Abstract
Occupational therapy focuses on therapeutic means to address participation in meaningful everyday tasks across the lifespan. No single setting is more conducive to this pursuit than individuals’ authentic contexts. Occupational therapists are therefore uniquely suited to lead the charge toward stimulating research and advancing evidence-based application of telehealth. To this end, the American Occupational Therapy Foundation digitally convened their 2020 Planning Grant Collective to focus on the topic of Telehealth. Participants of the interdisciplinary collective collaboratively identified four themes: (1) Using technology to assess and intervene in the everyday context, (2) Partnerships with caregivers, (3) Telehealth delivery, and (4) Uniform data collection. Subgroups explored potential research and funding opportunities in their specialty area while also addressing the centralizing concepts of equity and diversity of telehealth delivery and COVID-19. Here, we provide a summary of the key concepts and recommendations from the 3 days of collaboration.
Introduction
Occupational therapy (OT) is focused on increasing participation in authentic contexts; telehealth as an OT service delivery model is a natural fit for this pursuit. In September 2019, the American Occupational Therapy Foundation (AOTF) convened a planning grant committee with a focus on examining current trends in and evidence for telehealth application in OT, with the ultimate goal of stimulating research on the use of telehealth in OT. To this end, the committee assembled an interdisciplinary group of individuals who could collaborate and support these future research endeavors, the AOTF Planning Grant Collective (PGC). The onset of the COVID-19 pandemic in early 2020 resulted in OT practitioners making the rapid shift to telehealth across settings. By October 2020, when the AOTF PGC met, cases of COVID-19 surged and the use of telehealth was commonplace for all areas of OT practice. This white paper outlines the proceedings, themes, and discussion points that emerged from the 2020 AOTF PGC focused on telehealth research in OT. The goal of this white paper is to summarize proceedings and outcomes, and ultimately stimulate bi-directional discussion between researchers and practitioners as well as highlight the capacity of our OT community in leading innovative telehealth-focused research.
Telehealth in Occupational Therapy
OT practitioners recognize a fundamental component of health as being participation in meaningful activities. OT practitioners work with clients across the life span and in varied settings, including early intervention, schools, and in rehabilitation settings such as hospitals, inpatient, and outpatient clinics as well as in work and industry. OT practitioners work with clients to promote health, wellness, mental health, and productive aging as well as to improve performance and prevent injury. Through telehealth, OT practitioners can improve clients’ participation, quality of life, and promote health and wellness within the authentic context of individuals’ home or care settings.
The American Occupational Therapy Association (AOTA) first published telehealth guidelines in 2005, using the term telerehabilitation (AOTA, 2005). Since 2010, AOTA telehealth guidelines have been continuously updated (AOTA, 2010, 2013, 2018) officially endorsing the term ‘telehealth’ in 2013. This term better defines the scope of OT practice to include health promotion and prevention and mirrors the terminology being used by stakeholders outside of the profession. Additionally, the World Federation of Occupational Therapists (WFOT) published a Telehealth position statement in 2014 (WFOT, 2014). This position statement provided a global perspective with broad application of telehealth within OT for practitioners around the world.
As defined by AOTA (2018), telehealth is the “application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technology (p. 1).” The AOTA Telehealth position paper includes an overview of evidence-based applications of telehealth in OT; practitioner qualifications; ethics, supervision, legal, regulatory, and payment considerations; and an overview of telehealth technologies and case examples (AOTA, 2018). In addition, AOTA’s webpage dedicated to telehealth (www.aota.org/telehealth) contains telehealth decision guides, ethics advisory opinion, state-by-state regulatory resources, payment resources, and articles related to telehealth in OT.
The Impact of COVID-19 on Telehealth in Occupational Therapy
Payment.
Prior to COVID-19, primary settings where telehealth was implemented in OT included services provided through the Veterans Health Administration and pediatrics, including some early intervention and school-based settings. The early adoption of telehealth in these settings was a result of different payment structures that did not rely primarily on third-party payors. Some states had telehealth coverage parity laws that required third-party payors to pay for services provided through telehealth if those same services were covered when provided in person (Center for Connected Health Policy [CCHP], 2019). However, coverage parity does not equal rate parity, and lower payment rates for telehealth (when payment was available) dis-incentivized the use of telehealth by practitioners. In states without coverage parity laws, most third-party payers refused payment for services provided through telehealth. A few hospitals and clinics, despite not being able to be paid for the services, did integrate telehealth on a small scale due to the benefits of telehealth on continuity of care and patient satisfaction (Cason, 2019).
