key: cord-0946349-f62d5mye authors: Miller, Matthew J; Pak, Sang S; Keller, Daniel R; Barnes, Deborah E title: Evaluation of Pragmatic Telehealth Physical Therapy Implementation During the COVID-19 Pandemic date: 2020-10-19 journal: Phys Ther DOI: 10.1093/ptj/pzaa193 sha: 19536812f04bfbe5c753bfc0eeb2e63a22e536d4 doc_id: 946349 cord_uid: f62d5mye OBJECTIVE: To evaluate implementation of telehealth physical therapy in response to COVID-19 and identify implementation strategies to maintain and scale-up telehealth physical therapy within a large urban academic medical center. METHODS: The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework was used to evaluate telehealth physical therapy implementation. Patient-level data were extracted from electronic medical records between the dates of March 16 and May 16, 2020 (implementation phase). Reach was defined as the proportion of physical therapy sessions completed via telehealth. Effectiveness was assessed using a patient-reported satisfaction survey with a 5-point Likert scale. Adoption was defined as the proportion of physical therapists who used telehealth. Implementation was assessed through qualitative analysis of patient and clinician perspectives to identify emergent themes, retrospectively classify strategies used during the implementation phase, and prospectively identify evidence-based strategies to increase telehealth maintenance and scale-up. Maintenance of telehealth was defined as the proportion of patients who indicated they would attend another telehealth session. RESULTS: There were 4548 physical therapy sessions provided by 40 therapists from date to date, of which 3883 (85%) were telehealth. Ninety-four percent of patients were satisfied. All physical therapists (100%) used telehealth technology at least once. Retrospectively classified and prospectively identified evidence-based strategies were organized into five qualitative themes that supported implementation: organizational factors (policies, pre-existing partnerships), engaging external stakeholders (satisfaction survey), champions (clinician leaders), clinician education (dynamic, ongoing training), and process (promote adaptability, small tests of change). Ninety-two percent of patients reported they would attend another telehealth session. CONCLUSION: Findings from this study suggest that implementation of telehealth physical therapy during the COVID-19 pandemic was feasible and acceptable in this setting. IMPACT: These results can be used to guide future health policy, quality improvement, and implementation science initiatives to expand the use and study of telehealth for physical therapy. Telehealth technology has been long considered an option for delivering high quality, high value physical therapy intervention. 1 Use of telehealth within physical therapist practice has promising efficacy for improving rehabilitation outcomes in patients with orthopedic conditions (eg, total joint arthroplasty, low back pain), neurologic injury (eg, stroke, ALS), and chronic, disabling health conditions. [2] [3] [4] [5] [6] [7] [8] Further, the estimated cost of using telehealth technology in physical therapist practice appears feasible. 9 Reimbursement limitations have been a significant barrier to widespread telehealth physical therapy adoption in the United States. For example, the Center for Medicare and Medicaid Services (CMS) did not have billing codes for telehealth physical therapy services, and physical therapists were not eligible telehealth providers prior to the COVID-19 pandemic. In the early stages of the pandemic, local and state policies were enacted to slow the spread of the virus. 10, 11 Specifically, the San Francisco Bay Area, a region with early community spread of COVID-19, initiated an aggressive shelter-in-place plan, limiting contact with people outside of their immediate household, non-essential travel, and closing non-essential operations. 11 During the months of March and April, many commercial insurance providers minimized barriers to reimbursement of telehealth physical therapy. On April 30 th , the Centers for Medicare and Medicaid Services (CMS) issued policy changes to include physical therapists as eligible providers of telehealth services, allowing beneficiaries to access rehabilitative care during the public health emergency. 12 Implementation of promising innovations (eg, telehealth physical therapy) within healthcare operations should consider the complex interactions of contextual factors (eg, patient, clinician, administrative) with a guiding framework. [13] [14] [15] The RE-AIM framework has been used to prospectively, concurrently, and retrospectively plan and evaluate the translation of scientific innovations into a variety of pragmatic, "real-world" settings. 15, 16 The elements of the RE-AIM framework guide the planning and evaluation process by focusing efforts in five key domains. The domains, including reach, effectiveness, adoption, implementation and maintenance, are extensively described elsewhere. 