DELIVERING OCCUPATIONAL THERAPY THROUGH TELEMEDICINE An Innovative Program at the Salt Lake Community College Gabe Byars, MS, OTR/L Brenda K. Lyman, OTD, OTR/L

SESSION OBJECTIVES 1. Gain an awareness of the SLCC’s Telehealth Clinic providing OT for Utahns 2. Understand criteria for Utah residents to participate as clients in the SLCC Telehealth Clinic 3. Be informed about regulations surrounding telemedicine and telehealth services. 4. Determine steps in how to establish telehealth services as part of your job and place of employment.

CLINIC OPTIONS AT THE SALT LAKE COMMUNITY COLLEGE OTA Outpatient Clinic  Pro-Bono  Group & individual interventions  Pediatric and adult populations  10-weeks; 45 min sessions; fall/spring  Student clinicians supervised by licensed OT and OTA faculty In existence since 2009.

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GOALS OF SLCC CLINIC • Provide a platform for training OTA students • Enable individuals in need to access to occupational therapy services despite barriers • Uninsured and underinsured

• Currently 13.3% of Utahns are uninsured (HHS, 2015)

• Geography

GOALS OF SLCC CLINIC • Provide a platform for training OTA students • 2011 ACOTE Standard B.1.8

• Demonstrate an understanding of the use of technology to support performance, participation, health and well-being. This technology may include, but is not limited to, electronic documentation systems, distance communication, virtual environments, and telehealth technology.

Need to Grow into Telehealth

SECURING A GRANT FOR THE DEVELOPMENT OF TELEHEALTH SERVICES • Support our community of Utahns • Reach out to populations who are. . .

• uninsured, underinsured, underserved • geographically unable to • travel to an outpatient clinic • receive specialty services

• • • •

Kahlert Foundation $75,000 1-year Development of a Telehealth Clinic at the Salt Lake Community College

WHO WILL THIS GRANT SERVE? • Pediatric and Adult Clients • 1. implement services

• waitlists • consultations or interventions

• 2. continue services if interrupted by • insurance limitations • distance

• 3. reinforce and support OT for • in-home oversight

• individualized education programs • plan of care consistency • home treatment continuity

SLCC OCCUPATIONAL THERAPY TELEHEALTH CLINIC 1. Interventions by:

• Students in the OTA and PTA programs • Supervision by faculty--licensed

2. Appointments

• Weekly • 45-minutes

3. Delivery method • TruClinic

• HIPAA-secure video-audio platform

4. Timing

• Fall and Spring semesters • 10-week periods

5. Funding Inclusion

• Telecommunication • Adaptive equipment

DEFINING TELEHEALTH/REHAB • AOTA defines telehealth as “the application of evaluative, consultative, preventative, and therapeutic services delivered through telecommunication and information technologies (AOTA, 2013).” • American Telehealth Association (ATA) defines telerehabilitation as “. . .encompassing a range of rehabilitation and habilitation services that include assessment, monitoring prevention, intervention, supervision, education, consultation, and counseling (ATA, 2014).” • In 2011, AOTA defined telehealth as an emerging niche (AOTA, 2014).

HIGH

INTENSITY

Consultation

Therapy

Adaptive equipment recommendations /training LOW

SCOPE OF TELEHEALTH FOR OCCUPATIONAL THERAPY

Followup SHORT

In-home monitoring

DURATION

Support networks

LONG (Parmanto and Saptono, 2009)

EFFICACY STUDIES • Telehealth typically has similar or higher patient satisfaction as in person visits (Cason, 2015) • ¾ of Americans are interested in using telehealth (AOTA, 2014)

• Studies (Cason, 2015) show that telehealth has similar or greater outcomes for: • • • •

Evaluation using standardized and observational measures Interventions with a wide range of diagnosis Consultation and training of caregivers and professionals Recommendations for adaptive equipment and home safety

REGULATION • Telehealth is viewed as a service delivery model • Therefore, practitioners have all of the same obligations and duties • • • •

Ethics State and federal guidelines Scope of practice Licensure

STATE AND FEDERAL GUIDELINES • Examples

• Health Insurance Portability and Accountability Act (HIPAA • Health Information Technology for Economic and Clinical Health Act (HITECH)

LICENSURE AND SCOPE OF PRACTICE • Licensure and scope of practice are dependent on state laws and licensure boards. • The Utah Practice Act and other Utah law does not address telehealth with occupational therapy • DOPL OT board did rule that the practitioner must be licensed in the state where the client is present, consistent with other state and federal regulations

FUNDING • Funding of telehealth services for occupational therapy services is highly variable. • “It is the position of AOTA that occupational therapy services provided with telehealth technologies should be valued, recognized, and reimbursed the same as occupational therapy services provided in person (AOTA, 2013).”