There were few states whose Medicaid program covered OT services provided through telehealth prior to COVID-19 (AOTA, 2020c; CCHP, 2019). In addition, the Center for Medicare and Medicaid Services (CMS) did not recognize OT practitioners as telehealth providers in the Medicare fee-for-service payment model. In response to COVID-19, executive orders, legislation, and state-based waivers resulted in rapid expansion of payment for OT services provided through telehealth (AOTA, 2020b). In addition to expanded coverage, some private insurers also waived co-pays for services provided through telehealth, adding even greater incentive for its use. Many state-based executive orders and waivers expanded coverage for OT services provided through telehealth by Medicaid programs (AOTA, 2020c). Then, for the first time, OT practitioners were authorized by CMS to use telehealth to provide OT services to Medicare beneficiaries using e-visits and specific CPT codes with a modifier (AOTA, 2020a).
Attitudes and Perceptions of Telehealth.
Efforts to educate practitioners and stakeholders about the use of telehealth in OT have occurred over the past decade (AOTA, 2005; 2010, 2013, 2018; Cason, 2012a, 2012b, 2014, 2015). Many of these efforts aimed to help stakeholders conceptualize telehealth in OT and how it could benefit individual clients, groups, and populations. Prior to COVID-19, research about the perceptions and attitudes towards telehealth were positive (e.g., Serwe et al., 2019), but limited to research studies. It was unclear how translation to “real world settings” would influence client perceptions of telehealth during and following COVID-19. Limited data suggests that clients and therapists reported moderate to high satisfaction with telehealth during COVID-19 (Tenforde et al., 2020). An increasing number of OT clients viewed telehealth as a way to eliminate travel, incorporate healthcare advocates in sessions, and receive therapy in familiar environments.
Access to Telehealth.
Information and communications technologies are increasingly available in the United States. Nearly 81% of Americans own Smartphones and 73% have broadband at home (Pew Research Center, 2019). Although telehealth is a service delivery model that may increase access to OT services for a majority of Americans, access greatly varies by demographics and location. Racial and ethnic minorities, rural residents, those with lower incomes, and older adults report decreased smartphone ownership and access to broadband (Pew Research Center, 2019). Though there have been tremendous improvements in technology performance and affordability, many clients may be unable to access telehealth due to barriers such as technology access, healthcare costs, and digital literacy. Moreover, the direct and secondary effects of COVID-19 disproportionately affected racial and ethnic minorities and drew attention to existing disparities in technology and internet access that influence the use of telehealth. Data suggest that Black Americans were less likely to use telehealth for health-related visits during COVID-19 (Weber et al., 2020). Black and Latinx Americans, as well as those from lower income neighborhoods, were also less likely to have the technology and data to access online learning for their children during the pandemic which translated to decreased access to school-based OT services delivered via telehealth during the pandemic (Bacher-Hicks et al., 2020). Clearly, the pandemic exacerbated inequities in access to telehealth which must be integrated in the OT telehealth research agenda.
Difficulty as Opportunity
We approached the rapidly changing landscape of telehealth in OT with a “difficulty as opportunity” mindset. The rapid expansion and adoption of telehealth by OTs during the COVID-19 pandemic, along with our profession’s ongoing research on telehealth, presented the opportunity to create a research agenda that would ultimately enhance and improve OT practice. By leveraging our expertise in authentic contexts, we have an immense opportunity for data collection and analysis of OT delivered via telehealth during COVID-19. Additionally, we have the opportunity to position ourselves at the forefront of innovative telehealth research that will inform practice well into the future.
Methods
The Telehealth Planning Grant Collective workshop was the fourth installment hosted by the American Occupational Therapy Foundation with the goal of stimulating OT research around an important and timely topic: Telehealth and OT. Dr. Rachel Proffitt chaired the Planning Committee alongside Drs. Jana Cason, Lauren Little, and Kristen Pickett. AOTF CEO Scott Campbell and AOTF Board of Trustees Chair Dr. Mary Lawlor provided oversight and input throughout the process. Researchers and clinicians from numerous fields knowledgeable in the topic of telehealth were solicited and contacted for availability. See Table 1 for a list of attendees.
Table 1.
