key: cord-0959834-gumls1tb
authors: Lopez, Christian J.; Edwards, Beth; Langelier, David M.; Chang, Eugene K.; Chafranskaia, Aleksandra; Jones, Jennifer M.
title: Delivering virtual cancer rehabilitation programming during the first 90 days of the COVID-19 pandemic: A multimethod study
date: 2021-02-19
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2021.02.002
sha: c6c17c4a9d70362aeb398b82cb9629944f047a82
doc_id: 959834
cord_uid: gumls1tb

Objective To describe the adaptations made to implement virtual cancer rehabilitation at the onset of the COVID-19 pandemic, as well as understand the experiences of patients and providers adapting to virtual care. Design Multimethod study. Setting : Cancer Centre. Participants Adult cancer survivors and oncology health care providers. Interventions Not applicable. Main Outcome Measures Framework-driven categorization of program modifications, qualitative interviews with patients and providers, and a comparison of process outcomes with the previous 90 days of in-person care via referrals, completed visits and attendance, method of delivery, weekly capacities, and wait times. Results The majority of program visits could be adapted to virtual delivery, with format, setting, and content modifications. Virtual care demonstrated an increase or maintenance in the number of completed visits by appointment type compared to in-person care, with attendance ranging from 80-93%. For most appointment types, capacities increased, while wait times decreased slightly. Overall, 168 patients (11% of all assessments and follow-ups) assessed virtually were identified by providers as requiring an in-person appointment due to re-assessment of musculoskeletal and/or neurological impairment (n=109, 65%) and lymphedema (n=59, 35%). The interviews (n=24) revealed that virtual care was an acceptable alternative in some circumstances, with the ability to: 1) increase access to care; 2) provide a sense of reassurance during a time of isolation; and 3) provide confidence in learning skills to self-manage impairments. Conclusions Many appointments can be successfully adapted to virtual formats to deliver cancer rehabilitation programming. Based on our findings, we provide practical recommendations that can be implemented by providers and programs to facilitate the adoption and delivery of virtual care.

some circumstances, with the ability to: 1) increase access to care; 2) provide a sense of 23 reassurance during a time of isolation; and 3) provide confidence in learning skills to self-24 manage impairments. 25

Conclusions: Many appointments can be successfully adapted to virtual formats to deliver 26 cancer rehabilitation programming. Based on our findings, we provide practical 27 recommendations that can be implemented by providers and programs to facilitate the 28 adoption and delivery of virtual care. Cancer rehabilitation is an essential component of survivorship care and has become 60 increasingly relevant with a growing cancer survivor cohort, and high documented rates of 61 impairment and disability. 1,2 The COVID-19 pandemic has required a rapid transition from in-62 person rehabilitation to virtual care through telephone-or video-based visits. 3 However, this 63 shift has largely been made with little evidence on best practices. 64

Virtual care may improve access for geographically dispersed patients and reduce 65 physical, financial, and logistical barriers to in-person care. 4 

shown promise in addressing physical and psychosocial concerns among cancer survivors. 5,6 67

Notwithstanding these potential benefits, regulatory restrictions surrounding reimbursement, 68 licensing, and hospital credentialing, as well as patient and provider attitudes have impeded its 69 broader adoption. 7,8 Additionally, differential access to telecommunication technologies based 70 on social and geographic factors can pose a challenge to its implementation. 8 71

As a result of the evolving COVID-19 crisis, the Princess Margaret Cancer Centre 72 proactively suspended all non-essential in-person appointments. Therefore, the Cancer 73

Rehabilitation and Survivorship (CRS) Program abruptly shifted services to be delivered virtually 74 as of March 16 th , 2020. Despite recent recommendations for virtual care during the 75 pandemic, 3,9,10 research on virtual cancer rehabilitation is limited. Given the uncertainty for 76 when a return to previous levels of in-person care will occur, the current demand and surge in 77 virtual care use presents a unique opportunity to examine the implementation of virtual cancer 78 rehabilitation and provide strategies on how to adapt in-person care to deliver a sustainable 79 virtual care model. The purpose of this study was: 1) to describe the adaptations made to 80 J o u r n a l P r e -p r o o f

