Telerehabilitation in neurorehabilitation: has it passed the COVID test?

KEYWORDS:

• DayRehab®
• occupational therapy
• outpatient
• physical therapy
• rehabilitation
• speech therapy
• telerehabilitation

1. Introduction

1.1. The pandemic

On 11 March 2020, the WHO declared a global pandemic due to COVID-19, and the risk of severe disease and infection spread in all hospital- and clinic-based patient populations necessitated a rapid, coordinated response. Physical medicine and rehabilitation (PM&R), in particular, is one clinical service that requires care to be provided via an ongoing, repetitive patient–clinician interaction that lasts for a long period of time. Thus, the PM&R clinical care model has a high risk for disease transmission and for generating disease outbreaks among staff and patients. As expected, rehabilitation services across the world were severely impacted [1]. On 16 March 2020, as COVID-19 infections were increasing in the US, our hospital instigated a series of measures designed to limit risks to patients and staff, while we began to transition to a fully remote telerehabilitation therapy model (i.e. delivery of rehabilitation therapy services via a synchronous audio/video platform) for all outpatient and DayRehab® patients.

Both the COVID-19 emergency and its negative impact across the globe provided an opportunity and expedited the need to maximize the development and immediate implementation of telerehabilitation strategies in various clinical disciplines including PM&R [2,3]. Telemedicine, which was previously used sparingly in rehabilitation, quickly became widely adopted by rehabilitation services across the world, as most facilities responded to COVID-19 risk and patients with COVID-19. A clinicaltrials.gov search shows over 200 clinical trials on telehealth and rehabilitation. Current evidence generally suggests that the overall impact of telemedicine on rehabilitation services during the pandemic has been positive [4–6].

In this editorial, instead of summarizing expert opinions in the literature on use of telemedicine for rehabilitation services during the pandemic, we will focus on how the Shirley Ryan AbilityLab, where all the authors work, made a rapid shift across outpatient and DayRehab® programs from in-person therapy to a telerehabilitation model, using a HIPAA-compliant platform, in response to the COVID-19 pandemic in spring 2020. We discuss the process, the patients, and the benefits of our program, which we believe successfully passed the COVID test. This scenario can be considered a proof-of-concept case study on how institutional therapy services can pivot rapidly and successfully to telerehabilitation.

1.2. The hospital

The Shirley Ryan AbilityLab (SRAlab), a large, 240-bed rehabilitation hospital in Chicago, IL, is one of the leading rehabilitation institutions in the United States. In addition to our inpatient facility, we provide five outpatient programs: adult neurological, adult orthopedics, pediatrics, two community-based orthopedic/neurological clinics; a pain management center that focuses on providing multidisciplinary therapy and medicine services to treat chronic pain; and five day-rehabilitation (DayRehab®) programs that treat a variety of neurological conditions throughout the Greater Chicagoland area. Typical patient volumes are approximately 11,067 outpatient visits and 6513 DayRehab® in-person therapy sessions per month (a DayRehab® session is typically three hours of therapy).

1.3. The patients

Patients who were at high risk of severe outcomes from COVID-19, approximately 60% of our patient population, included those who were older than 60 (this was subsequently raised to 65 in accordance with CDC guidance); were immunocompromised (e.g. taking biologics for rheumatoid conditions, using steroids at higher doses than 20 mg per day); had underlying respiratory compromise (neurological, e.g. due to tetraplegia, amyotrophic lateral sclerosis, or multiple sclerosis; or medical, e.g. due to chronic obstructive pulmonary disease, a ventilator, or a tracheotomy); or had underlying cardiac disease (e.g. heart failure, heart valve disease, or used a ventricular assist device).

1.4. The transition

Only patients that our infectious disease physicians considered to be at low risk from COVID-19 infection were seen in person after 16 March. On 19 March, Governor Pritzker signed an executive order allowing therapy to be provided using telerehabilitation and requiring most insurance plans to cover these services. By 27 March, we were able to implement telerehabilitation visits, first in our adult outpatient orthopedic clinic and then across all other outpatient and DayRehab® clinics. Our last in-person appointments were held on 31 March, and most patients were transitioned to telerehabilitation appointments by 1 April, just 15 days after COVID-19-related restrictions and precautions were implemented.

Telerehabilitation was initiated by a team of Telerehabilitation Champions (therapists and operations leaders) who tested our virtual therapy platform, conducted the first treatment and evaluation sessions, created training materials for therapists and patients, and completed competency and fidelity checks to ensure that therapists had the necessary training and skills to provide effective, high-quality telerehabilitation services. Once we confirmed that our processes were sound, we were able to rapidly roll-out telerehabilitation across all of our outpatient and DayRehab® clinics.