15, 16 Implementation outcomes, which are measures of implementation success, may be particularly relevant in early implementation stages to understand the context and strategies (eg, Expert Recommendations for Implementation Change [ERIC] project) that should be used to facilitate maintenance and scale-up. 17, 18 To date, there have been few published reports describing telehealth physical therapy implementation planning or evaluation. Additionally, implementation strategies to maintain and scale-up telehealth physical therapy remain unclear. Therefore, the purpose of this study was to evaluate implementation of telehealth physical therapy in response to COVID-19 from patient and clinician perspectives and identify implementation strategies to maintain and scale-up longterm telehealth physical therapy within a large urban academic medical center. [H1]Methods Comorbidity burden was measured using the Charlson comorbidity index. 20 To contextualize potential differences in telehealth use, data were also extracted from March 16 to May 16, 2019. Administrative incident reports related to telehealth physical therapy were also extracted from the implementation phase to identify potential safety concerns. A patient satisfaction survey ( Fig. 1) Clinic clinicians' and supervisors' perspectives were obtained using qualitative methods. The lead author (MJM) took extensive field notes while engaging in telehealth-focused staff meetings, task force meetings, educational sessions, and clinician interviews. During these meetings, clinician leaders (ie, champions) described patient, clinician, and administrative barriers to telehealth implementation, facilitated problem solving to address barriers, and provided education. Clinicians volunteered for one-time videoconference interviews (~45 minutes each) in groups of 1 to 3 participants with a stated goal to understand how clinicians are adapting to telehealth sessions, identify emergent challenges, and explore potential solutions. Clinician interview procedures included a welcome, introductions, description of interview goals, a statement of interview confidentiality, and interview questions (eg, "What is going well with telehealth?", "What isn't going well with telehealth?", "What would you change to make improvements?", "What aspects of telehealth do you need more training?"). Throughout qualitative data collection from clinicians and supervisors, the lead author had opportunities to ask clarifying and probing questions to obtain additional detail and perspectives. The University of California San Francisco Institutional Review Board determined this study involved quality improvement activities and did not require IRB oversight. Each element of the RE-AIM framework was analyzed separately. The primary measure of reach was the proportion of sessions that were telehealth physical therapy (new, follow-up). Effectiveness was conceptualized as patient satisfaction and safety. 18 Satisfaction was measured as the proportion of patients who had an average score of ≥3 (at least satisfied) on the ten-item satisfaction survey. Safety was assessed as the number and description of adverse events during the implementation phase. Adoption was measured as the proportion of physical therapists using telehealth technology at least once and the average proportion of physical therapists' sessions that were delivered using telehealth technology during the implementation phase. Qualitative methods have previously been used to assess implementation with the RE-AIM framework. 22 An applied thematic analysis approach, which emphasizes pragmatic, efficient, and rigorous analysis, was selected for the purpose of identifying emergent themes 10 from qualitative data. 23 Patient satisfaction survey open ended questions and field notes (clinician interviews, implementation-focused meetings) were coded by the lead author (MJM) using a structural coding strategy, where responses to primary questions were assigned unique codes. 23 Following coding, data from patients and field notes were merged, similar codes and concepts were condensed into categories, and emergent themes (barriers/facilitators) were identified. The iterative qualitative analysis was led by MJM and enhanced by weekly feedback from a clinical champion (DRK) and/or clinic supervisors to discuss, refine, and finalize emergent themes. Potential for maintenance and scale-up of telehealth implementation was assessed as the proportion of patients who responded "yes" to the single question regarding participation in another telehealth physical therapy session. Finally, MJM and DRK used the ERIC framework 17 to retrospectively classify strategies used in the implementation phase, prospectively identify strategies to maintain and scale-up telehealth, and identify strategy application exemplars. A stakeholder meeting with champions, supervisors, and academic stakeholders was convened to obtain feedback and consensus on prospective implementation strategies for telehealth maintenance and scale-up. The funders played no role in the design, conduct, or reporting of this study. Effectiveness: The satisfaction survey was sent to 1153 (75%) patients, and surveys were returned by 307 (27%) patients. The ten-item patient satisfaction survey was complete for 270 patients and 254 (94%) were at least satisfied. There was one adverse event during the implementation phase, which was a non-injurious controlled fall. Adoption: All physical therapists conducted at least one telehealth session, indicating 100% adoption. The average (SD) proportion of physical therapists' sessions that were delivered using telehealth