We collected data on process measures including: 1) referrals; 2) completed visits and 128 attendance; 3) method of appointment (i.e., video or phone); 4) weekly appointment 129 capacities; and 5) wait times. These outcomes were compared with the previous 3 months. 130

Patients could be placed on a waitlist to be seen by our team in-person once services resumed 131 or brought in if their condition was deemed serious. These appointments included 132 comprehensive assessments, one-on-one appointments, and CaRE initial or follow-up We conducted semi-structured interviews via telephone with CRS HCPs and patients 139 who had received care virtually during the study period. We applied a pragmatic approach to 140 recruitment and aimed to recruit 10 HCPs and 10 patients for interviews due to our narrow 141 research question. 14 However, data was collected until saturation was reached, meaning there 142 were little or no changes to the codes from new interviews. Interviews were completed by two 143 members of our team with experience with qualitative interviewing (C.L., and B.E.). HCP 144 interviews were informed by the FRAME and explored experiences with adapting to virtual care 145 (Supplementary File 1). We purposively sampled patients based on the type of CRS virtual visit 146 they were attending (i.e., comprehensive assessments, follow-up assessments, and CaRE 147 assessments), and interviews explored their perspectives with virtual care (Supplementary File 148 2). Patients were also asked to complete a demographic questionnaire. Context and content modifications were qualitatively synthesized based on the 153 FRAME. 13 Descriptive statistics were used to summarize process outcomes of the CRS program 154 during the 90 days before and after adapting to virtual care. Patient and HCP interviews were 155 analyzed separately, and emerging themes were subsequently aligned to develop a cohesive 156 understanding of experiences with virtual care. We followed a six-step approach for thematic 157 analysis. 15 Interviews were digitally recorded and transcribed verbatim and each transcript 158 underwent a process of open coding by a member of the team (C.L.). The generated themes 159 were reviewed in relation to the coded data and the entire data set and underwent further 160 review by another interviewer (B.E.) to ensure they reflected the interviews conducted. These 161 themes were refined and representative quotes were chosen for each theme. Several strategies 162 were used to ensure trustworthiness including the appropriateness of the interview sample, the 163 relevance of interview questions, and the steps taken to ensure the accuracy of the interview 164 transcripts and generated themes. 16 The weekly capacities of appointments were adjusted to accommodate setting and 211

format (e.g., removal of group classes) modifications, as well as removed need for clinic space. 212

The maximum number of comprehensive assessments that could be scheduled per week 213 slightly decreased (in-person n=40 vs. virtual n=36). Nevertheless, the capacity for most one-on- Table 3 . Participating patients were referred to the CRS 247 program for multiple and varied reasons including lymphedema (n=6), musculoskeletal (n=5), 248 fatigue (n=5), deconditioning (n=3), neurological (n=2), difficulties with activities of daily living 249 (n=2), and neurocognitive (n=2) issues. The majority of patient participants were on post-250 treatment surveillance (n=9, 75%). The mean duration of the interviews was 27 minutes (range 251 = 15-58 minutes). Three themes emerged from the interviews. Each theme is described below 252 and representative quotes for each theme are provided in Table 4 . being initially aware of the purpose of the visit or the reason for the referral. As a result, HCPs 265 recommended providing pertinent information to patients prior to the appointment (e.g., 266

instructions on how to access the virtual platform, and guidelines on ensuring high-quality 267 virtual appointments). 268

Patient participants expressed a sense of reassurance and noted that they felt 270 supported during a time of isolation and uncertainty. Several patients emphasized feeling 271 empowered to cope with the worries of the pandemic in addition to their rehabilitation needs. 272

