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 around 70 days to 25 to 40 days, it became clear to the center’s administrators that something would have 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 was a big problem," says Gary Ulicny, PhD, president and chief executive officer of the 100-bed specialty hospital.
Due to managed care pressures, which have contributed to the declining LOS, 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 tele medicine 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 intensive care unit. 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 more convenient way for patients to receive services.
The hospital recently began a three-year, tele- rehabilitation study in conjunction with Emory University School of Public Health 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 telemedi cine 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:
1. 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 (the Picasso Still-Image Phone) 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 of the wound and be able to provide instructions pertaining to 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 Picasso videophones cost $10,000 for both the receiving and transmitting pieces of equipment, so the center tried the models before buying them. After the trial period, the center deemed it worthwhile to buy seven of them from Basking Ridge, NJ-based AT&T. Released in 1995, the Picasso phones since have been discontinued.
2. Revise and update as technology changes. As technology rapidly advanced, the center soon added other less-expensive cameras for use in telemedicine. Shepherd Center now has nine videophones called Aviva, manufactured by American TeleCare Inc. in Eden Prairie, MN. These rugged units were made for health care use, and they include a speakerphone and TV monitor, costing $5,000 to $6,000 per unit, says Richard Burns, BS, telerehabilitation engineer.
The Aviva videophones have additional features, including blood pressure cuffs, so the patient can send readings to nurses on the other line. Also, the hospital bought eight 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 Picasso cameras, says Roxanne Hauber, PhD, RN, CNRN, manager of the telerehabilitation program. "If we’re looking at pressure ulcers, then the Picasso gives us a very high definition picture with a clear image," she explains. "But if we’re checking out the patient’s home environment and doing discharge planning where we look around the home, then we have the Aviva to give us a moving image."
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 appli- cation," Temkin says. "If the phone is going to be in the patient’s home for several months and then move from location to location, we will want to use something sturdier."
Burns says the hospital also is experimenting with some of the latest videophone technologies and has a phone made by a company called 8x8 in Santa Clara, CA.
3. Train staff and patients. When the telerehabilitation program first began, Burns visited each home where a Picasso would be placed and set up the phone for patients. The hospital had only one phone, 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."
The new equipment is easier to use, requiring the user to plug the fax machine-size gadget into an electrical outlet and a telephone jack. The monitor is built in, and all the user has to do is press a green button after answering the hospital’s telephone call.
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. We even trained someone who speaks only Spanish, and the person was illiterate as well."
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.
It’s crucial to use a repeat demonstration method because it builds clients’ confidence, says Susan Vesmarovich, RN, BSN, CRRN, nurse coordinator. "When someone is successful doing something, then there is a good chance that person will be successful the next time they do it," she says. "But when you fail at something, there’s a tendency to quit trying."
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.
4. 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.
"We also have a telerehabilitation project going on as part of our model systems for brain injury patients, who will receive training via videophones," Hauber says.
The hospital is studying a third use for telemed icine 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 when compared with providing no videophone services after discharging patients.
5. Market program and seek new payer sources. Reimbursement is a big question mark when it comes to telerehabilitation services. "It’s still very much up in the air in terms of how it will be reimbursed and what services 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. "And we’ve been very fortunate that the administration at Shepherd has been supportive of our efforts," she adds.
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. Shepherd Center has been marketing its service to payers, including workers’ compensation companies. The hospital, for example, has a product geared toward workers’ compensation payers that provides patients with maintenance and follow-up care for a set fee.
The hospital accepts responsibility for patients’ readmission in exchange for a fee contract that allows the hospital to provide whatever post-discharge services the patient needs, 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 yet to share, 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."
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