1.5. TeleRehabilitation

Telerehabilitation visits at SRAlab are provided using Cisco Webex, a HIPAA-compliant platform, in a private, virtual room. Appointments are made, and the visit is documented as for in-person appointments. Patients are carefully screened before participating in a telerehabilitation therapy session to ensure that they are at a low risk for falls and other adverse events and that they can participate in a safe, clear, well-lit environment. Therapists use clinical judgment when providing care to patients with a fall risk, for example, requiring the presence of a caregiver/family member during the session. For safety reasons, patients are asked to provide their exact address and an emergency phone number before each session, so that the provider can call for assistance if necessary.

The patient needs a web-enabled device (computer, table, or smartphone) with a camera; Internet service or a data plan; and the ability to access WebEx video conferencing. Clear instructions for downloading the Webex app are provided through YouTube videos on the SRAlab channel, available on our website (https://www.sralab.org/services/telehealth). After scheduling the appointment, the patient receives an invitation to participate in the session via a clickable link in an e-mail. Before treating patients from out of state, we examine the relevant waivers that were put in place during the pandemic to ensure compliance with licensure guidelines.

2. Results

After transitioning to using telerehabilitation, SRAlab used this system to provide over 8000 45-minute therapy sessions (approximately 785 patients) for outpatients and over 6000 1-hour therapy sessions (approximately 275 patients) for DayRehab® patients between 31 March and 31 July 2020. For April and May 2020, most appointments were via telerehabilitation. In June, we began allowing in-person visits once again for low-risk patients but continued telerehabilitation for high-risk patients. In July, we slowly started increasing in-person visits within the hospital.

Throughout the time our patients were receiving telerehabilitation, we continued to deliver high-quality care aligned with the patient’s goals and to assess outcome measures, as appropriate, to measure progress. If clinicians were unable to administer typical outcome measures, they adopted other means of determining patient progress. It was our experience that most patients continued to meet all patient and therapist goals. If goals were not achieved, it was due to changes in medical status or poor adherence to therapy, as seen in in-person therapy, and not necessarily due to the use of telerehabilitation.

As of March 2021, we were back to approximately 9500 patient visits (approximately 780 patients) per month in our outpatient clinics and 5500 visits (approximately 260 patients) per month for DayRehab®, both approximately 90% of pre-COVID patient volumes, almost exclusively as in-person visits. However, we still offer telerehabilitation appointments for our outpatient programs and have found that a hybrid model of in-person and telerehabilitation appointments can be very successful for patients.

A pilot Telehealth Patient Satisfaction survey of approximately 150 patients selected at random from across our DayRehab® and outpatient clinics (a similar sample size to other rehabilitation-related satisfaction surveys conducted during COVID-19 [4–6]) indicated that patients found our telerehabilitation system very easy to set up and participate in, that the video and sound quality were high, and that they were very satisfied with their experience:

• 92% reported the care they received via telerehabilitation was good/very good

• 89% reported they were very/somewhat satisfied with the provider’s ability to give necessary recommendations via telerehabilitation

• 88% reported they were very/somewhat satisfied with their own ability to explain and demonstrate symptoms

• 96% reported their experience with telerehabilitation was better than, or as expected

• 70% reported they were likely to continue using telerehabilitation after the COVID-19 pandemic has resolved.

  • The most common patient-reported benefits of telerehabilitation and areas in need of improvement are shown in Table 1. (Note, patients could select more than one option in each category.)

Table 1. Most commonly reported benefits and areas needing improvement reported by patients and percentage of respondents who chose this response (patients could choose more than one response)

Benefits	% Responses	Need for improvement	% Responses
No traveling required	79	More available space in patient’s location	43
Ability to choose location for participation in therapy	75	Better video connection	28
Decreased time away from home	44	Better audio connection	23
Improved attendance at therapy sessions and improved exercise compliance	18	Helpful to have a caregiver present during the session	8

3. Expert opinion

SRAlab, like many other institutions across the world, had to rapidly, efficiently, and effectively respond to the sudden need to stop in-person visits due to the rapidly evolving public health emergency of the COVID-19 pandemic. Therapists and operations leaders, recognizing the impending gap in care, worked together to pursue options for providing safe and effective virtual therapy. Operations leaders collaborated with departments across SRAlab (centralized scheduling, information services, legal, compliance, billing, financial clearance, and the electronic medical records documentation team) to rapidly implement telerehabilitation, so that clinicians could continue to provide quality care for neurological and orthopedic patients in our outpatient, DayRehab®, and pain management center settings, in a way that was safe for both patients and therapists. Telerehabilitation was an invaluable tool in providing continuity of care during very risky and uncertain times. Although it has been an emerging technological innovation in the field of rehabilitation for some years [7], the absolute need for telerehabilitation presented itself during this public health crisis [8]. This was the first time we implemented institution-wide telerehabilitation, and we did so at a rapid pace, for a large number of patients and clinicians.