Attendees of the Telehealth Planning Grant Collective
| Name | Affiliation |
|---|---|
| Planning Committee | |
| Rachel Proffitt, OTD, OTR/L | University of Missouri |
| Jana Cason, DHSc, OTR/L, FAOTA | Spalding University |
| Lauren Little, PhD, OTR/L | Rush University |
| Kristen Pickett, PhD | University of Wisconsin- Madison |
| Mary Lawlor, ScD, OTR/L, FAOTA | University of Southern California |
| Scott Campbell, PhD | American Occupational Therapy Foundation |
| Attendees | |
| Peter Adamczyk, PhD | University of Wisconsin- Madison |
| Ava Bittner, OD, PhD | University of California- Los Angeles |
| Susan Cahill, PhD, OTR/L, FAOTA | American Occupational Therapy Association |
| Felicia Chew, MS, OTR/L, FAOTA | Genesis Rehab Services |
| Evan Dean, PhD, OTR/L | University of Kansas |
| Karen Duddy, OTD, MHA, OTR/L | VA Long Beach |
| Winnie Dunn, PhD, OTR/L, FAOTA | University of Missouri |
| Kimberly Erler, PhD, OTR/L | MGH Institute of Health Professionals |
| Megan Gately, PhD, OTD, OTR/L | Bedford VAMC |
| Andrea Gilmore-Bykovskyi, PhD, RN | University of Wisconsin- Madison |
| Debi Hinerfeld, PhD, OTR/L, FAOTA | Brenau University |
| Dwight Irvin, PhD | Juniper Gardens Children’s Project |
| Douglene Jackson, PhD, OTR/L, LMT, ATP, BCTS | Global Interventions for Therapy Services/GIFTS Institute, LLC |
| Karen Jacobs, EdD, OTR/L, CPE, FAOTA | Boston University |
| Katie Jordan, OTD, OTR/L, FAOTA | University of Southern California |
| Theresa Kimberly, PhD, PT | MGH Institute of Health Professionals |
| Andrew Persch, PhD, OTR/L, BCP | Colorado State University |
| Bobbi Pineda, PhD, OTR/L, CNT | University of Southern California |
| Tammy Richmond, MSOT, OTR/L, FAOTA | Go2Care |
| Jan Rowe, OTD, OTR/L, FAOTA | Children’s of Alabama |
| Roger Smith, PhD, OT, FAOTA, RESNA Fellow | University of Wisconsin- Milwaukee |
| Steven Taylor, OTD, OTR/L | Rush University Medical Center |
| Evelyn Terrell, OTD, MHSA, OTR/L | Nicklaus Children’s Health System |
| Anna Wallisch, PhD, OTR/L | Juniper Gardens Children’s Project |
| Grace Wilske, OTR/L | Minneapolis VA Health Care System |
| Monica Wright, MHA, CPC, CPMA, CPCO | American Occupational Therapy Association |
| Organization Partners | |
| David Banks, PhD, MPH, RN | National Institute of Nursing Research (NINR) |
| Theresa Cruz, PhD | National Center for Medical Rehabilitation Research (NCMRR) |
| Ellie Daniels, MD, MPH | American Cancer Society, Inc. |
| Lyndon Joseph, PhD | National Institute of Aging (NIA) |
| Andrew Murtishaw, PhD | Alzheimer’s Association |
| Mary Rooney, PhD, ABPP | National Instiute of Mental Health (NIMH) |
The topic of “Stimulating Research to Advance Evidence-Based Applications of Telehealth in Occupational Therapy” was selected prior to the COVID-19 pandemic and the workshop was originally planned to be held in-person during Summer 2020. With subsequent limitations on travel and in-person meetings, the Planning Committee shifted to a virtual workshop held on October 5, 6, and 7, 2020. Given the virtual format, the workshop was scheduled for four hours each day to allow for flexibility in the demands of remote work, childcare, and other responsibilities.
On Day 1 of the PGC workshop, the Planning Committee gave framing presentations to set the stage for the topic of telehealth and provide background on telehealth and OT research, practice, and policy. The first day concluded with a large group discussion on broad topics and vision for the future. To promote ongoing collaboration during the sessions, attendees were encouraged to provide ideas and notes via a shared electronic file. This document was used during the discussion to stimulate identification of additional topics and focus areas. At the conclusion of the discussion, six topics were identified and posted to the shared file. Attendees indicated their interests, and four small breakout groups were formed for Days 2 and 3.
Day 2 opened with a short discussion of the four identified small group topics and a funder panel (Table 1). Attendees then broke out into the four small workgroups. One member of the Planning Committee attended each small workgroup to facilitate discussion, take notes, answer questions, and coordinate with the Planning Committee across groups. At the end of Day 2, the small workgroups presented back to the larger group and discussion on overarching themes occurred. The majority of Day 3 was devoted to small virtual workgroup meetings. Outputs from the small workgroups were ideas for cross-institutional studies and grant submissions, identification of potential doctoral student capstone projects, and themes for white papers and conference presentations. The virtual workshop concluded with a final discussion and plans for moving the small workgroup outputs forward. The Planning Committee met with each small workgroup approximately 2–3 months after the virtual workshop to check in on progress and identify resources to support each group.
