An Overwhelming Need
The COVID-19 pandemic has created an unprecedented need to care for patients remotely. Worldwide, the pandemic continues to accelerate, even as U.S. case numbers show signs of a possible plateau.1,2 The World Health Organization (WHO) has warned that without a unified national and world response, the worst of the pandemic may be ahead of us.3
Both infectious disease experts and the White House’s reopening plan indicate a slow, gradual return to normal,4,5 driving an ongoing intermediate- and long-term need for telehealth as an alternative care delivery model.
Even when things are what we would consider “normal,” one of the primary benefits of telehealth is improved access to care for patients with a variety of limitations. These limitations might include:
- Transportation challenges
- Socioeconomic barriers
- Long distances between providers and patients
These limitations are particularly amplified in rural areas, especially when patients are seeking specialty providers. Of course, access issues are amplified when”shelter in place” orders are the norm, and once these are lifted for the general public, high-risk populations may still be asked to shelter in place, and social distancing precautions in modified forms may continue for the foreseeable future.4,5
At this time, there does not appear to be any consensus guidelines for telerehab precautions or contraindications.6 So how can practitioners know when telehealth is an appropriate choice for their patients?
The following list offers examples to help you make individual judgments about whether your patient is a candidate for ongoing care with telerehab.
- Patients at high risk for severe COVID-19.7 This includes:
- People over the age of 65
- People living in a long-term care facility
- People of all ages with underlying medical conditions such as:
- Chronic lung disease or moderate to severe asthma
- Serious heart conditions
- Compromised immune systems due to cancer, smoking, bone marrow or organ transplant, immune deficiencies, poorly controlled HIV/AIDS, prolonged use of corticosteroids, or immune weakening meds
- Severe obesity (BMI >40)
- Chronic kidney disease (undergoing dialysis)
- Liver disease
- People with transportation barriers (including distance)
- Patients who desire and consent to telehealth care
- Patients with scheduling and time limitations
- Does the patient demonstrate a need for an intervention that requires a hands-on technique? If you could accomplish the same goal with therapeutic exercise, your patient may still be a candidate.
- Does the patient have moderate fall risk that can be managed with in-home safety precautions during treatment?
- Patients with red flag conditions or symptoms that require physical examination, reflex testing, or imaging
- Patients who are medically fragile enough that monitoring of vitals or cardiopulmonary status cannot be safely accomplished remotely
- Patients who are at severe fall risk
- Patients who fail the clinical prediction rule that would indicate imaging. Examples of these include Canadian C-Spine Rules and Ottawa Ankle Rules. If the rule requires palpation, the practitioner may try to have the patient self-palpate with video guidance, but the practitioner should understand the limits of this and thus have a lower threshold for referral, particularly in cases of traumatic onset, which requires physical examination.
- Patient whose cognition limits ability to participate by video
- Patients whose outcome would be harmed by lack of a specific physical intervention
If you need to “pause” telehealth visits for referral to another provider or for an in-person visit, this does not preclude resumption of telehealth visits when or if these concerns are cleared. Depending on the clinical situation, a blended delivery model of face-to-face visits and telehealth shouldn’t be excluded as a viable option as well.
For more information on incorporating telehealth into your practice, please see:
- Johns Hopkins University & Medicine. Coronavirus Resource Center. https://coronavirus.jhu.edu/us-map. Accessed April 28, 2020.
- Financial Times. (April 28, 2020). Coronavirus tracked: the latest figures as the pandemic spreads. Financial Times. https://www.ft.com/coronavirus-latest. Accessed April 29, 2020.
- Associated Press. (April 20, 2020). WHO head warns worst of virus is still ahead.The New York Times. https://www.nytimes.com/aponline/2020/04/20/world/europe/ap-eu-virus-outbreak-world-health-organization.html?auth=login-google. Accessed April 25, 2020.
- Walensky, R. P. & Carlos Del Rio. (2020). From mitigation to containment of the COVID-19 pandemic: putting the SARS-CoV-2 genie back in the bottle. The Journal of the American Medical Association.
- United States Government, www.whitehouse.gov. (April 16, 2020). Opening Up America Again. https://www.whitehouse.gov/openingamerica/. Accessed April 17, 2020.
- Lee, A. (2020). COVID-19 and the advancement of digital physical therapist practice and telehealth (accepted manuscript). Physical Therapy, pzaa079
- Centers for Disease Control and Prevention. (2020). People Who are At High Risk for Severe Illness. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html. Accessed April 20, 2020 and April 28, 2020.