MEDICARE FUNDING • Currently Medicare does not recognize occupational therapy, or other rehab disciplines, as reimbursable telehealth providers

• Legislation for Medicare telehealth parity has failed to pass during the 20132014 and 2015-2016 congressional sessions • HR 5380 – Telehealth Parity Act of 2015 • http://capwiz.com/aota/issues/alert/?alertid=67207626

MEDICAID FUNDING • Medicaid is a state run program • Funding decisions regarding telehealth are largely state decisions • Utah Medicaid does not currently recognize occupational therapy, or other rehab disciplines, as telehealth providers

(Thomas and Capistrant, 2016)

PRIVATE INSURANCE FUNDING • Dependent upon federal and state laws and individual company decisions • 28 states and the District of Columbia have enacted fulltelemedicine parity laws • Utah currently has no active or proposed proposed on telemedicine parity (Thomas and Capistrant, 2016)

OTHER POTENTIAL FUNDING SOURCES • Veterans administration • Workers compensation • Private pay • Other

WHAT’S NEXT? • Becoming active with Utah and national legislative efforts • Expanding your practice

www.utn.org

• Referring clients to the SLCC Telehealth Clinic

EXPANDING TO YOUR SETTING • Start slow and with one patient • Get a platform that is HIPAA compliant • Define your objectives—what do you want to accomplish • Define your visits—what is a reasonable period of time between checking in • Save time—make sure your client can contact you (readiness of computer usage)

REFERRING TO THE SLCC OTA CLINIC What is the SLCC OTA Clinic looking for? • An opportunity for collaboration with Utah OT & OTA practitioners • With an existing plan of care • To establish a new plan of care

• A variety of clients

• Diagnoses • Ethnic Backgrounds • Ages

Contact Gabe Byars @ 801-957-6214 or email [email protected]

BIBLIOGRAPHY Accreditation Council for Occupational Therapy Education [ACOTE]. (2016). 2011 Accreditation Standards and Interpretive Guide (Effective July 31, 2013) - August 2016 Interpretive Guide version. Retrieved November 04, 2016 from http://www.aota.org/~/media/Corporate/Files/EducationCareers/Accredit/Standards/2011Standards-and-Interpretive-Guide.pdf American Occupational Therapy Association. (2014). Emerging niche: Telehealth. Retrieved November 2, 2016 from http://www. aota.org/Practice/RehabilitationDisability/Emerging- Niche/Telehealth.aspx American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association. (2013). Telehealth. American Journal of Occupational Therapy, 67(6 Suppl), S69-S90. American Telehealth Association. (2014). State Medicaid Best Practice. Washington, DC: American Telemedicine Association. Cason, J., & Brannon, J. A. (2011). Telehealth regulatory and legal considerations: Frequently asked questions. International Journal of Telerehabilitation, 3(2), 15-18. Cason, J. (2014). Telehealth: A Rapidly Developing Service Delivery Model for Occupational Therapy. International Journal of Telerehabilitation, 6(1). doi:10.5195/ijt.2014.6148 Carson, J. (2015).Telehealth and Occupational Therapy: Integral to the Triple Aim of Health Care Reform. American Journal of Occupational Therapy, 69(2), 6902090010p16902090010p8. Health and Human Services [HHS]. (2015, November 2). 5 Years Later: How the Affordable Care Act is Working for Utah. Retrieved November 04, 2016, from http://www.hhs.gov/healthcare/facts-and-features/state-by-state/how-aca-is-working-for-utah/index.html Parmanto, B., & Saptono, A. (2009). Telerehabilitation: State-of-the-art from an informatics perspective. International journal of telerehabilitation, 1(1), 73-84. Thomas, L., & Capistrant, G. (2016). State telemedicine gaps analysis: Coverage and reimbursement. Washington, DC: American Telemedicine Association.