Results
Several themes emerged from the large workgroup’s initial brainstorming and discussion on Day 1. Themes included: re-envisioning assessments with technology, access to and measurement of natural context, uniform data collection, involvement of caregivers, improving telehealth delivery, diversity and equity issues associated with telehealth, and population health and prevention. Discussion and consensus among organizing committee members and participants resulted in the sub-themes being collapsed into four overarching themes: (1) Using technology to assess and intervene in the everyday context, (2) Partnerships with caregivers, (3) Telehealth delivery, and (4) Uniform data collection. Issues related to access, diversity, and equity were threads that presented throughout each of the overarching themes. The variations in the results and the format in which they are presented, are reflective of the diverse content, discussions, and outputs of the small workgroups.
Using technology to assess and intervene in the everyday context
Several areas of study were identified related to using technology to assess and intervene in the everyday context. First, Ecological Momentary Assessment could be used to predict complex activity and norms of behavior for specific populations. An initial study could be the examination of micro-occupations relative to space and time resulting in the development of a descriptive database of micro-occupations. This study could occur in four stages (see Table 2).
Table 2.
Using Technology to Assess and Intervene in the Everyday Context Workgroup Results
| Study Focus | Emphasis |
|---|---|
| Use Ecological Momentary Assessment to develop a descriptive database of micro-occupations to predict complex activity and norms of behavior for specific populations. | Study micro-occupations relative to space and time resulting in the development of a descriptive database of micro-occupations.
|
| Examine the validity of using technology and the descriptive database of micro-occupations for remote monitoring of rehabilitation outcomes, safety, and quality of life for individuals with disabilities or at risk for decline in independent living. | Data collected through remote monitoring could be compared to past/current/future behavior related to disability, goals, problematic issues or benchmarks for action.
|
| Method comparison studies to determine the equivalency and non-inferiority of telehealth compared to in-person service delivery. |
|
A second study could explore the validity of using technology and the descriptive database of micro-occupations for remote monitoring of rehabilitation outcomes, safety, and quality of life for individuals with disabilities or at risk for decline in independent living. Data collected through remote monitoring could be compared to past/current/future behavior related to disability, goals, problematic issues or benchmarks for action. Technologies are available that can unobtrusively monitor activity performance in the home. For example, Emerald wirelessly monitors vitals, sleep, movement, and behavior by applying an artificial intelligence algorithm to reverse-engineered waves created in wireless signals (Emerald, n.d). This, or similar technology, could be incorporated into a feasibility study (see Table 2).
Method comparison studies are a third area related to using technology to assess and intervene in the everyday context. Method comparison studies may include equivalency studies and non-inferiority studies (Russell et al., 2017). Evidence has established that some OT assessments are valid and reliable when administered through telehealth (AOTA, 2018). The development of method comparison research protocols could facilitate more rapid growth of evidence in this area.
Partnerships with Caregivers
For many settings and populations, partnership and active participation of caregivers is integral to telehealth. For example, best practice in early intervention necessitates that OT practitioners coach caregivers to promote learning activities for their children during everyday routines (e.g., Rush and Sheldon, 2011). Additionally, OT practitioners working with adults with dementia in their homes via telehealth necessitates that a caregiver is present to ensure safety and promote generalization to routines outside of the session. For participants in this workgroup, the range of settings and client populations varied; however, commonalities across settings, clients’ ages, and diagnoses were apparent and this workgroup identified seven areas for study (see Table 3).
Table 3.
Areas of Study and Associated Recommendations for Telehealth Research in Partnerships with Caregivers
| Area of Study | Recommendation |
|---|---|
| 1) Recognize caregivers as essential participants in the OT process, with description and measurement of their role(s). | Research must address the essential role of caregivers in the OT process. Instead of conceptualizing caregivers as ‘extra’ or as an extension of the therapy process, we need to recognize the caregiver role as integrated within the OT telehealth process. |
| 2) Identify processes for coordinating care among caregivers across OT interventions provided through telehealth. | Telehealth allows us to follow best practices related to client-centered care. Therefore, the group recommends that future studies and everyday practice consider specifically outlining, identifying, and describing the process in which the caregiver engages to coordinate care for the client. |
| 3) Identifying caregiver characteristics that influence preferences for accessing OT services through telehealth. | Across studies and populations, caregivers may prefer accessing OT services differently. To understand the efficacy of OT telehealth studies, we must also consider the specific telehealth modalities (e.g., text v. videoconference) and the potential influence of caregiver/client characteristics on preferences related to modalities. |
| 4) Determine the extent to which caregivers / clients choose different telehealth modalities (e.g., phone or videoconference, asynchronous or synchronous) and perceive quality of services across modalities. | Research is needed to understand the preferences of telehealth contact (e.g., phone call, text, or videoconference) among caregivers, and if any caregiver characteristics are related to such preferences. |
| 5) Reframe outcomes of OT interventions provided through telehealth that encompass caregiver health, stress, and efficacy. | In framing caregivers as essential participants in the OT process, measurement of caregiver characteristics and outcomes (in addition to the client’s outcomes) contributes to research that may inform policy and payment structures. |
