March/April 2022

Occupational Therapy and Telehealth
By Jennifer Van Pelt, MA
Today’s Geriatric Medicine
Vol. 15 No. 2 P. 14

An Emerging Model of Care and Delivery for Older Adults

Telehealth applications have rapidly increased in the last two years, catalyzed by the need to reduce in-person interactions due to the COVID-19 pandemic—a recent research review found that video health visits increased threefold in 2020. The review’s authors also reported that video visits were just as effective as in-person office visits for managing patients with several chronic conditions, including chronic pain, diabetes, heart issues, and neurological disorders.1

Occupational therapy (OT) telehealth services also increased substantially since 2020. The public health emergency (PHE) declared in 2020 due to COVID-19 by the federal government was the first time OT providers were approved as telehealth providers for Medicare beneficiaries and could receive Medicare reimbursement. “Prior to the pandemic, OT telehealth services delivered to the older adult population were almost nonexistent because the OT therapists were not on the telehealth Medicare/Medicaid provider lists. In addition, not all states had telehealth policies that allowed for OT telehealth or payment for virtual services,” explains Tammy Richmond, MS, OTR/L, FAOTA, Founder and CEO of Go2Care (go2care.com).

“Once COVID forced providers to offer services remotely, OT telehealth became much more common,” says Sue Dahl-Popolizio, DBH, OTR/L, a clinical associate professor and program director of the integrated behavioral health program at Arizona State University, and chair of the legislative committee for the Arizona Occupational Therapy Association (ArizOTA).

A Long Time Coming
Even though the delivery of OT services via telehealth in a variety of settings has been of interest for more than a decade, its widespread adoption has been slow. The American Occupational Therapy Association (AOTA) defined telehealth in 2013 as “the application of evaluative, consultative, preventive, and therapeutic services delivered through telecommunication and information technologies” when the client is in a different location than the provider. A telehealth visit can be as simple as a phone conversation between an OT provider and a patient to review a care plan and discuss the patient’s health status.2 With the widespread use of smartphones and computers, live video visits have become the most common form of delivery for OT telehealth services across a range of settings (eg, school-based, workplace). In the older adult population, OT telehealth is still emerging and evolving. As providers and patients realize its many benefits, barriers to access and adoption, such as limitations in reimbursement, provider training, and patient comfort/familiarity with technology, remain.

Currently, a variety of OT telehealth services for older adults are offered by individual providers and organizations dedicated to telehealth. Richmond says, “At Go2Care, we provide therapeutic virtual telehealth OT and PT services to older adults. Currently, OT services delivered through technology (video or telephone visits) with the older adult population include chronic disease management, caregiver training, therapeutic coaching through activities of daily living, home exercise programming, postsurgical rehabilitation, injury prevention, home environmental safety and fall prevention, and wheelchair evaluation and positioning.”

Richmond emphasizes that the benefits of delivering OT services through telehealth technology are tremendous. “It allows the older adult to stay at home and have access to OT during this pandemic, avoiding the risk for COVID exposure,” she says.

Other benefits of OT telehealth for older adults, Dahl-Popolizio adds, include the following:

• increased access to care from the relative safety of their home;
• the input of caregivers who may not be able to travel;
• the fact that transportation is not required; and
• the need for minimal preparation prior to the visit.

In a published review of OT telehealth experiences during the pandemic, Dahl-Popolizio and colleagues noted that cost, time, and distance are known limitations to accessing health care, and telehealth visits can result in savings related to these three barriers. OT telehealth visits were touted as a major benefit for older adults, whose access to in-person care is more often limited by travel requirements, inclement weather, lack of transportation, and lack of nearby providers.3

Richmond agrees that increased access to OT care during the pandemic is an important benefit. “Not all older adults had access to in-home OT services before the pandemic. In addition, virtual visits promote patient engagement within the home environment, which can result in better outcomes,” she says. Compared with in-person visits at a health care facility for older adults, a more natural and customized plan of care within the home environment where the patient lives and engages can be provided with telehealth services, Richmond explains. One example of a successful Go2Care telehealth case was in an older female patient who had a reverse total shoulder replacement, a complicated surgery in which a postoperative rehabilitation care plan is critical. “We saw the patient three times in person prior to the pandemic, and then went completely to online OT/PT services. She was able to make a full and successful recovery,” Richmond says.

