounts to $25 to $30 savings per visit by using telehealth to avoid an itinerant physical therapist.
Discussion
This case report described the process of telehealth implementation in SNFs served by Infinity Rehab. Our experience began with a small pilot program, which led to a change in Washington State laws allowing telehealth supervision of physical therapist assistants. We identified several benefits of telehealth implementation. Financially, the cost savings to Infinity Rehab were achieved through reduced labor costs by avoiding use of itinerant physical therapists and avoiding travel-related expenses. Clinically, functional outcomes in SPPB and 6MWT achieved via telehealth were comparable to those achieved with in-person care. In addition, user satisfaction with telehealth implementation was positive.
Telehealth implementation programs have been described in other health care professions, including physiatry, psychotherapy, ergonomics, and wound management.24–28 Several telehealth resources and guidelines are now available in health care.6,7,23 Within the FSBPT recommendations,7 the administrative, clinical, ethical, and technical guidelines provide regulatory recommendations for telehealth practice. The telehealth program described in this case report illustrates several of FSBPT's regulatory recommendations, including informed consent, privacy, and data security. Furthermore, one of APTA's 2015–2016 public policy priorities includes ensuring patient access to physical therapist services by achieving coverage of and payment for physical therapist services under Medicare.29 In our telehealth program, access to timely periodic re-evaluations was achieved via telehealth implementation at SNFs in Washington. Recently, a study by the Medicare Payment Advisory Commission (MedPAC) and the Urban Institute concluded that the Centers for Medicare & Medicaid Services should adopt an alternative reimbursement design in SNFs because past changes have not improved payment accuracy.30 Thus, fundamental reforms are necessary with a concerted effort for physical therapist practice in SNFs.
Our experience is consistent with recent evidence of patient satisfaction with telehealth services in physical therapy.31,32 For example, a random sample of 65 participants in a telehealth outpatient physical therapy rehabilitation following a total knee replacement demonstrated noninferior Western Ontario and McMaster Universities Osteoarthritis Index outcomes and high patient satisfaction in a 6-week trial.31 Finally, Schwamm discussed 7 critical strategies for successful implementation of telehealth to transform health care: (1) understanding user expectations, (2) untethering telehealth from traditional revenue expectations, (3) deconstructing the traditional health care encounter, (4) being open to discovery, (5) being mindful of the importance of space, (6) redesigning care to improve value, and (7) being bold and visionary.33 Overall, this case report's findings highlight several of these key strategies in order to advance innovative practice in physical therapy.
The experience with telehealth implementation in the SNFs described in this case report may not be generalizable to other SNFS or to sites not involved in this project during this time period. Provider and resident bias could have influenced human factors and clinical outcomes with telehealth implementation. Furthermore, it is possible that the beneficial effects of telehealth may fade with further practice. Telehealth implementation was limited to a selected resident population compared with broader applications in the literature.24,31,32 Therefore, future research is needed to examine telehealth opportunities in contemporary physical therapist practice in various settings with diverse patient populations. One strategy is to conduct multisite telehealth implementation programs to address the triple aim of health care reform. Medicaid and private insurance programs could serve as a starting point, as demonstrated by the MaineCare demonstration program by speech therapists.14 In addition, health care organizations with existing telehealth programs can deploy interprofessional programs, including physical therapy and care coordination, in order to improve older adult's quality of life via telehealth. For example, the Veterans Administration and federal health care plans already use telehealth programs for chronic disease management where physical therapists can add value-based outcomes with remote patient monitoring.13 Hence, asynchronous store-and-forward digital telehealth models of care warrant further research. Lastly, telehealth, as a delivery model to reduce hospital readmissions with right technology at the right time for the right patient, deserves attention.
This case report demonstrated that telehealth implementation in an SNF for the purpose of physical therapist re-evaluation was a feasible alternative to in-person encounters. We found equivalent clinical outcomes and satisfaction in patients receiving telehealth compared with nontelehealth physical therapist re-evaluations. Additionally, telehealth implementation in SNFs resulted in real cost savings from reduced travel by the physical therapist to the SNF to complete the re-evaluation.
Appendix.
Patient Satisfaction Survey
Footnotes
Both authors provided concept/idea/project design and writing. Mr Billings provided facilities/equipment. Dr Lee provided consultation (including review of manuscript before submission).
The authors acknowledge the contributions of Joan Brassfield, PT, Tim Esau, PT, Stacy Portier, PTA, and Julie Buker, PTA, for their participation in the telehealth innovation initiative at Infinity Rehab, as well as the Washington Physical Therapy Board. In addition, the authors acknowledge the leadership from Dr Steven Wolf and Dr Colleen Kigin from the Frontiers in Rehabilitation Science and Technology (FiRST). Lastly, the authors are grateful to the residents at the skilled nursing facilities for participating in the telehealth programs.
- Received February 13, 2015.
- Accepted December 4, 2015.
- © 2016 American Physical Therapy Association
References
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