| 6) Identify the bidirectional nature of the change in caregiver factors (e.g., stress, efficacy) with changes in client factors as targeted by the specific delivery method. | Examine evidence that accounts for the potentially mediating effects of caregiver change on client outcomes. Large scale studies with adequate sample sizes must be conducted to gain insight into the complexity of client and caregiver change resulting from telehealth delivered OT interventions. |
| 7) Reimagine the term ‘caregiver’ to include all individuals that serve as ‘trusted supporters’ for the client receiving OT interventions through telehealth. | Across settings, caregivers may include a variety of supporters. While this may not be the adult’s caregiver, the supporter is nonetheless essential in the OT intervention process and must be recognized. It is vital that, as OT practitioners and researchers, we involve the trusted supporter, whoever that person is as identified by the client. |
Telehealth Delivery
The switch from in-person clinical practice to effective telehealth is reliant on much more than the efficient use of a communication platform. Practitioners who are successful in pivoting to a telehealth service delivery model are those that are able to safely and effectively use what clients have available to them in their setting toward the goals of the therapeutic session while continuing to focus on the individual needs of those being served. While some practitioners have been provided with training on the delivery of telehealth-based OT, many have struggled to find workable solutions for adoption. AOTA and state associations responded to the COVID-19 pandemic by establishing on-line communities of practice that attempted to address barriers and supported OT practitioners in their implementation and use of telehealth. However, little evidence has been provided to support the use of a guided, systematic approach to OT telehealth. Approaches or frameworks that provide guidance for session planning, therapeutic interactions, charting, and problem solving are needed to help facilitate implementation and support payment of services provided through telehealth. Further, data addressing the effectiveness, adoption, and implementation of such tools is needed to support evidence-based practice.
The workgroup determined that the path forward requires examining implementation of and fidelity to a systematic approach to telehealth delivery and that this research should use a dissemination and implementation science approach to examine the feasibility, effectiveness, and barriers to adoption. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenace) approach (www.RE-AIM.org) was used by the group to frame the discussion around telehealth delivery. The group first worked to generate considerations for telehealth implementation (see Table 4). An existing tool was identified by the group as meeting the established criteria and it was agreed that the group would move forward with a small scale, dissemination and implementation science focused study to examine sustainable adoption.
Table 4.
OT Telehealth Delivery Framework Requirements
|
Uniform Data Collection
There is a need for collecting data related to telehealth delivery and outcomes in both the short-term (related to the COVID-19 pandemic) and in the long-term. A data registry would easily achieve the long-term goal of improving uniform data collection in OT telehealth services. Additionally, sufficient evidence is necessary to support lasting uptake, adoption, and payment of telehealth in occupational therapy. These two long-term goals are described below with related short-term goals.
The first long term goal for uniform data collection (see Table 5) reflects the need for systematic data collection of client outcomes resulting from OT delivered via telehealth. As insurance continues to pay for services provided through telehealth and we move towards value-based payments for OT services, it is essential that OT practitioners are able to demonstrate that provision of services via telehealth leads to improved outcomes for clients and has value for organizations (e.g., reduced hospital readmission rate). There is also a need to characterize telehealth use across settings and client populations.
Table 5.
Uniform Data Collection Workgroup Goals
| Long Term Goals (LTG) | Associated Short Term Goals (STG) |
|---|---|
| LTG 1: Provide a data registry platform for occupational therapists and researchers to investigate health and system-level outcomes from the provision of OT services provided through telehealth. | STG: Identify common data elements for current and future OT services provided through telehealth. STG: Explore existing registries from other professions to determine potential structures and usage. STG: Determine client characteristics that impact participation with OT services provided through telehealth. STG: Identify characteristics of telehealth access including assessments utilized, billing codes used, length of time, participants involved in the visit (e.g., caregiver), and other tools used during the visit. |
| LTG 2: Build evidence, systems, and technology to optimize telehealth delivery of OT to the largest number of people possible. | STG: Identify technologies and systems that currently exist to leverage and/or improve OT services delivered via telehealth. STG: Identify specific assessments and screening tools utilized during OT service provision. STG: Identify measures of client engagement, satisfaction, and perception of value as well as any data using these measures in OT services delivered via telehealth. STG: Identify the “pressure points” facing the uptake and adoption of telehealth and how OT can address and mitigate these areas. STG: Develop protocols from existing telehealth practices that support value-based care. |
The second long term goal for uniform data collection (see Table 5) is rooted in OT practitioners’ extensive experience and training in understanding motivation and behavior change. Roles, habits, and routines underlie the day-to-day experience for our clients and the occupational disruption they experience means that OT practitioners are often the “go-to” professionals for many clients. There is an opportunity for OT to be at the forefront of a rapidly changing healthcare environment and contribute substantially to the research evidence that supports practice, the design of systems including referral, screening, assessment, intervention, and follow-up, and integration within and across technologies for telehealth.