Some Concerns Remain
Despite individual reports of successful OT telehealth delivery, published survey research shows mixed results from both OT patients and providers. A recently published survey of patient satisfaction with OT telehealth found high patient acceptance. The survey included some older adults up to age 64. Approximately 87% of surveyed patients reported satisfaction and value of telehealth visits, citing travel elimination, convenience, and ability to include others (eg, caregiver), in their visits.4 However, results of a November 2021 Associated Press-NORC Center for Public Affairs Research survey of 1000 adults aged 50 years and older, published in mHealth Intelligence, indicate that despite telehealth use for a variety of health reasons by 62% of respondents, many older adults expressed concerns with telehealth visits. Almost one-third were worried that telecare was not as effective as an in-person visit. When asked about whether they would continue to seek care via telehealth after the pandemic, only 27% of older adults said they were extremely or very likely to use telehealth in the future, whereas 38% said they were not too or not at all likely to use telehealth. When asked specifically about telehealth for OT or PT services, 46% indicated they would not be too comfortable or not all comfortable using telehealth.

Citing these survey results, Richmond says, “Even though seeing an older adult patient online is more convenient and in some cases more affordable, older patients still report concerns or difficulties in using technology and feeling confident in the quality of care delivered online vs in person.

Dahl-Popolizio adds, “Limitations in Internet access, devices that use the Internet, and the ability to navigate technology are a challenge in the use of telehealth with older adults.”

Technology use associated with OT telehealth is likely the major barrier for acceptance by older adults. Resistance due to a lack of familiarity and comfort with technology use in general, lack of Internet access or an Internet-enabled device due to cost or skill issues, and lack of an “e-helper,” an individual within the home to assist the client with technology, are all barriers to OT telehealth delivery, says Mary Schmitz, OTD, OT/L, an OT since 1986, ArizOTA legislative committee member, and founder of the ArizOTA Telehealth Special Interest Section in 2020.

Dahl-Popolizio adds that because the geriatric population often has limited technology experience, they may also fear using technology.

Surveys of OT practitioners have also reported mixed results related to acceptance and satisfactions. A 2021 study of OT telehealth provided for older veterans by the Veterans Health Administration, considered a pioneer in general telehealth services, revealed a lack of experience among providers. Of 305 surveyed occupational therapists, less than one-half had used telehealth with patients. Of those who did provide services via telehealth, those who had used such technology previously reported greater comfort in delivering OT telehealth services, including for activities of daily living, therapeutic exercise, veteran and caregiver education, instructions for using medical equipment and assistive devices, wheelchair positioning, and home safety.5

Dahl-Popolizio and fellow researchers also surveyed 230 occupational therapists and OT assistants providing telehealth in 32 states, finding that 77% supported telehealth as a substitute for in-person services and 78% supported it as a permanent option for OT service delivery. Respondents highlighted caregiver involvement, ability to assess the home environment, and ability to see more patients in a day as benefits for OT providers. However, several issues with OT telehealth were brought to light, including the following:3

• technical issues, such as audio/video problems or slow internet;
• lack of personal contact with patients, such as when helping to facilitate an exercise or posture;
• difficulties effectively managing certain conditions or exercises, such as for wound management or cognitive retraining; and
• lack of appropriate equipment at the patient’s home.

Overcoming Barriers
“Adapting to telehealth has been challenging for therapists. “For example, therapists often have to be creative regarding the use of resources or equipment as they have to use what the patients have on hand. Patients have to find things in their home that the therapist needs to complete the visit,” Dahl-Popolizio notes.