Furthermore, patient and HCP participants indicated that they were able to establish rapport, 273

particularly during video appointments, as this normalized the virtual care experience. 274

However, several HCPs indicated that compared to in-person appointments, communication 275

barriers were more pronounced in a virtual environment, which hindered their ability to assess 276 and build rapport with patients utilizing interpretation services. Additionally, a few patient 277 participants described virtual care as an isolating approach to their rehabilitation and expressed 278 a desire for virtual group interactions with other cancer survivors. This was acknowledged by 279 many HCPs, who discussed challenges with abruptly adapting the group classes to a virtual 280 platform. 281

HCPs indicated that virtual visits were effective for screening many cancer-related 283 impairments including neurocognitive, psychosocial, fatigue and diet concerns. However, HCPs, 284 specifically PTs, OTs, and physiatrists, experienced more difficulties due to limitations in 285 assessing musculoskeletal and neurological impairments, and lymphedema. Due to a lack of in-286 J o u r n a l P r e -p r o o f Virtual Cancer Rehabilitation During COVID-19 person examination, HCPs often relied on patient self-report and self-assessment. Virtual visits 287 made it difficult to reliably test, palpate and observe patients in order to evaluate their level of 288 impairment and function. This led to a greater level of difficulty narrowing the differential 289 diagnosis, ordering pertinent medical tests, and evaluating their condition at follow-up 290 appointments. HCPs also indicated several challenges teaching loco-regional rehabilitative This study describes the adaptations made to implement virtual cancer rehabilitation 308 programming at the onset of the COVID-19 pandemic. The rapid shift to virtual care presented a 309 challenge and an opportunity to ensure cancer survivors had access to rehabilitation services. 310

The CRS program was able to translate the majority of appointments to virtual formats and 311 deliver care at similar or greater volumes compared to in-person care prior to the pandemic. 312

Virtual delivery is a priority in cancer rehabilitation due to its ability to mitigate barriers 313 to in-person care. 4,17,18 Our findings demonstrate that virtual care may be feasible, consistent 314 with previous studies, 19-21 with a few important limitations for physical examinations (e.g., 315 musculoskeletal and neurological impairments, and lymphedema). We were able to deliver care 316 at high volumes and attendance rates across a variety of visit types. Our findings suggest that 317 cancer survivors feel they can easily access care and gain confidence in learning skills to self-318 manage their impairments. However, the value of group-based interventions was highlighted in 319 this study, reflecting previous findings on their social benefits. 22 Accordingly, we have begun 320 piloting virtual group education classes. 321

The ability of the CRS program to abruptly shift to virtual care was facilitated by 322 regulations surrounding billing for virtual care, as well as organizational capacity and readiness 323 for change. 23 The provincial government approved virtual care to be covered by insurance and 324 introduced temporary billing codes and procedures. Additionally, the Princess Margaret Cancer 325

Centre had been delivering virtual appointments on OTN in a limited capacity prior to the 326 pandemic, which facilitated its rapid adoption within the CRS program, and all HCPs were 327 trained on how to navigate OTN prior to delivering care virtually. Finally, previous use of 328 telephone visits (e.g., return to work, social work) and previously developed resources (e.g., e-329 Additionally, although this study described the changes to the CRS process outcomes over time, 366

we did not determine whether these changes were significant. Moreover, we did not examine The findings of this study suggest that many appointments can be successfully adapted 379

to virtual formats to deliver cancer rehabilitation programming. Virtual delivery can be a 380 feasible and acceptable alternative to in-person care during physical distancing 381 recommendations. While these findings are encouraging and can inform implementation 382 efforts for virtual models, further research is needed to understand its effectiveness. Format: Appointment includes an initial screen with an OT or PT, followed by an assessment with a MD (physiatrist). Setting: Patients are seen in-person. Content: Patients complete electronic questionnaires inperson, and moderate to high distress scores are flagged on a clinician report for the oncology team to assess. Assessments are guided by objective measures including a surveillance physical exam. Appointments include a comprehensive rehabilitation assessment and care plan based on a patient's identified impairment, level of disability, and personal goals. Appointments are booked for a total of 1.5 hours.