Discussion
As OT researchers and practitioners, we are distinctly positioned to lead innovative and impactful studies that demonstrate OT’s influence on the health and quality of life for those we serve. With the move by payors towards value-based payments for OT services (AOTA, 2020d), it is imperative that we continue to advance the science behind OT services delivered both in-person and via telehealth. The themes and associated recommendations that resulted from the workgroups demonstrate the intersection of approaches that telehealth research in OT can leverage given our expertise in holistic approaches in authentic contexts. Because our interventions are situated in real world settings, our research must reflect the diversity of all clients who stand to benefit from OT service. Additionally, as the COVID-19 pandemic revealed, we no longer have the luxury of the linear progression of research studies and cannot afford the 17-year gap from research to practice (Hanney et al., 2015). The bidirectionality emphasized in this AOTF PGC should be a model in all stages: practice informs research and research informs practice.
The goals and areas of study identified by workgroups were extensive and the findings from the various work groups shared many intersecting areas of focus. To fully conceptualize these findings within the larger field of telehealth, we draw from three existing research measurement and evaluation frameworks to discuss intersections of workgroup findings: the Institute of Health’s four aims of healthcare reform (Berwick et al., 2008; Bodenheimer & Sinsky, 2014), the National Quality Forum’s (NQF) five Domains of Telehealth Measurement (NQF, 2017), and the SPROUT Telehealth Evaluation and Measurement Framework (Chuo et al., 2020). The PACE model provides a framework for telehealth research in occupational therapy and includes the following pillars: Population and Health Outcomes, Access for All Clients, Cost and Cost Effectiveness, Experience of clients and OT practitioners.
Population and Health Outcomes
The workgroup findings and recommendations demonstrate the need to identify and measure population and health outcomes, with a particular focus on performance of occupations in authentic contexts. Telehealth can be used to examine how the environment supports or hinders participation for populations, and how activities and tasks can be adapted to promote participation in home and community settings. Client and caregiver outcomes can be measured and activity and norms of behavior can be identified for specific populations that would inform population health. Some ways to achieve progress in this domain include data registries, multi-site efforts, and consistent measures of population and health outcomes as a result of OT via telehealth.
Access for All Clients
Although telehealth can improve access for those in rural and/or underserved communities, OT researchers must be cognizant of the process measures necessary to build access. Across research studies, we must focus on ways to improve upon and build access to OT interventions for those with a lack of technology or internet. Relatedly, we must make the process components of access provision explicit in our studies so that the OT community can continue to move the needle on this essential domain of telehealth research. This may include providing primers and tutorials on the use of tablets, webcams and smartphone. It may also include using time and resources to ensure that individuals who are not familiar with safe internet use know how to protect their data and privacy once internet services are provided. In addition, access extends beyond technology and internet. Our research must identify the cultural responsivity components that facilitate access to and effectiveness of interventions. This is particularly salient when considering that use of telehealth requires individuals to allow us into their authentic context rather than them coming to our clinic or lab space. Well-documented and systematic measures must be taken to provide OT services through telehealth that are culturally and contextually appropriate for each individual.
Cost and Cost Effectiveness
COVID-19 has highlighted the importance of telehealth and has changed the payment and practice landscape. Because the Veteran’s Health Administration, schools, and early intervention programs do not rely primarily on payment from third-party payors, they were able to integrate telehealth much sooner than hospitals, clinics, and community settings where the benefits of telehealth are just beginning to be realized with the increased use of telehealth in response to the COVID-19 pandemic. OT practitioners and clients are seeing firsthand the many benefits of telehealth, many who would never have participated in a telehealth service delivery model were it not for clinic and school closures. Research is needed to understand how generalizability of clients’ performance gains result from OT interventions delivered via telehealth, and how such generalizability contributes to cost effectiveness over time. Telehealth also may improve the affordability of care by transitioning care to the home versus more costly institutional settings, and research indicates that telehealth may yield comparable outcomes and lead to improved efficiencies (Cottrell et al., 2017; Kairy et al., 2009; Laver et al., 2020; Shigekawa et al., 2018), though more research is needed in this area.
