key: cord-0725439-r5g5jwr6
authors: Middleton, Addie; Simpson, Kit N; Bettger, Janet Prvu; Bowden, Mark G
title: COVID-19 Pandemic and Beyond: Considerations and Costs of Telehealth Exercise Programs for Older Adults With Functional Impairments Living at Home—Lessons Learned from a Pilot Case Study
date: 2020-05-05
journal: Phys Ther
DOI: 10.1093/ptj/pzaa089
sha: b6093f9dfca53b795851b769156a9a5d484d71eb
doc_id: 725439
cord_uid: r5g5jwr6

OBJECTIVE: The purpose of this study was to describe the process and cost of delivering a physical therapist–guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. METHODS: Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. RESULTS: A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the “value proposition” of this type of intervention were also reported. Per-session cost of $158 appears to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. CONCLUSIONS: The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a “blue print” for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. IMPACT: As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study’s experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.

The current coronavirus disease (COVID-19) pandemic highlights areas in health care where we could be better prepared for disruptive events. In rehabilitation, a clear need for more telehealth-delivered options has emerged. This need has been recognized by the Centers for

Medicare and Medicaid Services (CMS). In response to the COVID-19 pandemic, CMS has temporarily loosened restrictions and permitted physical therapists to provide "e-visits" shortterm (ie, up to 7 days) to already established patients. 1 Although temporary, this landmark move by CMS highlights the importance of improving access to services during the current pandemic.

To slow the spread of COVID-19, social distancing and quarantine protocols have been enacted. "Social distancing" refers to keeping space (>6 feet) between yourself and others,

whereas "quarantine" refers to remaining in your home or current location as much as possible when you have been exposed or might have been exposed to COVID-19. 2 Social distancing and quarantine protocols not only limit access to skilled services but to opportunities for physical activity. Lack of physical activity is detrimental to older adults' health, functional independence, and quality of life. 3, 4 These detrimental impacts may be compounded in individuals with functional impairments and disability. 5 The rehabilitation field should be proactive rather than reactive and leverage alternative strategies, such as telehealth, to provide services that diminish the impacts of social distancing and quarantine on physical function. As movement experts, physical therapists are wellpositioned to lead efforts to develop programs that provide opportunities for physical activity to individuals at increased risk of decline, such as older adults with functional impairments.

We used information and cost estimates from a pilot study testing the feasibility of a physical therapist-guided synchronous (ie, live and interactive) telehealth exercise program and describe: (1) the process used to develop and deliver the program; and (2) the cost incurred in

developing and successfully delivering the telehealth program to an older adult with functional impairments. Our findings will help inform the planning, budgeting, and implementation of telehealth programs designed to improve access to physical activity for older adults with functional impairments.

We used a descriptive study design to document the steps involved in development and delivery of a physical therapist-guided synchronous telehealth exercise program. We derived process and cost information from the feasibility arm of a parent study, which piloted the program with 1 participant. The steps and considerations were refined postprogram to reflect our actual procedures and serve as a guide informed by our experiences developing and delivering the program. The study complies with the Declaration of Helsinki and was approved by the Medical University of South Carolina's Institutional Review Board. We obtained informed consent from the participant.

We recruited the participant through local physical therapists. The telehealth exercise program provider (A.M.) held information sessions about the study at 2 outpatient physical therapy clinics and provided physical therapists who attended a handout detailing study inclusion/exclusion criteria (Tab. 1). The physical therapists were asked to refer patients who met the criteria and expressed interest in participating. The first individual referred met the selection criteria and was enrolled after discharge from physical therapy.

[H2]Program Content

The telehealth exercise program consisted of 36 sessions, each of which were 45 minutes in duration, delivered approximately 3 times per week. The duration (36 sessions) and content of the program was founded on high-quality evidence from the stroke literature, as the parent study focused on a telehealth exercise program for survivors of stroke. 6, 7 All exercise sessions were delivered via a telehealth platform on a tablet computer. The exercises performed in each session were individualized to the participant's impairments and progressed with the goal of maintaining a rating of perceived exertion (RPE) between 12 and 16 on the 6-to-20 RPE scale. [8] [9] [10] The participant was provided an RPE handout that used color-coding and pictures to increase understanding of the scale. We asked the participant to report the RPE after each exercise set (eg, 12 repetitions) and adjusted the next set accordingly. The primary focus was strength and balance, and we included both seated and standing exercises. In Table 2 , we show example exercises from the program and their progression.

To inform session activities and determine the effects of the program on the participant's functional status, we performed preprogram and postprogram evaluations. The evaluations included the following measures: 5 Times Sit-to-Stand Test, 11 Berg Balance Scale, 12 Activitiesspecific Balance Confidence Scale, 13 Stroke Impact Scale, 14 5-Meter Walk Test (self-selected and maximal speeds), 15 and steps per day. Steps per day were collected via 7 days of activity monitoring using an ActiGraph GT3X+ accelerometer (Actigraph Corporation, Pensacola, Florida, USA) worn on the ankle of the nonhemiparetic leg. 16 We selected these measures because they provide a fairly global view of functional status (mobility, strength, and balance).