Format: No change.

Setting: Adapted to video or phone. Tailored elements: 1) Questions within standard distress screening questionnaires could be used as probes to guide the assessment, but summary reports were not available as a remote system had not been implemented within the cancer centre; 2) physical tests and assessments were demonstrated and described to allow patients to complete them on their own; and 3) objective measures of function were not completed. Pacing/Timing: No change was made to the scheduled appointment duration.

Patients are referred to the CaRE@Home program based on their comprehensive assessment. Format: Initial one-on-one visit with a RKin, and follow-up visits at 8 weeks, and 3 and 6 months. Setting: All assessments are conducted in-person. Weekly counseling is delivered via phone. Content: In-person visits include a fitness assessment (6minute walk test, hand grip dynamometry, body composition, balance) and distress reports via questionnaires completed inperson. Patients are supported with exercise Therabands, emodules for education, a mobile application and wearable technology, and weekly brief telephone counselling. Assessments are booked for 1.5 hours and weekly counseling is scheduled for 20 minutes.

No change to the referral process. Format: No change.

Setting: All assessments were switched to phone or video. Weekly counseling could now be delivered over video. Removed elements: 1) Fitness assessment (6-minute walk test, hand-drip dynamometry, body composition, 30-second balance); 2) provision of exercise Therabands; and 3) provision of wearable technology. Tailored elements: 1) Exercises were demonstrated and described by the RKin over video, phone, or through online instructional videos; and 2) patient-reported outcomes were completed online at assessment timepoints, but summary reports were not available. Pacing/Timing: No change was made to the scheduled appointment duration.

Patients are referred to the CaRE@ELLICSR program based on their comprehensive assessment. Format: Initial one-on-one visit with a RKin, weekly group classes for 8 weeks, and one-on-one follow-up visits with a RKin at 8 weeks, and 3 and 6 months. Setting: All visits and classes are conducted in-person. Content: Patients receive an initial assessment and exercise prescription. Assessments include objective measures and distress reports via questionnaires completed in-person. Group classes consist of supervised exercise and skills management education. Patients are supported with exercise Therabands, a mobile application, and wearable technology to track activity. Assessments are booked for 1.5 hours. Weekly exercise and education classes are 60 minutes each.

Patients currently enrolled in the CaRE@ELLICSR program were switched to CaRE@Home. All future groups were suspended. Format: Weekly supervised group exercise classes were modified to individual weekly one-on-one telephone or video calls with a RKin for the remaining weeks of the program. Group skills management education was modified to individual online education. Setting: In-person assessments were adapted to video or phone. Education content was delivered via e-modules. Removed elements: 1) Fitness assessment (6-minute walk test, hand-drip dynamometry, body composition, 30-second balance). Pacing/Timing: No changes were made to the scheduled duration of assessments.

Format: A one-on-one visit with an OT or PT. Setting: Primarily in-person; however, OT consults could be delivered via phone. Content: Assessments are guided by distress reports via questionnaires completed in-clinic prior to the appointment and objective measures (e.g., hand grip dynamometry, sit to stand, range of motion). Appointments are booked for 45 minutes.

Format: No change. Setting: All appointments were delivered via phone or video. Tailored elements: 1) Questions within standard distress screening questionnaires could be used as probes to guide the assessment, but reports were not available; and 2) physical tests and assessments were demonstrated and described to allow patients to complete them on their own. Removed elements: Objective measures of strength and function. Pacing/Timing: No change was made to the scheduled appointment duration.

Format: A one-on-one visit with a PT or RMT. Setting: Patients are seen in-person. Content: Treatments include manual lymphatic massage, compression bandaging, kinesiotaping, and education. Appointments can be booked for 30 or 60 minutes.

