PHOTO CAPTION: When the therapist is remote, the client must have a caregiver available to assist with such things as transfers and guarding/supporting the client at the request of the therapist.
By Susan Johnson Taylor, OTR/L,
What just happened?? Late winter/ early spring brought situations that necessitated measures that no one could have anticipated. The swiftness with which clinics had to be vacated or severely limited was head-spinning. Closures had to be cascaded across the country like nothing we had ever seen. Suddenly, access to clients was cut off.
It is not as if complex rehabilitation technology (CRT) clients can “go without” the technology they count on to be functional and safe. A client with a broken wheelchair, or a client who has a change in their condition, needs to have appropriate technology in many cases, just to be able to get out of bed.
Thanks to an emergency ruling by CMS, telehealth became available in the tool bag to maintain, as much as possible, connection to CRT clients. This applied to therapists and CRT suppliers (the clinical team) alike. Physicians have successfully been able to provide telehealth appointments for a while through a variety of compliant platforms.
Suppliers, therapists, and CRT companies began using platforms such as Microsoft Teams. ATP/suppliers and therapists juggled multiple tablets, phones, views of clients and their homes, to continue as much as possible, bringing service delivery to their clients. Both parties need to have as clear a view as possible of the client to maximize effectiveness of the evaluation. Problem-solving was the phrase of the day.
Time has gone on since mid- to late March, which seems like a period that instead of 8 months ago seems like 8 years ago. Since then, thousands of successful telehealth visits for CRT have taken place, providing clients the services they need. However, therapists do need to be aware of state licensing regulations as well as funder regulations before undertaking a telehealth evaluation.
This time is reminiscent of the early days of CRT as a field, when all involved were trying to “figure it out” and mold it into a profession and distinct practice area. The Clinician Task Force, a nationwide group of clinicians headed up by Executive Director Cathy Carver, PT, ATP/SMS, has had a task force to gather objective information together to guide the application of telehealth, as CMS considers whether to make the emergency allowances permanent. The end result will be a tool that can help to guide the decisions about whether or not to have a telehealth visit as well as to guide structure and behavior during a telehealth visit. Erin Michael, PT, ATP, board member, added that we are all still learning this system, and all just want, in the end, a safe and effective telehealth experience for all. They are heavily basing the framework of this on the RESNA Service Provision Guide.
There are different types of CRT telehealth evals, and different circumstances. One thing remains constant: either the ATP/supplier or the therapist needs to be with the client, and not every client is appropriate for a telehealth evaluation. The ATP/supplier and the therapist need to be clear on ground rules and how the appointment will proceed. Telehealth appointment types are quite varied.
Who is there?
• Therapist remote, ATP/supplier with the client
• ATP/supplier remote, therapist with the client
Different Times in the Process
• Pre-evaluation questions- subjective information/outcome tool completion
Many therapists have used this as an opportunity to get to know the client and complete the subjective interview portion of the evaluation. Several used to send out a questionnaire but realized they could get ears and eyes on the client in a pre-appointment that was reimbursable. They then share the information with the ATP/supplier so they can both be better prepared for the rest of the evaluation, perhaps even bringing select pieces of trial equipment. For many clinically based therapists, or therapists who are the remote party in the evaluation, this allows eyes on the home environment, and the client’s ability to function in that environment, invaluable feedback.
This is also the time that therapists who engage in outcome measures such as the ATOM (Assistive Technology Outcome Measure) or the FMA (Functional Mobility Assessment) can complete them with the client.
• Evaluation: therapist remote (these seem to be a bulk of the evaluation types at this time)
Early in the process, a Tucson PT, Diane Carrillo, PT, ATP/SMS, set out figure out what to do. She has a seating and mobility private practice, and was very hesitant to buy in to doing telehealth. Realizing that, as she said, “my clients and I needed to pivot or perish,” she began a detailed look at evidence-based, observation-based therapy measures that she could use in her own telehealth evaluations. She takes the 24-hour posture management approach of viewing clients in lying, sitting and, when possible, standing on which to base these observations. The resources are shared at the end of this article.
The therapist and ATP/supplier roles still need to be maintained. The therapist is the licensed professional and is therefore responsible for that evaluation. When the therapist is remote, the client must have a caregiver available to assist with such things as transfers and guarding/supporting the client at the request of the therapist.
One therapist shared a story about she and the ATP/supplier seeing an obstacle in the home the client had not told them about as the supplier made their way through the home, that made it impossible to use the wheelchair they were thinking of. This avoided a great deal of wasted time when chosen equipment was trialed.