technology during the implementation phase was 89% (16). Implementation: Qualitative analysis of patient satisfaction open-ended questions, and field notes from clinician interviews (N = 19 clinicians) and implementation focused meetings resulted in five emergent themes (barriers/facilitators). These emergent themes were placed within a context that shelter-in-place was perceived as temporary, and would move to a new phase with less restrictive guidelines. Specific to the shelter-in-place, clinician discussions and Maintenance: The single yes/no question was completed by 305 patients, with 92% of respondents reporting willingness to participate in additional telehealth physical therapy sessions. The purpose of this study was to evaluate implementation of telehealth physical therapy in response to COVID-19 and identify implementation strategies to maintain and scale-up long- 13 term telehealth physical therapy within a hospital-based outpatient clinic. During the implementation phase, telehealth was used to reach patients in 85% of sessions, and adopted by 100% of physical therapists. Patients were largely satisfied and indicated they would attend another telehealth physical therapy session. Finally, implementation strategies were retrospectively classified with the ERIC framework, and prospectively identified for future telehealth maintenance and scale-up. There is mounting evidence supporting telehealth physical therapy for people with a variety of disabling health conditions. [2] [3] [4] [5] [6] [7] [8] [9] Despite this evidence, the rigorous methods used in prior research limits generalizability of findings into "real-world" settings, where telehealth is yet to be adopted. 15, 16 Telehealth physical therapy implementation has previously been evaluated in the skilled nursing facility setting, 8 but there were limited reports from other practice settings. The positive findings from the present study contribute to the understanding of telehealth physical therapy implementation by providing evidence of the feasibility and potential for success within a large urban medical center. Evaluating reach during the implementation phase can inform future work to make access to telehealth equitable. 15 Low acceptability, satisfaction, and adoption can be a significant barrier to implementation maintenance. 18 In general, patients were more than satisfied, and 92% of patients reported willingness to participate in another telehealth session. Additionally, an average of 89% of physical therapist caseloads was completed using telehealth. For patients and clinicians, the perception of shelter-in-place as a temporary period placed telehealth as a suitable alternative to no physical therapy, and many patients and clinicians desired maintenance of telehealth sessions beyond the pandemic. While there is risk of response bias towards those who had a telehealth session, were sent, then completed the satisfaction survey, the positive findings suggest there are patients who find telehealth as an acceptable option for physical therapy access. The application of evidence-based implementation strategies from the ERIC project is relevant for the generalizability of the present study findings. 17 Although a priori implementation planning is recommended, 16,18 prospective selection of telehealth implementation strategies was not feasible for this study. Therefore, strategies from the implementation phase were retrospectively classified, and prospectively identified to increase the potential for maintenance and scale-up of telehealth. The majority of prospectively identified strategies were a progression of retrospectively classified strategies. For example, clinician education will be progressed from basic topics (eg, connectivity troubleshooting, benefits of telehealth) to advanced topics (eg, screensharing anatomic images, exercise videos, telehealth clinical decision making). Alternatively, some prospective strategies were not formally used during the implementation phase, and require ongoing effort. For example, collaborative rehabilitation clinics (eg, Integrated Sports Rehabilitation Group, Pelvic Health, ALS Clinic) were aware of the telehealth implementation efforts; yet, formal engagement and network weaving was not undertaken during the implementation phase. Iterative, small tests of change will inform the development of specialized processes to optimize the function of collaborative clinics using telehealth technology. This quality improvement study using the RE-AIM framework was conducted within one setting, and emergent themes (barriers/facilitators) may not generalize to other contexts. Although the RE-AIM framework is used for implementation planning, research suggests the application of multiple theories, models, and/or frameworks is needed optimize implementation success at different stages. 