Telerehabilitation’ may be in future of rehab care

Atlanta hospital uses video education, consulting

When Atlanta-based Shepherd Center’s length of stay (LOS) dropped within the past five years from about 70 days to 25 to 40 days, it became clear to the center’s administrators that something needed to be done to help patients and their families during the transitional period after discharge.

"Our rehab functional outcomes are better than they were five years ago, but the incidences of secondary complications and difficulties of families in the transition period were big problems," says Gary Ulicny, PhD, president and CEO of the 100-bed specialty hospital.

Due to managed care pressures, it’s likely the hospital will continue to experience a decrease in its LOS, which will accentuate the need for more efficient, less expensive follow-up care. "As we were looking for alternative ways to support these families at a lower cost, the telemedicine idea came up, and we began to explore it as a research project," Ulicny says.

"Our undertaking was motivated by a desire to find different ways to continue to provide services despite the managed care environment," says Ann Temkin, MA, ACSW, a senior researcher.

Shepherd Center has both a med-surg floor and an ICU. The facility serves as a hospital for catastrophic injuries, including spinal cord and brain injury, and treats patients with multiple sclerosis and other neurological problems. The hospital’s patients arrive from all over the southeastern United States, and some live in rural areas where follow-up health care is not readily available. So, telemedicine has the added advantage of being a convenient way for patients to receive services.

The hospital recently began a three-year telerehabilitation study in conjunction with Emory University School of Public Health, also in Atlanta. The study is funded by a grant from the Centers for Disease Control and Prevention (CDC) in Atlanta. It will look at the cost-effectiveness and quality of care provided by telerehabilitation to patients who’ve been discharged from the hospital. The results aren’t in yet, but hospital officials say they have every reason to believe telemedicine will improve patients’ outcomes.

For example, one small pilot study showed promising results. The study evenly divided 75 discharged patients into three categories: those who had regular telephone contact with the hospital, those who received the hospital’s standard care, and those who received telerehabilitation. "We found that among the 25 who received telerehabilitation, half of those people were back to work within one year of their injury," Temkin says. "Nationally, only 23% of people are back to work after as many as five years."

Moreover, the telephone-supported group also had a high back-to-work rate, although not as high as the telerehabilitation group, and those who received no telephone or video follow-up care had a back-to-work rate of 15% to 17%.

"We thought the people who received regular intervention from us through telerehabilitation got a quicker sense of being able to manage their lives, so they were able to move on with things like work," Temkin says.

Here’s how Shepherd Center’s telerehabilitation program was developed:

Start telemedicine on a trial basis, carefully selecting equipment. "We experimented with different technology before purchasing anything," Temkin says. At first, the center rented video telephones that provided a still image to use with wound care patients. Patients took the phones home, and when a wound care nurse called them, patients pointed the phone’s camera to the wound. The nurse would see a clear image and be able to provide instructions on how they should treat it, Ulicny explains. They also could use the still-photo telephone cameras to help families fix mechanical problems with equipment, such as wheelchairs that needed adjustment. The videophones cost $10,000 for both the receiving and transmitting pieces of equipment. After a trial period, the center decided it was worthwhile to buy seven sets.

Revise and update as technology changes. As technology advanced, the center soon added other less expensive cameras. Shepherd Center now has nine videophones made for health care use. They include a speakerphone and TV monitor, costing $5,000 to $6,000 per unit, says Richard Burns, telerehabilitation engineer. The videophones have additional features, including blood pressure cuffs, so the patient can send readings to nurses. Also, the hospital bought eight additional videophones costing less than $1,000 each that are suitable for some short-term telerehabilitation cases.

Despite having cameras with moving images, the hospital still has use for the first cameras they bought, says Roxanne Hauber, PhD, RN, CNRN, manager of the telerehabilitation program. "If we’re looking at pressure ulcers, they give us a very high-definition picture with a clear image," she explains. Likewise, the hospital makes good use of several different types of video cameras with moving images. "Now there’s a wide range of devices, so if we have a case where we may need the videophone for one use, then we may send the inexpensive phone because that will work for one application,"

Patient education proves easy

Train staff and patients. When the telerehabilitation program first began, Burns visited each home where a videophone would be placed and set up the phone. The hospital had only one, and managers were unsure how best to train families to install and use the equipment. Now Burns and other staff teach patients and families how to use the videophones before they leave the hospital. "I learned a lot about the home environment from clinicians here and from working with people in their homes and seeing realistic barriers," he says. "It helped me to develop a process where we can train other people in our telerehabilitation program." Also, Shepherd employees now are so skilled at teaching patients and families how to set up and use the equipment that the whole training process takes about 15 minutes, Burns says. "We have patient-teaching down to a science."

The typical training session involves having the patient use the videophone at the hospital by having them connect it themselves and then transmit information to a videophone set up in another room in the hospital. So far, patients have adapted easily to using the equipment, Burns says. The hospital also has trained employees how to use the equipment, but learning the mechanics of the video cameras proved easier than the philosophical change they required, Hauber says. "The human factors play in this very strongly when working with clinicians," she explains. "For many clinicians, it’s a problem if they can’t lay their hands on patients." The hospital reinforced the importance of using telerehabilitation as a way to improve quality of care by helping patients stay out of the hospital after they are discharged.

Study outcomes. The hospital’s telerehabilitation study with the CDC should yield a variety of outcomes data. The study will compare post-discharge follow-up costs and care quality between standard care and telerehabilitation. The hospital is studying a third use for telemedicine by having therapists work by videophone with patients who have language and communication problems. For example, a speech therapist is working with patients who have communication problems because of severe disabilities such as a spinal cord injury or cerebral palsy.

This type of therapy offers such patients a great convenience and extra therapy time, Hauber says. "The first individual we worked with has severe cerebral palsy, and he lives in a group home," she says. His disability makes it difficult to transport him to even one therapy session a week. But because the therapist now can train him through telerehabilitation, he doesn’t have to come into the center, and he receives two therapy sessions a week. In coming years, the hospital will have outcomes data collected from these various projects and may be able to use that information to show payers how efficient telerehabilitation is.

Market program and seek new payer sources. Reimbursement is a big question. "It’s still very much up in the air in terms of how [telerehabilitation] will be reimbursed," Hauber says. Medicaid reimburses for certain telemedicine services in some states, including Georgia, she says. Shepherd Center also has received grant money to cover some of the program’s costs. But while managed care companies are continuing to apply pressure for rehabilitation hospitals to decrease patients’ inpatient stays, they haven’t fully embraced telerehabilitation as a safety net alternative.

The hospital accepts responsibility for patients’ readmission in exchange for a fee contract that allows the hospital to provide for patients whatever post-discharge services they need, Ulicny says. For some patients, that might mean nurses simply will call them to see how they’re doing; for others, it might involve video teleconferencing. "What we’re saying is, for X number of dollars, we will follow this person for a designated period of time, and if they have a preventable secondary complication, we’ll use this money to pay for it," Ulicny explains. So far, the hospital has signed some pilot partnership contracts with national workers’ compensation payers. Because there are no outcomes data to share yet, the payers have agreed to let the hospital study outcomes on these cases.

Shepherd Center will continue to develop its telerehabilitation program because hospital officials see this as the wave of the future, Hauber says. "We can’t have a gap in care, and this is a wonderful way to address the issue of extending the continuum of care."