Telerehab supports community reentry

Technology eases gaps caused by shorter stays

Shepherd Center in Atlanta saw its average length of stay dwindle from about 90 days to 30 days over the past decade and a half, primarily due to pressure from managed care organizations. The 100-bed specialty hospital, which works with the most complex spinal cord- and brain-injured patients, found that 30 days was not adequate time to prepare patients for reentry into the community.

"Some of our initial reductions in length of stay were due to improved efficiencies, but by far the biggest impact on our length of stay has been managed care," notes Michael L. Jones, PhD, founding director of the Virginia C. Crawford Research Institute at Shepherd Center. "We began looking at telerehabilitation models around the country in 1996 as a means to fill the service gaps left by early discharge."

Jones says "telerehabilitation" is simply the use of telecommunication and electronic technologies to provide rehabilitation and long-term support to people with disabilities in remote settings. He explains that this new capability has some definite benefits for patients reentering their communities:

  • Extended follow-up after discharge."As our lengths of stay got shorter, we tried to cram everything we used to do in 100 days into the 30 days we had," notes Jones. "Our patients and their families were leaving overwhelmed with the intensive training we put them through in such a short time. We sent them home with mountains of manuals and hoped that they would figure it all out when they got home."

    Now, Shepherd Center sends some patients home with telerehabilitation systems that allow Shepherd’s professional staff to provide ongoing monitoring, education, and support for patients who are either too disabled or too remote to travel easily back to the center for follow-up.

  • View into the home environment. "Video cameras allow the Shepherd staff to tour’ the patient’s home even when there is no coverage for a home assessment," says Jones.

  • Remote monitoring of functional status. "It’s very helpful for the therapists to see how patients function in their own homes, not just in the physical therapy clinic," he says.

  • Elimination of transportation hassles.

  • Expert consultation. "Patients who live in rural areas may have difficulty finding local providers with adequate training in the care of spinal cord injury," Jones says.

Many patients in remote areas also may have difficulty finding the help they need to set up their equipment, he says. Shorter lengths of stay mean that most Shepherd patients are discharged in loaner chairs. If a patient lives in Atlanta, it’s not difficult to get them into the seating clinic when their own wheelchair is ready for a final seating. However, if the patient lives in rural Georgia, it may be impossible for the patient to return to Atlanta for seating follow-up, he notes.

"A DME [durable medical equipment] vendor may deliver the patient’s new seating system by UPS. It’s going to be left on the patient’s doorstep in a box. A patient may be able to find a bicycle mechanic who can figure out how to assemble the system, [or] he may not," Jones explains. "The telerehabilitation systems allow us to have our seating clinic specialist guide someone through the types of fine adjustments necessary for proper positioning to prevent complications such as pressure ulcers."

Jones urges health care organizations considering telemedicine programs to let patients’ needs rather than technology drive their programs. "We spent more than a year visiting other health care facilities who were doing telemedicine. We talked to them and learned from their experiences, and then we developed some guiding principles that we used as we began to implement our telerehabilitation program," he says.

Practicality, simplicity are key

Here are those principles:

  • Put people first. "We talked to some folks who had purchased systems without first determining any practical use for them. We didn’t just want to buy a system because it was there," he notes. "We first asked how we were going to use an available system. We asked ourselves, What is the patient problem we can solve with this technology?’ And we let the answer to that question drive what systems we bought."

    He also recommends that health care organizations start small and keep things simple. "You can easily get set up with as little as $15,000 of equipment. Don’t be glitzed by available technology. Decide on the application first and then go out and research the available technology."

  • Gear efforts to home- and community- based services and support. Everything Shepherd Center has done to date is designed for use over POTS (plain old telephone systems) to maintain support in the home, he says. There are other telecommunication channels available, including cable modem systems that offer faster transmission and clearer images. However, Jones cautions that even the best technology breaks down, and not every area offers the more advanced options.

    "Telephone lines work fine for almost any application you might consider and are available everywhere," he notes.

  • Use technology to support, not replace, hands-on interaction. "When we first tried to roll out this program, our therapists didn’t want anything to do with it," says Jones. "They were afraid we would take them away from their patients. We made it a firm rule that remote intervention never, except in very extreme circumstances, replaces hands-on interventions. In addition, all the initial rehabilitation and assessments are done hands-on."

  • Use technology to support, not replace, local providers. Shepherd also recognized that local providers might be concerned that telerehabilitation systems would ease them out of business, says Jones. "We’ve made it a major tenet of our work that we don’t practice medicine over the telephone lines," he notes. "Local providers were concerned that we would come in as a major specialty hospital with our new technology and replace them, but in fact, we support them in their work with our patients and in some cases may actually have created more work for them."

    If Shepherd observes a problem during a remote visit, the center encourages the patient to go to the local provider for treatment or further evaluation, he says. "Our specialists also serve as consultants to local providers. It’s not unusual to find physical therapists in remote locations who have not worked with spinal cord-injured patients since their clinical training," he says.

  • Appoint a staff member to spearhead the telemedicine program. "You have to have a staff member dedicated to the program to help clinical staff with training," says Jones. "Don’t start something like this without identifying a point person."

    Shepherd faced three main challenges to implementing its telerehabilitation program: technical, legal, and financial, he says.

    "The best way to minimize technical issues is to visit other organizations currently using telemedicine applications and learn from their mistakes," he says. "We visited one hospital whose IS [information systems] department had purchased a cutting-edge system that still wasn’t in use because the clinical staff couldn’t find an application for it."

    As for legal issues, the entire area of telemedicine and e-health is still so new there is very little case law to turn to for guidance, Jones notes. "We are following federal guidelines [HIPAA, the Health Insurance Portability and Accountability Act] for protecting patient privacy and confidentiality. And we require staff members who work with out-of-state patients in the telerehabilitation program to be licensed in every state in which they interact with patients," he says. "It’s a conservative approach, but we feel it’s worth the investment. And when we’re in doubt about a patient, we send the patient to a local provider rather than risk trying to practice medicine or nursing or therapy over the telephone lines." (See story, p. 167, for more on liability issues.)

    Finally, Jones says Shepherd hopes to develop a global pricing strategy and assume some risk for secondary complications in order to get more payers to buy into the telerehabilitation program. "We’ve had some limited luck approaching workers’ comp payers to purchase an additional add-on telerehabilitation follow-up protocol for patients at risk for certain complications," he says.

    In addition, some rural states have funded telerehabilitation for Shepherd patients through their Medicaid and Medicare programs, he says.