Setting: Adapted to video or phone. Removed elements: Objective measures of lymphedema. Substituted elements: Manual therapy was postponed, and patients were provided with online resources for manual lymphatic self-massage (videos and pamphlets). Pacing/Timing: No change was made to the scheduled appointment duration.

Format: A one-on-one visit with the HCP. Setting: Primarily in-person; however, all visits could be delivered via phone. Content: Assessments are guided by distress reports via questionnaires completed in-clinic prior to the appointment and objective measures. Appointments are booked for 1 hour.

Setting: All appointments were delivered via phone or video. Tailored elements: 1) Questions within standard distress screening questionnaires could be used as probes to guide the assessment, but reports were not available.

Removed elements: Objective measures of body composition for RD appointments; and 3) neuropsychological testing. Pacing/Timing: No change was made to the scheduled appointment duration.

Format: Group-based. Setting: In-person. Content: Monthly 1-hour classes. Topics included return to work, brain fog, lymphedema, and sex and intimacy.

Format: Group format was postponed as additional time was required to adapt the content of the classes to a virtual format and ensure privacy concerns were addressed. Patients registered for an upcoming class were contacted by the class lead and offered a one-on-one appointment or other resources. Setting: Adapted to video or phone consults or online resources. Substituted elements: Resources included previously developed e-modules for return to work and brain fog classes, as well as a pamphlet on lymphedema management. Emodules on lymphedema and sex and intimacy were in the process of being developed.

Format: Group-based. Setting: In-person; however, cooking classes were streamed live online for patients. Content: Classes included cooking and nutrition demonstrations, mindfulness meditation, and gentle therapeutic exercise.

Format: In-person classes were postponed. Setting: Patients were directed to online videos and resources available on the program website and external mediums. Tailored elements: Cooking and nutrition classes were streamed live without an inperson audience. Removed elements: 1) mindfulness meditation; and 2) gentle therapeutic exercise.

Abbreviations: MD, medical doctor; OT, occupational therapist; PT, physiotherapist; RMT, registered massage therapist; HCP, health care provider; NC, neurocognitive; SW, social work; RD, registered dietician. J o u r n a l P r e -p r o o f Table 4 . Representative quotes from participant and health care provider interviews Theme Quote Access to Care "Our clinic usually struggles with issues of having enough rooms, so the option of virtual care gives us some more clinic space in a way. I think it'll solve our issue of clinic space which means we can see more patients or hire more staff and allow our program to grow." (HCP, Occupation Therapist)

"My acceptance to virtual care has allowed me to see people with very strong barriers to rehabilitation such as those with mobility issues or who live far away." (HCP, Physiatrist)

"We have to think about whether we should keep this as an option because maybe I won't have as easy access to downtown hospitals, but I want to maintain my relationship with my doctors and other providers. This would be an amazing source to rely on until together as a team, you decide on when an in-person appointment would be necessary." (P08)

Virtual helped me get the care I needed while managing my kids. The convenience was important. If I had to go downtown, I would have to think of a lot of different things to plan my day with the kids and travel. The convenience of it was very helpful." (P09)

"The benefit is that we can still connect with patients and they seem to really appreciate that we can speak with them. We can still build a therapeutic relationship with patients and still provide some sort of connection and opportunity to check in. So, I think that has been working well. I think we actually have been needed more now as many other points of connection may have stopped." (HCP, Occupation Therapist)

"I think it would be helpful to tell patients what to expect for the virtual visit. So, like a module or link on how to make the most out of the visit. Giving them steps like arriving five minutes before the visit, test the camera and audio, wear clothes for exercise, bring any equipment they have. Also, continuing to communicate the expectations of the visit and that there are going to be limitations for what we can assess virtually." (HCP, Physiotherapist)

