Telehealth Update: Care & Considerations for Older Adults

By William Dieter, PT, DPT, GCS, FSOAE

Director of PT Clinical Services

Physical, occupational, and speech therapists have been advocating for their patients. Because of those efforts and the coronavirus crisis, Medicare is allowing telerehabilitation for beneficiaries throughout the duration of the public health emergency. While a regulatory change was necessary, perhaps the larger hurdle is translating our hands-on, in-person model of care into a valuable virtual product for older adults in their homes.

While the Centers for Medicare &  Medicaid Services is allowing evaluations, re-evaluations, and many common CPT codes typically billed by therapists to be provided through telerehabilitation, we, as healthcare providers, must make prudent clinical decisions. At FOX, the typical patient we see within our geriatric house-calls model of care is 82 years old with deficits in strength, stamina, balance, flexibility, and communication. Many also present with mild cognitive impairment (MCI) or dementia. An evaluation, re-evaluation, or certain high-intensity activities may not be efficient, effective, or safe over two-way audiovisual communication.

PTs, OTs & SLPs: What Do the Evidence and Professional Organizations Say?

The body of evidence specific to telerehabilitation, while emerging, is limited in scope. However, a few concepts appear consistent. First, a hybrid model that includes both in-person and telerehabilitation visits are optimal. Second, patients post-joint replacement surgery with low back pain, post-stroke, or receiving cardiac rehabilitation typically benefit from telerehabilitation, and it is feasible to deliver. Lastly, those with more mild impairments who require limited supervision are the best candidates.

Scope of practice, licensure, and ethical responsibilities apply to care delivered via telerehabilitation just as they do for in-person care. Documentation requirements and standards also remain unchanged other than the addition of documenting the audiovisual platform utilized. The Federation of State Boards of Physical Therapy, American Occupational Therapy Association, and American Speech Hearing Association recommends that practitioners refer to their own state’s board and discipline-specific practice act for more information.

5 Important Factors to Consider for Your Patients’ Care

Little to no evidence exists as it pertains to telerehabilitation, older adults, or those with MCI or dementia. You must consider if the patient is able to attend to the exercises, tasks, or instruction being provided. The patient should also be able to process verbal or visual feedback to ensure that the care provided is valuable and skilled in nature.

Many older adults require some level of assistance to truly overload their physiological systems. They must also be safe in these activities. If the amount of assistance required outweighs the amount available, the therapist must consider modifying the activity or not performing telerehabilitation.

One-quarter of older adults fall each year and our healthcare system is generally reactive in responding to fall risk. That means, most older adults being seen for physical or occupational therapy are at significant fall risk. Truly challenging balance via telerehabilitation is a matter of risk vs. reward.

Patient response to physiological overload is key in maintaining safety and making proper clinical decisions. During telerehabilitation access to these details is often limited. Considerations must be made for significant cardiopulmonary comorbidities, the patient’s history, and consistency of physiologic responses to guide your decisions about true overload that drives skilled care that is valuable.

Our ability to deliver telerehabilitation is a step forward, but it does not come without additional responsibility. You will be challenged more than ever to make sound clinical judgments while appreciating the need for skill and value in all that we provide.

While we will access more patients, we must use telerehabilitation wisely for each individual patient we serve.