Another consideration for older adults is the critical source of social contact that in-person visits often provide, Schmitz says. “Weighing the risk of isolation with telehealth visits vs the risk of illness with in-person visits is something to consider when establishing plans of care for the older adult population,” Dahl-Popolizio says.

In addition to patient and provider issues with OT telehealth, future use will depend on continued reimbursement for the Medicare population at the federal level, as well as state legislation regarding telehealth use and therapist licensing. As founder and section chair of the ArizOTA Telehealth Special Interest Section, Schmitz provides support to OT practitioners who had to adapt to telehealth services due to the pandemic PHE. Currently, she is part of a collaborative planning committee of the Arizona Telemedicine Program and the Arizona Physical Therapy Association that will provide telehealth training to OT and PT practitioners.

In May 2021, Arizona jumped to the forefront of state telehealth delivery when legislation was passed that expanded patient access to telemedicine, ensured that providers receive equal compensation from insurance companies for telemedicine services, and allowed out-of-state health care professionals to provide telemedicine in the state. Unfortunately, national legislation that authorized telehealth use by OT providers and reimbursed it as a covered service for Medicare beneficiaries was set to expire as this edition of Today’s Geriatric Medicine went to press, pending new legislation granting a lengthy or permanent extension. As of this writing, no national decision had been made, though there were some indications that the PHE would be extended in light of the omicron virus variant.

Other states are evaluating telehealth services based on its overall popularity and acceptance for a variety of health issues, so OT providers will have to pay attention to evolving federal and state requirements for telehealth delivery, especially as related to licensing and reimbursement. “Since the implementation of telehealth during the COVID pandemic, individual states have or are in the process of legislating reimbursement and best practices, so issues related to how a therapist is able to use telehealth, reimbursement rates, and other rules vary among states,” Dahl-Popolizio says.

The AOTA has a telehealth resource center for OT providers and has published position papers on ethics and general telehealth practices (www.aota.org/Practice/Manage/telehealth.aspx).

Regardless of reimbursement decisions and legislation, poor provider adoption and lack of comfort with online OT services among the older adult population will continue, Richmond says. The challenges of provider training and adoption, patient acceptance, and consumer demand will remain after the PHE is lifted, she adds.

OT telehealth is still an emerging model of care and service. Establishing best practices, training programs, and older adult outreach and education strategies, while addressing technical issues and limitations associated with equipment needed for effective therapy to be delivered to the patient at home, are aspects of telehealth that must be addressed to ensure patients receive optimal care, Dahl-Popolizio says.

The future of OT telehealth services for the older adult population is likely to include a hybrid of in-person visits when needed, combined with telehealth sessions when possible.

— Jennifer Van Pelt, MA, is a freelance writer and health care researcher located in the Lancaster, Pennsylvania, area.

References
1. Albritton J, Ortiz A, Wines R, et al. Video teleconferencing for disease prevention, diagnosis, and treatment: a rapid review [published online December 7, 2021]. Ann Intern Med. doi: 10.7326/M21-3511.

2. Cason J. Telehealth: a rapidly developing service delivery model for occupational therapy. Int J Telerehabil. 2014;6(1):29-35.

3. Dahl-Popolizio S, Carpenter H, Coronado M, Popolizio NJ, Swanson C. Telehealth for the provision of occupational therapy: reflections on experiences during the COVID-19 pandemic. Int J Telerehabil. 2020;12(2):77-92.

4. Tenforde AS, Borgstrom H, Polich G, et al. Outpatient physical, occupational, and speech therapy synchronous telemedicine: a survey study of patient satisfaction with virtual visits during the COVID-19 pandemic. Am J Phys Med Rehabil. 2020;99(11):977-981.

5. Gately ME, Tickle-Degnen L, Voydetich DJ, Ward N, Ladin K, Moo LR. Video telehealth occupational therapy services for older veterans: national survey study. JMIR Rehabil Assist Technol. 2021;8(2):e24299.