Experiences of Clients and OT Practitioners
Through telehealth, we can provide the ‘right care, at the right time, in the right place’. Telehealth can be used to overcome geographical barriers of distance and travel, enhance access to care and continuity of care, and build capacity and efficiencies within the healthcare system (Cason, 2015). Research indicates generally a high level of satisfaction with telehealth among clients and practitioners across OT practice areas (Renda & Lape, 2018; Wallisch et al., 2019; Worboys et al., 2018). In addition, telehealth improves access to care and facilitates care coordination and chronic disease management; and fosters care in the community - all of which can improve the care experience. Telehealth can build professional capacity among practitioners through consultation with specialists and can improve work life of health care providers by improving efficiencies. Many practitioners in home health, with early intervention and adult populations, may drive hours each day between clients’ homes. Through telehealth, practitioners in the home health setting could spend more time working with clients and less time traveling between client’s homes. The reduction in travel and practice efficiencies may improve the work life of health care practitioners.
Conclusion
There are vast opportunities in telehealth research for OT researchers and practitioners. The pandemic resulted in rapid shifts in telehealth service delivery across settings, and our profession demonstrated its resourcefulness and resilience in expanding the ways in which we conduct research and serve our clients. While such rapid changes present uncertainty, we also are presented with a critical moment to demonstrate the distinct value of OT. The 2020 American Occupational Therapy Foundation Planning Grant Collective identified OT-led telehealth research initiatives to advance evidence-based practice using a collaborative and interdisciplinary approach. It is imperative to act now to provide evidence to support OT led telehealth practice.
Acknowledgments
This paper was made possible by the extraordinary efforts of the 2020 American Occupational Therapy Foundation Planning Grant Collective and the hard work and oversight of Dr. Scott Campbell and Dr. Mary Lawlor. In addition, the authors sincerely thank Gabrielle Garcon and Kristin Bukovsky for their assistance in planning and conducting the PGC.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Planning Grant Collective was sponsored by the American Occupational Therapy Foundation. KAP was supported by the National Institutes of Health (UL1TR002373, KL2TR002374).
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Research Ethics: No data were collected as part of the Planning Grant Collective.
References
- American Occupational Therapy Association. (2005). Telerehabilitation position paper. American Journal of Occupational Therapy, 59(6), 656–660. 10.5014/ajot.59.6.656 [DOI] [PubMed] [Google Scholar]
- American Occupational Therapy Association. (2010). Telerehabilitation [Position paper]. American Journal of Occupational Therapy, 64(6), S92–S102. 10.5014/ajot.2010.64S92 [DOI] [PubMed] [Google Scholar]
- American Occupational Therapy Association. (2013). Telehealth [Position paper]. American Journal of Occupational Therapy, 67(6), S69–S90. 10.5014/ajot.2013.67S69 [DOI] [Google Scholar]
- American Occupational Therapy Association. (2018). Telehealth in occupational therapy [Position paper]. American Journal of Occupational Therapy, 72(Supplement 2), 7212410059. 10.5014/ajot.2018.72S219 [DOI] [Google Scholar]
- American Occupational Therapy Association. (2020a). AOTA update: CMS expands therapy e-visit services during COVID-19 outbreak. https://www.aota.org/Practice/Manage/telehealth/Nonphysician-Evisits.aspx
- American Occupational Therapy Association. (2020b). Commercial insurance plans adding coverage for OT telehealth services in response to COVID-19. https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/Commercial-Insurance-Plans-Add-Coverage-OT-Telehealth-Services.aspx
- American Occupational Therapy Association. (2020c). COVID-19 state updates: Summary of telehealth, insurance, and licensure developments; and comprehensive state-by-state chart. https://www.aota.org/Advocacy-Policy/State-Policy/StateNews/2020/COVID-19-Summary-Telehealth-Insurance-Licensure.aspx
- American Occupational Therapy Association. (2020d). Payment for Value Based OT: implications for Quality and Practice. Retrieved from https://www.aota.org/Practice/Manage/value.aspx.