29 For example, determinant frameworks (eg, Consolidated Framework for Implementation Research, 14 Theoretical Domains Framework 30 ) and/or implementation theory (eg, Normalization Process Theory 31 ) could be used to formally assess barriers, facilitators, and strategies of telehealth PT implementation during subsequent maintenance, scale-up, and optimization phases. The pragmatic nature of this study was largely a retrospective analysis of administratively collected data that could be queried from the medical record during a relatively short period of time, therefore analyses of prospectively planned quantitative and qualitative data collection was limited. The use of a satisfaction survey has potential to increase the risk of response bias towards patients who participated in telehealth physical therapy and completed the survey. The Implementation of telehealth physical therapy during the COVID-19 pandemic was successful in a large urban medical center. Compared to prior utilization, the reach and adoption of telehealth physical therapy during the implementation phase were higher. Further, patients' satisfaction and willingness to have additional telehealth physical therapy sessions was high. The positive findings from this study demonstrate that patients find telehealth acceptable and physical therapy services may be delivered using telehealth technology. These study findings can be used to guide future policy, quality improvement, and implementation science initiatives to expand the use and study of telehealth for physical therapy. • Clinicians and champions will develop and refine marketing materials for patients and referring providers. • Patients with unaddressed concerns were encourage to speak with a physical therapist to answer specific questions. • Expand use of social media and clinic website. • Supervisors, champions, and clinicians contacted referring providers to inform them of telehealth implementation. • In addition to satisfaction survey use, data experts and academic partners will iteratively explore qualitative barriers to telehealth within specific patient populations. • Social media and websites were updated to reflect implementation of telehealth sessions. • Champions, supervisors, and academic partners will target specific populations to increase reach and uptake of telehealth. Involve patients/consumers and family members • Satisfaction survey was developed and implemented to obtain patient feedback. Identify and prepare champions • Champions were identified by supervisors for smaller implementation-focused task forces, and led small cycles of change to inform planned scale-up strategies. • Champions will be an ongoing departmental resource for supervisors, clinicians, administrative staff, and administrative staff. • Assessment of barriers, facilitators, and needs by champions and supervisors will be ongoing. For example, adjustment to clinical environment to include telehealth physical therapy while maintaining physical distancing. Change physical structure and equipment • Patient barriers to access (eg, technology, scheduling) were identified using satisfaction surveys and open forums for discussion with clinical and administrative staff. • Supervisors and data experts will use satisfaction surveys and qualitative engagement with external stakeholders to guide targeting of specific barriers to telehealth access. Conduct local needs assessment • Local technical assistance for patients was provided by Rehabilitation Aides when needed. • Supervisors will explore centralized technical support for patients with UCSFMC Telehealth Department for technical issues, pre-visit education. Centralize technical assistance • Hospital system IT department was consulted for clinician technical assistance when needed. • Champions to lead scale-up of higher volume of in-person visits and flexibility of mixed in-person and telehealth physical therapy sessions. Provide local technical assistance • Small tests of change throughout implementation, led by champions, created opportunities for planned scale-up. • Scale-up to include increasing reach to specialty populations (eg, neurology, pelvic health). Stage implementation scaleup • Patient satisfaction survey, specific to telehealth physical therapy, was developed, tested, and implemented by data experts using Redcap. • Patient satisfaction survey will continue, potentially managed by a third party to centralize data collection and management. Report of the WCPT / INPTRA Digital Physical Therapy Task Force. World Confederation for Physical Therapy and International Network of Physiotherapy Regulatory Authorities Telerehabilitation is non-inferior to usual care following total hip replacement -a randomized controlled non-inferiority trial A feasibility study for improved physical activity after total knee arthroplasty Telerehabilitation services for stroke. 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Front Public Heal. 2019;7. underlying health conditions among patients with Coronavirus Disease 2019 -United States Telemedicine in Complex Diabetes Management The digital divide in adoption and use of a personal health record Failure of an internet-based health care intervention for colonoscopy preparation: a caveat for investigators Telerehabilitation feasibility in total joint replacement Making sense of implementation theories, models and frameworks Validation of the theoretical framework Implementing, embedding, and integrating practices: an outline of normalization process theory The authors thank the patients, clinicians, and leaders at the University of California, San Francisco Medical Center (UCSFMC) Outpatient Physical Therapy Faculty Practice who participated in the telehealth physical therapy implementation. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.