"I feel I got really great guidance. I feel continued to be cared for. If I need support or more understanding because something changes, I feel like I could reach out and I can get help. And with the continued uncertainty in the world, it might be necessary to be virtual for the next year. So, it feels really good moving forward." (P02)

"I feel blessed for this opportunity. I was given the confidence to manage my wellness, and needed support during a pandemic. You can feel like you're still working towards something that is going to help you. I think it has made an improvement in my physical and mental life. I had tools that were able to help me handle the cancer and the COVID situation." (P04)

"Assessing range of motion is okay for upper extremities, but sometimes people don't have that mobility with their camera to show their whole body or a good distance from the camera. It's hard to get a good visual of their lymphedema unless the swelling is quite pronounced and visible. Also, often we're doing this over the phone, where I can only go by patient description about their mobility, strength, and lymphedema." (HCP, Physiotherapist) "We also have an app we use where patients see the videos and instructions of the exercises, and they can message us on that if they have questions. Through that, we can also share our screen and show them the videos on the app and show the videos and talk it through with them. This makes it easier to teach the exercises and build rapport." (HCP, Kinesiologist) "I might have the language to be able to describe what I'm feeling, but the majority might not be able to. So, for someone who doesn't know a lot about the body and can't see or tell if something bad is going on, then you're relying on self-description and they may not describe it well or accurately. Not being able to have a someone go and feel my armpit for example and feel what's swollen, or even look at it well is a problem because you can't visibly see something like that well on a screen."

"The worry about the care not being very personalized was removed right away during the first appointment because I could see [the health care provider], they could see me, and we could communicate with each other. I didn't really know how I was going to be able to say a certain exercise was not okay for me because you can't do an exercise in front of someone virtually. It just doesn't work for me or them actually. So, the video of the exercises were shown to me during the appointment and everything was explained to me so well that it removed all my worries and made it easy." (P11)

Abbreviations: HCP, health care provider; P, participant.

J o u r n a l P r e -p r o o f 

Appointments with multiple health care providers should be organized in a consistent manner to ensure providers are accessing the correct virtual visit. This includes ensuring emails sent to a second provider containing links to access a combined virtual visit contain information such as the time and nature of the visit (e.g., initial, follow-up, referral type).

Time allotted for virtual visits may need to be increased in order to accommodate any technological issues, as well as extra time to assess patients' needs given the absence of an in-person physical assessment and provide information to patients electronically after the appointment.

Provide patients with detailed instructions on how to access the virtual platform and guidelines for ensuring a high-quality virtual appointment (e.g., testing of audio and video quality). Patients should be reminded about potential wait times as a virtual environment does not provide patients with a sense of the clinic flow.

Provide patients with educational material related to the virtual appointment (e.g., lymphedema, exercise, diet) to help patients become familiar with potential topics, test, and self-management skills they may be asked to complete during the appointment, as well as overall expectations of the virtual visit. This includes information from local/regional medical authorities or governing bodies on the limitations of a virtual visit compared to an in-person visit.

Health care providers should strongly encourage the use of video assessments for patients referred for musculoskeletal, neurological, and lymphedema concerns, and ensure patients are informed of the potential benefits and reasons for a video appointment compared to an appointment over the phone.

Develop and implement an online screening tool that patients can complete prior to the appointment to provide relevant outcomes to health care providers to guide the accuracy and reliability of the assessment and care plan.

Health care providers may need to take a more cautious approach to care, including ordering more tests and investigations, requesting a follow-up for re-assessment virtually or at the earliest possible in-person visit, and reduced volume and intensity of prescribed exercise.

Incorporate mobile or online applications to deliver interventions and monitor progress and adherence remotely.

Take advantage of seeing patients in their home environment by personalizing discussions and recommendations (e.g., supplements or foods available for dietary and nutritional advice, and equipment, household supplies, and furniture for exercise). 

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healthcare, rehabilitation, and self management

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