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Delivering Occupational Therapy through Telemedicine Gabe Byars, OTR/L and Brenda Lyman, OTD, OTR/L UOTA 2016 18, 103–111. Germain, V., Marchand, A., Bouchard, S., Drouin, M. S., & Guay, S. (2009). Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behaviour Therapy, 38, 42–53. http://dx.doi.org/10.1080/16506070802473494 Girard, P. (2007). Military and VA telemedicine systems for patients with traumatic brain injury. Journal of Rehabilitation Research and Development, 44, 1017–1026. http://dx.doi.org/10.1682/JRRD.2006.12.0174 Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: Predictors of treatment completion and outcome and comparison to treatment delivered in person. Behavior Therapy, 42, 276–283. http://dx.doi.org/10.1016/j.beth.2010.07.005 Hegel, M. T., Lyons, K. D., Hull, J. G., Kaufman, P., Urguhart, L., Li, Z., & Ahles, T. A. (2011). Feasibility study of a randomized controlled trial of a telephone-delivered problem solving occupational therapy intervention to reduce participation restrictions in rural breast cancer survivors undergoing chemotherapy. Psycho-Oncology, 20, 1092–1101. http://dx.doi.org/10.1002/pon.1830 Hermann, V. H., Herzog, M., Jordan, R., Hofherr, M., Levine, P., & Page, S. J. (2010). Telerehabilitation and electrical stimulation: An occupation-based, client-centered stroke intervention. American Journal of Occupational Therapy, 64, 73–81. http://dx.doi.org/10.5014/ajot.64.1.73 Hoffmann, T., & Russell, T. (2008). Pre-admission orthopaedic occupational therapy home visits conducted using the internet. Journal of Telemedicine and Telecare, 14, 83-87. Hoffmann, T., Russell, T., Thompson, L., Vincent, A., & Nelson, M. (2008). Using the Internet to assess activities of daily living and hand function in people with Parkinson’s disease. NeuroRehabilitation, 23, 253–261. Jones, A., Hedges-Chou, J., Bates, J., Loyola, M., Lear, S. A., & Jarvis-Selinger, S.(2014). Home telehealth for chronic disease management: Selected findings of a narrative synthesis. Telemedicine Journal and eHealth, 20, 346–380. http://dx.doi.rg/10.1089/tmj.2013.0249 Kairy, D., Lehoux, P., Vincent, C., & Visintin, M. (2009). A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation, 31, 427– 447. http://dx.doi.org/10.1080/09638280802062553 Lutz, B. J.,Chumbler, N. R., Lyles,T., Hoffman, N., & Kobb, R. (2009). Testing a hometelehealth programme for US veterans recovering from stroke and their family caregivers. Disability and Rehabilitation, 31, 402–409. http://dx.doi.org/10.1080/09638280802069558 Neubeck, L., Redfern, J., Fernandez, R., Briffad, T., Bauman, A., & Freedman, S. B. (2009). Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review. European Journal of Preventive Cardiology, 16, 281–289. http://dx.doi.org/0.1097/HJR.0b013e32832a4e7a Gabe Byars [email protected] Brenda Lyman [email protected]

Delivering Occupational Therapy through Telemedicine Gabe Byars, OTR/L and Brenda Lyman, OTD, OTR/L UOTA 2016 Palsbo, S. E., Dawson, S. J., Savard, L., Goldstein, M., & Heuser, A. (2007). Televideo assessment using Functional Reach Test and European Stroke Scale. Journal of Rehabilitation Research and Development, 44, 659– 664. http://dx.doi.org/10.1682/JRRD.2006.11.0144 Rintala, D. H., Krouskop, T. A., Wright, J. V., Garber, S. L., Frnka, J., Henson,H. K., . . .Monga, T. N. (2004). Telerehabilitation for veterans with a lower-limb amputation or ulcer: Technical acceptability of data. Journal of Rehabilitation Research and Development, 41, 481–490. http://dx.doi.org/10.1682/JRRD.2004.03.0481 Sanford, J., Hoenig, H., Griffiths, P., Butterfield, T., Richardson, P., & Hargraves, K. (2007). A comparison of televideo and traditional in-home rehabilitation in mobility impaired older adults. Physical and Occupational Therapy in Geriatrics, 25, 1–18. http://dx.doi.org/10.1080/J148v25n03_01 Savard, L., Borstad, A., Tkachuck, J., Lauderdale, D., & Conroy, B. (2003). Telerehabilitation consultation for clients with neurologic diagnoses: Cases from rural Minnesota and American Samoa. NeuroRehabilitation, 18, 93–102. Schein, R. M., Schmeler, M. R., Holm, M. B., Pramuka, M., Saptono, A., & Brienza, D. M. (2011). Telerehabilitation assessment using the Functioning Everyday with a Wheelchair-Capacity instrument. Journal of Rehabilitation Research and Development, 48, 115–124. http://dx.doi.org/10.1682/JRRD.2010.03.0039 Schein, R. M., Schmeler, M. R., Holm, M. B., Saptono, A., & Brienza, D. M. (2010). Telerehabilitation wheeled mobility and seating assessments compared with in person. Archives of Physical Medicine and Rehabilitation, 91, 874–878. http://dx.doi.org/10.1016/j.apmr.2010.01.017 Steel, K., Cox, D., & Garry, H. (2011). Therapeutic videoconferencing interventions for the treatment of long-term conditions. Journal of Telemedicine and Telecare, 17, 109–117. http://dx.doi.org/ 10.1258/jtt.2010.100318 Verburg, G., Borthwick, B., Bennett, B., & Rumney, P. (2003). Online support to facilitate the reintegration of students with brain injury: Trials and errors. NeuroRehabilitation, 18, 113–123.

Gabe Byars [email protected] Brenda Lyman [email protected]