When the COVID-19 pandemic began, one of the first adjustments we all made was finding new ways to connect with our families and friends. Virtual game nights quickly rose in popularity, becoming a good way to relax and laugh with loved ones across the country and even around the world during a stressful time.
However, the more game nights we had, the more we realized that they just aren’t the same as socializing in person. While they helped keep us connected, using them to replace all of our in-person contact wouldn’t be healthy for us.
As great as virtual communication can be, it’s not the same as face-to-face interaction. That doesn’t mean that virtual hangouts and game nights will go away once it is safe to travel and visit in-person again. Many families are spread across the country and may only be able to get together once a year. While they will cherish those visits even more when they can do it again, they’ve also now found a great way to supplement their limited face-to-face interactions—virtual communication. These families may still plan summer vacations around visiting each other every year, but now they’ll do a virtual game night every few months to stay even more connected than they were before.
Telehealth in rehabilitative therapy is very similar. We have realized that there are challenges and benefits associated with it from both the patient’s and the provider’s point of view. It is, of course, not the same as face-to-face treatment sessions.
The question is not whether telehealth is great or telehealth is terrible. The question is:
How do we best use telehealth to help solve our patients’ problems and provide them with the best possible care under any circumstances?
Just like with family time, virtual care can serve as a supplement for in-person treatment. The key to using telehealth effectively is understanding who will do well with it and what they need at different phases of treatment.
Which Patients Want Telehealth?
This is actually a trick question. It’s not that anyone specifically wants telehealth.
Our patients want answers for why they hurt. They want to know that it’s going to be ok and that they can trust us to help them get back to doing the things they need, want, and love to do. Patients want to know that their investment of time, energy, and money is going to help them achieve their desired outcomes and that it’s going to be as pleasant of an experience as possible to get there.
When we start from this understanding, it’s easier to understand that what we’re selling is not actually telehealth. We are not even selling rehabilitative therapy.
We’re selling results and experiences, not services.
In the case of the virtual family game night, we understand that those family members don’t feel as connected virtually as they do when they are in-person. Our patients understand the same thing. While it can be enjoyable to communicate online with people when we’ve already established a trusting relationship with them, it can be more challenging to communicate online with people we do not already trust. In fact, Townsend, et al., found that online networking is an unsuitable context for building the trust needed to gain tangible benefits. However, it is effective to use online communication to maintain trust that has been developed in-person.1
We must understand that even though it can be more difficult to establish trust online, we can still capitalize and even build on trust that has already been formed. When you couple this knowledge of how trust can be developed with the understanding that therapeutic alliance with patients is strongest after about three visits,2 we start to get some good information on how to make telehealth work for our patients. It may be most effective when we can establish trust in-person for a few visits, and then bridge that trust online in a telehealth session.
Our Experience Learning This in Our Clinic
In the days and weeks following the start of the pandemic, we saw exactly what was described above happening in our own practice. It was difficult to gain traction with patients when they started with their first session via telehealth, and many of those patients opted to wait until they could come into the office to see us.
When we used telehealth with existing patients, however, nearly everyone we saw was extremely impressed by how smooth and effective it was. It even worked well for patients who had worked with their therapist before but were being evaluated for a new injury.
In our experience, telehealth works best when the patient and therapist have an established and trusting relationship.
Demonstrating the Value of Telehealth
One of the most challenging aspects of the pandemic for practice owners and administrators—for everyone, really—has been the uncertainty. Almost everyone has dealt with therapists or patients needing to quarantine. One way to combat this issue is to prepare patients for the possibility of telehealth sessions before they are needed.
Our patients are generally expecting to receive hands-on care, and their expectations have an impact on the outcome of treatment.3 In fact, our patients may find our manual interventions to be one of the more memorable aspects of the visit.
As care progresses and becomes more active, we need to highlight to patients that they are creating meaningful changes when we prescribe movement instead of hands-on care. This can be accomplished by saying something as simple as, “When you came in today, you couldn’t bend down to touch your knees because your back was hurting. Now you just touched your toes with no pain at all. The best part was that I didn’t even have to put my hands on you. You created all that change by yourself with just some coaching and the right exercises. We could have done the same thing over telehealth if we needed to.”
