Telehealth Part 1: Is Telehealth OT a viable option for a neurological population?
The outbreak of Coronavirus has disrupted all levels of society across the globe. Social distancing restrictions have resulted in vulnerable people being left without the support they need - inpatient rehabilitation centres have shut, community rehabilitation teams have withdrawn input, and home care packages have been suspended. In times such as these, we need to respond creatively and find innovative ways to support those who need rehabilitation. In light of this, I’ve been considering the potential of using telehealth to reach those who can no longer access traditional occupational therapy.
In part 1 of this blog post I share some of my initial thoughts and in part 2 I describe what practical steps I'm taking to adapt my practice in order to utilise telehealth. I’ve provided links to the resources I found most informative and listed these at the bottom of the post for you to check out for yourself. I hope you find this blog helpful to your own practice and please get in touch with any comments and suggestions.
What is telehealth?
‘Telehealth’ refers to any digitally-based health intervention. We already use some telehealth interventions in our standard practice:
Apps such as calendar, reminders, timers, activity trackers etc
Telephone clinics (pre-admission or follow up)
Home exercise programme software such as PhysioTools
Education leaflets and handouts
Web-based training programmes such as UCL’s Eye-Search for visual search training
Obtaining photos of a home environment to aid clinical decision making
The telehealth I discuss in this blog post focuses mostly on video conferencing and video calls, as well as recorded video content.
Is something better than nothing?
Naturally, our preference as health professionals is to have face-to-face contact with our clients, and certain interventions require our physical presence in a session. However, when face-to-face contact is not possible, telehealth can offer much-needed support to our clients. Our Australian colleagues are streets ahead of us in the UK when it comes to telehealth - their remote and rural communities are often unable to access traditional healthcare settings and as a result they have been using telehealth for several years already. I found their webinars, podcasts, facebook dicussion groups and guidelines very helpful in my research and have shared the links below.
Is something better than nothing?
I certainly had my reservations about using telehealth with a neurological population initially, particularly regarding risk management and the importance of modifying the task and environment within a session to suit the client’s ability. I was reassured to see that OTs in the US and Australia are routinely using telehealth and have published Telehealth Guidelines: Australia: https://otaus.com.au/publicassets/553c6eae-ad6c-ea11-9404-005056be13b5/OTA%20Telehealth%20Guidelines%202020.pdf, USA: https://www.aota.org/Practice/Manage/telehealth.aspx. The Australian Stroke Foundation (https://informme.org.au/telehealth) and the Australian Physiotherapy Association (https://australian.physio/sites/default/files/APA_Telehealth-Guidelines-COVID19_FA.pdf) also have lots of useful resources that are applicable to OT.
I listened to a podcast by an old Physiotherapy colleague of mine, Matt Wingfield (A Neuro Physio Podcast (http://aneurophysio.com/covid19apa/) in which he interviewed Natalie Fini (PhD lecturer and physiotherapist in neurological rehabilitation). She remarked that in times such as these “something is better than nothing” and I considered all of the patients, families, and caregivers who could benefit from OT input via telephone or video call. Sure, it may not trump face-to-face input, but I am of the opinion that it is certainly better than nothing.
Particularly with a neurological population, there are considerations we must make with using telehealth: communication impairments, ability to follow instructions, visual impairment, physical ability to use a computer or smartphone, cognitive impairments, impulsivity and behaviour changes (increased frustration etc), risk of falls from reduced balance. The therapist should, as always, risk assess the situation and only proceed if they feel it is safe and appropriate to do so. There are many patients who won’t be able to participate via telehealth and it is our responsibility to weigh up the risks and make safe decisions.
Considerations for successful use of Telehealth
At this point in time, I think the success of telehealth for my client group will depend largely on the involvement of a committed next of kin or caregiver. Having a skilled second person present who can act as a proxy and offer support within the session will be of huge benefit and will mitigate some of the safety concerns I have. In my view, telehealth lends itself to some areas of neuro OT better than others. For example, fatigue management, implementation of cognitive strategies, vocational rehabilitation and other education-based interventions could be quite effectively delivered via video conferencing in my opinion. I believe there is potential to support more physical interventions as well, such as upper limb rehabilitation. However, this possibly relies more heavily on a skilled caregiver to be present, depending on the level of disability.