To assess and improve our telerehabilitation operation, we conducted a pilot patient satisfaction survey. Preliminary findings revealed that patients had a very positive experience, and we utilized this information to improve telerehabilitation operational processes and quality of care. This positive response also provided insights about the role telerehabilitation may play in the future of therapy beyond the COVID-19 pandemic [9]. Furthermore, telemedicine has been shown to provide significant clinical efficacy and to maintain the standard of rehabilitation care being provided prior to the pandemic [10,11].

Initially, telerehabilitation was the sole mechanism we had to provide quality care safely to our patients. As we learned more, and were able to safely re-open our clinics, we started using telerehabilitation in different capacities. For those patients who were able to return for in-person care but were hesitant, we were able to provide a hybrid model of care, including some in-person visits and some telerehabilitation visits. On days when patients were unable to attend their therapy sessions, for example, because of the need to quarantine due to COVID-19 exposures, we were able to continue their care without interruption. Telerehabilitation provided clinicians the tools they needed to continue to provide quality care to their patients despite the many factors at play during a public health emergency.

4. The next five years

Ultimately, clinicians and patients alike agree that the ideal use of telerehabilitation in rehabilitation is within a hybrid approach, consisting of some in-person and some virtual care visits [12,13]. This provides clinicians with hands-on time as needed but also allows the patient greater flexibility and convenience, thus enhancing patient compliance with their care. Telerehabilitation promotes flexibility and allows greater continuity of care for our patients in the event of inclement weather, civil unrest, or illness, which may make it difficult for the patient to physically travel to our clinic. Improved continuity of care helps us resolve patients' issues more quickly and decreases costs [14]. Telerehabilitation also allows us to provide services to those living in rural areas or too far away to typically seek our care. Lastly, telerehabilitation is a tool that can help decrease racial and economic disparities in health care, providing a means of access to medical services for those who disproportionately face barriers to receiving in-person care.

Our hope is that our government agencies and insurance providers will continue to support the use of telerehabilitation in physical, occupational, and speech therapy beyond the current public health emergency [15]. There are many advocacy efforts currently underway with this objective as the goal: for example, the Expanded TeleHealth Access Act of 2021 (H.R. 2168) is bipartisan legislation that would make permanent the current temporary policy that allows physical therapists and physical therapist assistants to deliver and bill for services provided via telerehabilitation under Medicare. Outside of our ongoing support of telerehabilitation, we foresee synchronizing virtual therapy with other medical technologies, such as use of wearable technologies that track patients’ progress and goal attainment, providing information to enhance clinician decision-making without the need for the patient to attend a clinic in person. Combining these technologies will further improve the continuum of care.

Article highlights

• In March 2020, outpatient therapy and DayRehab® at Shirley Ryan AbilityLab (SRAlab) responded to closure of in-person visits due to COVID-19 pandemic.

• Within two weeks, telerehabilitation for therapy was developed and implemented at SRAlab.

• Telerehabilitation training materials for therapists and educational materials for patients were consistently updated to reflect current practices. Internal staff development was tracked to create evidence-based guidelines for best practices.

• The evidence from our own survey supports the use of telerehabilitation for providing therapy.

• Telerehabilitation successfully allowed therapists to continue to care for patients during the uncertainty of the COVID-19 pandemic and it will also have a place in therapy beyond the pandemic. The SRAlab continues to offer telehealth services alongside in-person care, and many patients have opted to use it as an adjunct to their in-person care.

• The greatest hurdle we currently face is future reimbursement and regulatory support of telemedicine for physical, occupational, and speech therapy professionals. In order for us to continue to provide quality care despite the current and any future health care climate disruptors, we need the flexibility to provide care via multiple modes.

• To conclude: Yes, telerehabilitation at SRAlab passed the COVID-test.

Declaration of interests

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors would like to acknowledge the operations and ancillary department leaders, the Telemedicine Champions, and all others who contributed to the roll-out of telerehabilitation in our organization. A special thanks to our patients who worked with us during the biggest and most complex pandemic of our life time and to all of our health-care workers, who persevered, despite the adversities of the last 1.5 years, to provide the highest quality care, with the goal of optimizing patient outcomes.

Additional information

Funding

All authors are employees of Shirley Ryan AbilityLab, which funded the reported work.