[H2]Personnel Procedural Terminology (CPT) codes commonly billed in physical therapy.

The funders played no role in the design, conduct, or reporting of this study.

[H1]Results

The participant was a 67-year-old white man with a history of stroke (19 months prior), hypertension (controlled), and diabetes mellitus (controlled). He lived with his wife in a singlestory house and ambulated with a quad cane and bilateral ankle-foot orthoses. The participant completed all 36 exercise sessions over 14 weeks. He maintained an average RPE in the target range (12-16) for 35/36 sessions. His functional mobility, balance, and Stroke Impact Scale perceived recovery scores improved from preprogram to postprogram. However, little change was observed in his walking speed, steps per day, or overall Stroke Impact Scale score (Tab.

3).

[H2]Process

The steps involved in developing and delivering the telehealth exercise program are presented in Table 4 , along with important considerations for each step.

[H3]Development Step 1. Select telehealth platform. We selected the telehealth platform, Vidyo (Vidyo Inc, Hackensack, New Jersey, USA). 18 An important consideration was our need for a secure platform that allowed us to conduct synchronous sessions. We also wanted a platform that was easy to use and, once we secured a license, freely accessible to the participant. Another consideration was the flexibility of devices that could connect with the platform. Vidyo is compatible with smartphones, tablet computers, and personal computers. As we are learning in the current pandemic, we do not always have the luxury of going to individuals' homes to set up equipment. Under such circumstances, we need to select platforms that are compatible with commonly used technology (eg, smartphones and tablets) and avoid platforms that require in-home setup of additional equipment by program personnel.

[H3]Development Step 2. Develop documentation system. We developed a documentation system in REDCap (REDcap Consortium, https://www.project-redcap.org/software). 19 Our system was developed to collect data for the research component of the telehealth program;

new systems may not be needed if current systems can be used or modified to meet documentation needs. A consideration when developing or modifying a documentation system for a telehealth program is whether participants will enter information on their end, or whether all information will be collected and entered by the provider. During development, the provider should determine whether a system that captures audio, video, and/or text data from participants is needed, and, if so, whether these data need to be captured during sessions (synchronously), between sessions (asynchronously), or both.

Our first resource consideration was personnel. There are multiple approaches for setting up "who" delivers telehealth exercise programs. However, knowledge and experience are important considerations. Individuals who know how to safely prescribe and modify exercises for older adults with functional impairments should deliver programs designed for this population or, at a minimum, should supervise and train other staff involved in delivery. We decided to have a physical therapist and trained assistant deliver all sessions. This personnel mix allowed 1 person to closely supervise the participant while the other person documented the session.

Detailed documentation was required for the research component of the program.

We also considered the supplies needed to deliver the program. Because the participant would be performing the sessions in their home and might not have access to exercise equipment, we provided the participant with resistance bands (7 levels). Due to concerns about camera angles and being able to adequately see relevant parts of the participant during sessions (eg, lower extremities), we also supplied the participant with an adjustable stand for their tablet. Provision of supplies may need to be modified during periods of social distancing and quarantine.

Dropping off supplies while maintaining social distancing (eg, leave on porch) may be appropriate, or the equipment used during the program may need to be creatively constructed out of what the individual already has on hand. Creative construction will likely require guidance by the physical therapist either through video calls or emails with simple step-by-step guides.

[H3]Development Step 4. Identify recruitment sources and develop recruitment strategies.

An important consideration when developing a telehealth exercise program is determining how to identify individuals who are appropriate for the program. We believed that physical therapists

represented one avenue for identifying these individuals. However, other health care sources (eg, primary care providers) and community sources (eg, senior centers) should also be considered. Recruitment strategies will have to be modified during periods of social distancing and quarantine. Planning will need to focus on remote meetings with recruitment sources and development of electronic recruitment materials.

[ [H1]Discussion

We provide a description of the process and cost of developing and delivering a synchronous telehealth exercise program for older adults with functional impairments. During development, it is important to consider participant and provider needs related to the telehealth platform and documentation system. It also is important to identify necessary resources. During delivery, it is important to consider participant and provider needs related to assessments, telehealth technology training, environmental setup, and program content. Our cost findings support the value of telehealth exercise programs for older adults with functional impairments. The demand for programs that improve access to opportunities for physical activity to this at-risk population may grow as regions across the United States and countries around the globe respond to the current pandemic and enforce social distancing and quarantine protocols.