UK guidelines on Telehealth
Our governing bodies in the UK have produced very few guidelines so far with regards to telehealth. I found the following guidance to be most relevant at the time of writing this blog post:
NHSX advice on information governance, which covers data sharing, mobile messaging, video conferencing, homeworking and using your own personal device: https://www.nhsx.nhs.uk/covid-19-response/data-and-information-governance/information-governance/covid-19-information-governance-advice-health-and-care-professionals/
Information Commissioners Office (ICO): https://ico.org.uk/about-the-ico/news-and-events/news-and-blogs/2020/03/data-protection-and-coronavirus/ who basically say that they are being reasonable when reviewing data usage and sharing practices due to the requirement to rely on remote working during these times.
HCPC 10 principles for remote consultations - emphasise patient safety and completing adequate clinical assessments. https://www.hcpc-uk.org/standards/standards-relevant-to-education-and-training/standards-for-prescribing/high-level-principles/
RCOT: https://www.rcot.co.uk/coronavirus-covid-19-0 - see excerpt below
RCOT Specialist Section for Independent Practice: No guidelines published to date.
RCOT Specialist Section for Neurological Practice: No guidelines published to date.
The take-home message as far as I could see was that health professionals should exercise their clinical judgement when undertaking telehealth consultations, and adhere to their usual standards of practice. The RCOT has advised that initial contact is made via telephone to determine a person’s immediate needs and to consider if the consultation can be completed virtually. They have urged those not completing front line service delivery to start improving their digital service delivery. They suggest to:
“Start by thinking about what is your universal, targeted and specialist offer within the area you work. How could these services be offered online? Consider how much of your offer is providing information and look to add this information to your organisation’s webpage. Information can be written but many people prefer video, so consider recording information or finding safe/appropriate videos already available online from credible sources.
For targeted or specialist interventions, start by finding out what people who access your services need to manage their health and care conditions. This may have changed in light of current circumstances e.g. an increased need for peer support or quick access to professional advice that supports problem solving.”
(RCOT Website 23 March 2020)
What about Telehealth after Coronavirus?
Once I started thinking about the potential of telehealth in occupational therapy I have to admit, I got quite excited! Telehealth is already being utilised in some NHS hospitals in the form of pre-admission telephone assessments, or to complete follow-ups for patients with chronic conditions. If the therapist identifies a need for a face-to-face session, one can be arranged. These telephone clinics have been a fantastic way to safeguard resources, increase efficiency and reduce waiting lists. I believe there is potential to utilise telehealth even more in the NHS, and perhaps COVID-19 will be the catalyst to drive progress in this area.
Right now, Coronavirus is the reason people cannot access traditional occupational therapy. But there are many people who do not access the input they need even when we are not dealing with a global pandemic - people in remote areas, areas where NHS community teams have limited resources, people who are no longer ‘bad enough’ to be seen by NHS therapists but continue to have difficulties impacting on daily life. Perhaps we could offer generalised, high quality advice and make it freely available online for those who cannot access ongoing OT input. Of course, occupational therapy is not a ‘one size fits all’ profession but I do think there are some areas we could offer general advice on - ‘managing a hemiparetic upper limb after stroke’, for example, ‘how to tell if your splint no longer fits correctly’ or ‘general principles for fatigue management’.
When we want to know the answer to something these days, we google it. Chances are, our clients do the same. I think there is huge potential for occupational therapists to be the ones to answer their questions via short, simple online videos which are free and accessible to anyone with internet. As well as reaching a greater number of people with useful guidance to manage their condition, we would promote our role as occupational therapists and promote self-efficacy and self-management amongst our client groups.
In Part 2 of this blog, I share how I have adapted my initial assessment to make it suitable for telehealth.
Webinar by Karen Finnin - physiotherapist in Australia who runs an entirely online MSK practice: http://storage.rdbk.com.au.s3-ap-southeast-2.amazonaws.com/webinar/20200318_APA_1900.mp4
(Full list of webinars here: https://australian.physio/home/events/telehealth-apa-qa-webinars)
Karen Finnin’s website also has a blog with lots of articles about telehealth: https://www.karenfinnin.com
Facebook pages and discussion groups:
Australian Physiotherapy Association
Online Healthcare UK
The Virtual Therapist