With that treatment session and a simple conversation, we can turn a telehealth skeptic into a believer. We plant the idea that we can create the same changes for a patient even in a different medium. That is what telehealth ultimately is—a medium through which our patients can receive care, feel better, and get back to doing what they want to do.
If I can establish a trusting relationship with a patient and open that patient’s eyes to the fact that I can help them via telehealth in most of the ways that I can help them in person, we have done the hard part. Completing these first two steps is what makes the third and final step—creating buy-in on telehealth—successful. This process will always be more effective when it starts with trust and knowledge of the service. Without completing the first two steps, we are doing the equivalent of cold-calling someone. They wouldn’t trust us or really understand anything about the service we are offering.
Promoting Telehealth to Patients
Now that we have improved the likelihood of creating buy-in and we are aware that we are not actually selling telehealth, we are ready to take the next step. That step may occur with any phone call or any conversation, so both front office personnel and therapists need to be ready to handle it. Chances are, it will occur toward the end of the episode of care.
In rehab therapy, just like almost everything else, the first 80 percent of change takes about as much energy to attain as the last 20 percent. Our patients start to notice that they’re putting in the same effort, time, and money but are not improving as quickly as they were a few weeks ago. This point of care is frustrating for them, and they will be more likely to cancel appointment—or even drop off the schedule entirely.
We can use telehealth to combat that drop-off process. While progress will inevitably slow down for many patients, we can use telehealth to decrease the amount of time they are putting into their care. Here is a good example:
Ashley is currently in her fourth week of physical therapy for neck pain and headaches. She has a great relationship with her physical therapist, has progressed well, and is requiring less hands-on treatment. During her last visit, the therapist demonstrated how her pain with cervical rotation was reduced by 50 percent through performance of thoracic spine rotation exercises.
Today, Ashley has a busy day at work, and she will be pressed for time to get everything in and still pick up the kids on time. She decides that she can relieve a lot of her stress if she cancels her PT appointment. Cancelling the 45-minute appointment and the 15-minute commute each way may not be the best thing for her neck pain, but she needs to remove some stress.
Ashley calls into the office and lets you know that she is very sorry, but she is stuck at work and cannot make her appointment. She mentions that she hates that she can’t make it in because she’s got a headache right now, and her PT is always able to help her get rid of them.
Here’s how your front office could handle that conversation:
“It sounds like you’ve got a lot going on. I’m sorry things are so busy at work. I’m sure the headaches aren’t making it easier to get things done either. I may have a solution for you. I can save you all the commuting time today, and your therapist could still work with you on getting rid of that headache if we simply switch your appointment to telehealth instead of in-office. Your therapist could even work with you while you’re right there at your desk if that’s easiest for you.”
This conversation only takes 30 seconds, but it can help our patients meet their goals and keep appointment slots booked. What makes it work are the three steps highlighted above:
- Establish a trusting relationship between the patient and therapist.
- Make the patient aware of what can be done with telehealth.
- Understand what the patient needs and sell them that, not telehealth.
Ashley did not need telehealth. She needed time and reduced stress. Even though she would rather work with her therapist in-person, her need to save time and reduce her stress level were more important, so we used telehealth to give her those things.
If there’s one thing the pandemic has highlighted, it’s the importance of connecting with our patients. We need to understand what is going on in their lives and how we can adapt to help them—despite the challenges we are all facing. Telehealth can play an important role in that process.
When traveling, spending time with loved ones, and hugging are safe again, we’re going to return to doing those things. In the meantime, we’ll figure out the best ways to stay connected with loved ones when we can’t. In the long run, it will make families stronger.
In the same way for your practice, things may already be returning to some new form of normal. However, we can take what we have learned about telehealth and use it to build a stronger practice with even better patient outcomes. When we build trust with patients, our practices become resilient enough to survive—and even thrive—anything, even a pandemic.
- Townsend, L., Wallace, C., Smart, A., & Norman, T. (2014). Building virtual bridges: How rural micro-enterprises develop social capital in online and face-to-face settings. Sociologia Ruralis, 56(1).
- Ardito, R. B. & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270.
- Bishop, M. D., Bialosky, J. E., & Cleland, J. A. (2011). Patient expectations of benefit from common interventions for low back pain and effects on outcome: Secondary analysis of a clinical trial of manual therapy interventions. Journal of Manual & Manipulative Therapy, 19(1), 20–5.