Individuals who are currently receiving physical therapy will need to continue to receive skilled care during the pandemic. To address this need, many providers are exploring telerehabilitation options. We believe that it is important to continue to provide this skilled rehabilitative care, and we are not suggesting to replace it with an exercise program; however, exercise programs may be an appropriate strategy for preventing decline among at-risk populations. Rather than waiting and addressing declines in health and function after they occur, physical therapists can be proactive and keep at-risk individuals active. There is a growing focus on prevention in health care, which has extended to the rehabilitative field. 26 

During pandemics and other disruptive events, the short-term focus is timely solutions to address pressing needs. As already discussed, one short-term focus in rehabilitation is how to prevent declines due to inactivity in our at-risk populations. 29 We also need to consider the longer-term impacts and prepare for gaps that may appear moving forward. Early reports

suggest that older individuals and those with comorbidities experience more severe effects of COVID-19. 30 Because these individuals will likely need rehabilitative care, we may encounter a surge in older adult patients recovering from the virus. If the surge occurs while the health system is still strained and social distancing and/or quarantine protocols remain in place, we will need strategies for delivering remote care to these individuals. Telehealth exercise programs and/or telerehabilitation programs will be critical for filling this gap. While our program focused on exercise, the content was strength and balance, which also falls under the umbrella of "rehabilitation." Our findings, therefore, may help inform development of telerehabilitation programs for older adults with functional impairments, as well.

Our findings are purely descriptive and should be interpreted and generalized with caution.

However, we provide timely information that can serve as a foundation for future studies and potentially inform nonresearch telehealth exercise program development. We used information from a pilot feasibility study, which included only 1 participant in the exercise program part of the study. Due to the nature of recruitment (volunteer) and lack of randomization, there is potential for participant bias. The sample size did not impact our ability to address our objectives with this ancillary project focused on process and costs. The parent study focused on individuals poststroke. Although we believe the information shared in this article may be useful for other populations of older adults with functional impairments, further research and evaluation is needed to confirm its broader applicability.

Limitations related to the program should also be considered. Remote delivery increases fall risk, as providers cannot guard participants or assist during losses of balance. Remote delivery also requires access to internet services, which may be a limitation in resource-poor areas.

The current COVID-19 pandemic should serve as an impetus for progress in the rehabilitative field. It is urgent that we to develop innovative strategies for preventing functional decline among at-risk individuals during periods of social distancing and quarantine. However, the value of such programs is not limited to crisis periods. Many of our rural residents need these types of services even under normal circumstances. Telehealth exercise programs are one avenue for improving access to physical activity. Our findings provide insight into the process and cost of developing telehealth exercise programs for older adults with functional impairments. Research is needed to examine implementation and scalability during periods of social distancing and quarantine while maintaining effectiveness and safety. Consumer demand and provider preferences should also be explored. Importantly, we need to continue to work with payers and legislators to ensure regulatory and reimbursement barriers are removed to expand reach to those isolated by circumstances or geography. Steps per day collected via 7 days of activity monitoring (ActiGraph GT3X+ accelerometer worn on the ankle of the nonhemiparetic leg). 3. Identify and obtain necessary resources (personnel and supplies)

U N C O R R E C T E D M A N U S C R I P T U N C O R R E C T E D M A N U S C R I P T U N C O R R E C T E D M A N U S C R I P T

Medicare telemedicine health care provider fact sheet

Effect of structured physical activity on prevention of major mobility disability in older adults: The life study randomized clinical trial

Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses

Physical activity attenuates total and cardiovascular mortality associated with physical disability: A national cohort of older adults

Randomized clinical trial of therapeutic exercise in subacute stroke

Body-weight-supported treadmill rehabilitation after stroke

Perceived exertion as an indicator of somatic stress

Physical activity and exercise recommendations for stroke survivors: A statement for healthcare professionals from the american heart association/american stroke association

Exercise assessment and prescription in patients with type 2 diabetes in the private and home care setting: Clinical recommendations from axxon (belgian physical therapy association)

5-repetition sit-to-stand test in subjects with chronic stroke: Reliability and validity

Usefulness of the berg balance scale in stroke rehabilitation: A systematic review

Measurement properties of the activities-specific balance confidence scale among individuals with stroke

The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change

The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: A systematic review

Validity of the actigraph activity monitor for individuals who walk slowly post-stroke. Top Stroke Rehabil

Time-driven activity-based costing in health care: A systematic review of the literature. Health Policy

 Personnel -Qualifications of individual who will run program and/or deliver sessions  Supplies -Exercise equipment needed to deliver content -Additional supplies needed to enhance delivery of program (e.g., adjustable stands for communication devices) -Develop procedures for infection control, if equipment will be transferred to subsequent participants  Availability of family or caregivers for setup or participation  Environmental setup in participants' homes (eg, moveable and safe chairs, counters/rails for support)  Technology available in participants' homes (e.g., tablet, laptop)  Exercise equipment available in participants' homes  Safety of participants using equipment 4. Identify recruitment sources and develop recruitment strategies  Define target population  Identify individuals who interact regularly with target population (e.g., physical therapists, physicians)  Develop resources for recruitment (e.g., flyers) Characteristics of individuals who may benefit from a home telehealth exercise program  Characteristics of individuals who would not be appropriate for a home telehealth exercise program