- Bacher-Hicks A, Goodman J, & Mulhern C (2020). Inequality in household adaptation to schooling shocks: Covid-induced online learning engagement in real time (No. w27555). National Bureau of Economic Research. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Berwick DM, Nolan TW, & Whittington J (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. 10.1377/hlthaff.27.3.759 [DOI] [PubMed] [Google Scholar]
- Bodenheimer T & Sinsky C (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. 10.1370/afm.1713 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cason J (2012a, May 21). An introduction to telehealth as a service delivery model in occupational therapy [Continuing Educational Article]. OT Practice, 17(7), CE1–8. [Google Scholar]
- Cason J (2012b). Telehealth opportunities in occupational therapy through the Affordable Care Act. American Journal of Occupational Therapy, 66, 131–136. 10.5014/ajot.2012.662001 [DOI] [PubMed] [Google Scholar]
- Cason J (2014). Telehealth: A rapidly developing service delivery model for occupational therapy. International Journal of Telerehabilitation, 6(1), 29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cason J (2015). Telehealth and occupational therapy: Integral to the triple aim of health care reform. American Journal of Occupational Therapy, 69(2),6902090010. 10.5014/ajot.2015.692003. [DOI] [PubMed] [Google Scholar]
- Cason J (2019, January). Viewpoints—Telehealth: A Q&A with Sherry Kolodziejczak. OT Practice [Online]. Available at https://www.aota.org/Publications-News/otp/Archive/2019/viewpoints-telehealth.aspx
- Center for Connected Health Policy. (2019). State telehealth laws and reimbursement policies. https://www.cchpca.org/sites/default/files/2019-10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf
- Chuo J, Macy ML, & Lorch SA (2020). Strategies for Evaluating Telehealth. Pediatrics, 146(5). 10.1542/peds.2020-1781 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cottrell M, Galea O, O’Leary S, Hill A, & Russell T (2017) Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: A systematic review and meta-analysis. Clinical Rehabilitation, 31(5), 625–638. 10.1177/0269215516645148 [DOI] [PubMed] [Google Scholar]
- Emerald. (n.d.). Emerald is a touchless sensor and machine learning platform for health analytics. https://www.emeraldinno.com/
- Hanney SR, Castle-Clarke S, Grant J, Guthrie S, Henshall C, Mestre-Ferrandiz J, … & Wooding S (2015). How long does biomedical research take? Studying the time taken between biomedical and health research and its translation into products, policy, and practice. Health research policy and systems, 13(1), 1. 10.1186/1478-4505-13-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 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 & Rehabilitation, 31(6), 427–447. 10.1080/09638280802062553 [DOI] [PubMed] [Google Scholar]
- Laver KE, Adey‐Wakeling Z, Crotty M, Lannin NA, George S, & Sherrington C (2020). Telerehabilitation services for stroke. Cochrane Database of Systematic Reviews. 10.1002/14651858.CD010255.pub3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- National Quality Forum. (2017). Creating a Framework to Support Measure Development for Telehealth. Washington, DC: National Quality Forum. [Google Scholar]
- Pew Research Center (2019). Internet / Broadband Fact Sheet. Retrieved December 16, 2020 from https://www.pewresearch.org/internet/fact-sheet/internet-broadband/
- Renda M & Lape JE (2018). Feasibility and effectiveness of telehealth occupational therapy home modification interventions. International Journal of Telerehabilitation, 10(1), 3–14. 10.5195/ijt.2018.6244 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rush DD, & Shelden MLL (2011). The Early Childhood Coaching Handbook. Brookes Publishing Company, Baltimore, MD. [Google Scholar]
- Russell TG, Martin-Khan M, Asaduzzaman K, & Wade V (2017). Method-comparison studies in telehealth: Study design and analysis considerations. Journal of Telemedicine and Telecare, 23(9) 797–802. 10.1177/1357633X17727772 [DOI] [PubMed] [Google Scholar]
- Serwe KM, Schloer L, & Vigna S (2019). Increasing Caregiver Access to Programming: A Qualitative Exploration of Caregivers’ Experience of a Telehealth Powerful Tools for Caregivers Program. Home Healthcare Now, 37(5), 273–280. [DOI] [PubMed] [Google Scholar]
- Shigekawa E Fix M, Corbett G, Roby D, & Coffman J (2018). The current state of telehealth evidence: A rapid review. Health Affairs, 37(12), 1975–1982. 10.1377/hlthaff.2018.05132 [DOI] [PubMed] [Google Scholar]
- Tenforde AS, Borgstrom H, Polich G, Steere H, Davis IS, Cotton K, O’Donnell M, & Silver JK (2020). Outpatient physical, occupational, and speech therapy synchronous telemedicine. American Journal of Physical Medicine & Rehabilitation, 99(11), 977–981. 10.1097/PHM.0000000000001571 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wallisch A, Little L, Pope E, & Dunn W (2019). Parent perspectives of an occupational therapy telehealth intervention. International Journal of Telerehabilitation, 11(1), 15–22. 10.5195/ijt.2019.6274 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Weber E, Miller SJ, Astha V, Janevic T, & Benn E (2020). Characteristics of Telehealth Users in NYC for COVID-related Care during the Coronavirus Pandemic. Journal of the American Medical Informatics Association. 10.1093/jamia/ocaa216 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Worboys T, Brassington M, Ward EC, & Cornwell PL (2018). Delivering occupational therapy hand assessment and treatment sessions via telehealth. Journal of Telemedicine and Telecare, 24(3), 185–192. 10.1177/1357633X17691861 [DOI] [PubMed] [Google Scholar]
- World Federation of Occupational Therapists. (2014). Telehealth [Position statement]. Retrieved December 16, 2020 from https://www.wfot.org/resources/telehealth