• Evaluation: ATP/supplier remote
It is the responsibility of the supplier to clearly guide the therapist in measuring. This complicated and very important activity will need clear directions. Numotion has developed a tool to assist therapists under the guidance of their ATP/supplier, in measuring the client.
• Equipment trials
This is obviously the domain of the ATP/supplier. Telehealth allows the therapist to be an active part of this process, so the clinical team can problem-solve with each other and the client for the best outcome.
• Equipment fitting
Therapists who would like to be part of the fitting process, but cannot at this time, can be virtually present when the equipment is fitted to the client to see if the goals from the evaluation have been met.
• Equipment training
Some equipment, even when delivered in clinic, requires longer-term training and fine-tuning. An example would be a client who is new to powered mobility. Telehealth allows the clinical team to extend their reach to the client to provide more training and check-ins. Many clients live far away from the clinical team, so they cannot come back for many trips.
There are all kinds of possibilities that we likely would not have been pushed into considering had it not been for COVID-19. One CRT supplier, for example, has developed the ability, with the client’s permission, to bring in peer support via telehealth, invaluable for those who are not familiar with certain diagnoses/ impairments or those newer to the field who require mentorship. It doesn’t matter where the ATP/suppliers are, they can still “meet.”
This therapist, who was clinic-based for many years, has sat in on evaluations/problem-solving. One of them was with Diane Carrillo, so that her method of evaluation could be observed. This particular client had the CRT ATP/supplier and her caregiver at the home, with the therapist remote. The client has a diagnosis of limb-girdle muscular dystrophy, the effects of which she has been living with for 30 years. The observations of her in her own environment were invaluable, beginning with transferring into bed for the supine evaluation and ending with movements within her current wheelchair.
She is highly functional, and her function depends on her sitting in certain postures without seating that interfered with the movement of her trunk, which she needs to control her UE’s. She sits on a cushion, which had shims to support her pelvis from becoming too oblique, and therefore keeps her trunk midline, while offloading her ischial tuberosities. She needed a new power chair, with anterior tilt and seat elevation, and a new cushion. All of these were able to be ascertained, keeping in mind that her positioning cannot be changed or it would greatly impact her function. A client who requires a hands-on mat evaluation would not be appropriate for a full telehealth process.
Thank goodness this happened at a time when there were resources for evaluating and fitting remotely. Now is the time to embrace the technology we have and use it for the good of our clients.
These are Carillo’s resources, which she has kindly shared.
• Trunk Control Test – SRAL https://www.sralab.org/rehabilitation-measures
•Active Straight Leg Raise – Medbridge https://www.medbridgeeducation.com/
• Bridging – Medbridge
• Knee Extension with DF – NIH, Research Gate (combination of MMT and extensor lag test) https://www.researchgate.net/
• Sit to Stand – (5 Times Sit to Stand – ) APTA, SRAL https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures
• Chair Press Up – Researchgate has an article, but it’s related to assessing elbow pain. Most of the tests were push-up tests, which none of our population would be able to do. For the grading I modified a combination of push-up test and what you would see clinically. I believe the biggest goal is to demonstrate their ability or inability to perform independent pressure reliefs or positional changes.
• 30 Sec Sit to Stand – ATPA, SRAL
• Timed Up and Go – ATPA, SRAL
• Modified Trendelenburg Test – Special Test in Musculoskeletal Examination by Paul Hattam and Alison Simeatham, https://www.medbridgeeducation.com/
• Calf-raise Senior Test –Single Leg Stance – SRAL, PubMed
• Calf-raise senior: a new test for assessment of plantar flexor muscle strength in older adults: protocol, validity, and reliability
Helô-Isa André, et al. Clin Interv Aging. 2016; 1:1661-1674. Pub online 2016 Nov 15. RM
Susan Johnson Taylor, OTR/L, is an occupational therapist who has been practicing in the field of seating and wheeled mobility for 39 years primarily in the Chicago area at the Rehabilitation Institute of Chicago Wheelchair and Seating Center (now the Shirley Ryan AbilityLab). Taylor has published and presented nationally and internationally. She is both a member and fellow with RESNA, and currently a member of the RESNA/ANSI Wheelchair Standards Committee and the Clinician Task Force. Susan joined Numotion in 2015 and is the Director of Training and Education. For more information, contact [email protected].
This article was originally published in the November/December Rehab Management print edition and online with the title, “What Just Happened.”