Mar 30, 2016 | Insights
Smart application of the telehealth trend can provide clear benefits to physical therapists and patients, but there are still some significant challenges to widespread adoption.
Imagine you’ve suffered a recent musculoskeletal injury. You’re doing at-home exercises daily, but you’re worried your form may be off. What if instead of driving into the office, all you had to do was reach for your smartphone to videoconference with your therapist?
Advances in technology—in addition to growing needs prompted by the Affordable Care Act and an aging population—have telehealth projected to grow to 1.8 million users worldwide by 2017, according to the World Market of Telehealth. Now, telerehabilitation is becoming a viable option for physical therapists who want to supplement hands-on therapy with remote offerings such as online exercise demos, workout supervision, and secure patient communication tools.
How Telehealth is Changing Physical Therapy
How could telehealth stand in for the hands-on therapy and face-to-face communication integral to successful musculoskeletal treatment? The answer is, simple: it can’t.
Not all patient-provider interactions are currently translatable to telepractice. For instance, massage and manual manipulations are undeniably in-person treatment methods (although solutions like Microsoft Kinect, which uses a 3D motion sensor to allow patients and therapists to interact in real time, may soon change that).
While telehealth may never replace therapy appointments, the accessibility and convenience of a virtual therapist visit make it an ideal option for follow-up treatment, home treatment plans, questions and answers, and consultations with specialists.
Let’s look at few of the primary advantages this method of therapy has to offer.
- Cost and time savings: The incorporation of telerehabilitation into traditional care plans may allow PTs to develop more time-efficient and less costly care models. Electronic check-ins save patients the trip to and from their therapist’s office, which can be a significant return to their pocketbook—especially in rural areas.
- Flexibility: With the ability to facilitate patient-provider interactions remotely, telerehabilitation can connect patients with hard-to-find specialists that may be located hours away. It also allows therapists to deliver care in a more flexible way, even allowing some patients who are typically seen in clinical or hospital settings to be managed in their homes instead.
- Smoother care coordination: The option of checking in with your PT from home can strengthen the patient-therapist relationship, possibly even shortening the road to recovery. Additionally, telehealth can improve communication between providers, with potential benefits including quicker screening, assessment, and referrals for patients.
While it is clear how telehealth could bolster the rehabilitation process, there are still several barriers for physical therapists who want to offer virtual support services. Current challenges include:
- Hardware/software requirements: While many of the most common videoconferencing software programs don’t offer the level of security required by healthcare law, secure, HD platforms like GoToMeeting do comply with the Health Insurance Portability and Accountability Act (HIPAA) and allow for synchronous live video streaming, screen sharing, and shared presenter controls.
- Billing and coding issues: Telerehabilitation presents some coding complexities for physical therapists as billing codes have yet to adapt to telehealth activities. Some billing codes currently exist for PT telehealth, but they are not yet the standard and can vary depending on state and by insurer. Physical therapy has not yet been cited in federal legislation regarding telehealth services reimbursement.
- Legislation and regulations: Current law prohibits PTs from treating patients who live outside of the state in which the therapist is licensed. This precludes PTs from practicing across state lines—even in a virtual environment. Both the American Physical Therapy Association and the Federation of State Boards of Physical Therapy are working toward defining and eventually altering legislation to facilitate more widespread adoption of telehealth.
Could virtual PT become a mainstream piece of the recovery process? Quite possibly. But until legislations and regulations catch up to advancing technologies and growing patient demand, we must rely on innovative physical therapists to find a way to make telehealth work within the given parameters, to demonstrate the value it delivers to their patients, and to blaze a trail for this much-needed form of support in the rehabilitation world.
Bibliography
“APTA 2014 Recap: Forging Ahead with Telehealth: A Roadmap for Physical Therapists,” last modified February 11, 2014, http://wellpepper.com/apta-2014-recap-forging-ahead-with-telehealth-a-roadmap-for-physical-therapists.
“Telehealth,” last modified September 8, 2015, http://www.apta.org/Telehealth/.
“Telehealth in PT: Expanding Possibilities,” last modified March 31, 2015. https://www.webpt.com/blog/post/telehealth-in-pt-expanding-possibilities.
“Telerehabilitation: Will Telepractice Catch On for Occupational and Physical Therapy?” http://myptsolutions.com/telerehabilitation-telepractice-occupational-physical-therapy/.
Mar 11, 2016 | Insights
Psychosocial factors play a deeper role in injury rehabilitation than originally suspected, and innovative therapies are seeing surprising success.
Research suggests that pain accounts for only 10 percent of a disability, whereas psychosocial factors can explain as much as 30 percent variance in the magnitude of a disability experience. Historically, treatment for chronic pain-related conditions included opioid prescriptions, multi-disciplinary programs or cognitive-behavioral pain management tactics.
However, it wasn’t until recently that psychosocial intervention began to gain new ground, thanks in large part to the research and methods developed by Dr. Michael Sullivan of the University Centre for Research on Pain and Disability.
Sullivan has spent the last 20 years investigating how to introduce an intervention program targeting psychosocial barriers in the rehabilitation process. The program that emerged was the Progressive Goal Attainment Program, or PGAP™.
Now new studies have illuminated the positive impact PGAP can have on clinical outcomes when combined with physical therapy.
Why has this new intervention model seen more success than previous efforts?
1. Early intervention
Research has shown that the probability of return-to-work outcomes decreases the longer an injured individual is out of commission. Similarly, recently injured individuals have a faster recovery time than those who have a chronic work disability.
In the past, patients with complex psychosocial risk were often identified only after their condition had become chronic and treatment-resistant. At this stage, the multidisciplinary interventions, in combination with repeated treatment failures, tended to produce only modest improvements – if any.
Injured workers who require physical rehabilitation typically visit their physical therapist 1 – 2 times a week for a period of weeks. These professionals are ideally positioned to assist in the early identification of psychosocial risk factors for faster intervention.
2. Integrated treatment
Traditional cognitive behavioral therapy is handled by psychologists or those with a mental health background. This has been limiting in two ways: (1) it has restrained access to psychosocial resources and (2) it has often resulted in a fragmented physiological and psychological treatment program.
PGAP—when used in conjunction with physical therapy—creates a more integrated and more efficient treatment strategy that addresses both the physiological and psychosocial barriers to recovery at the same time.
3. Activity-based therapy
Unlike traditional pain management treatments, PGAP focuses on behavior versus cognition, yielding a much more active treatment process. The first few weeks of the program are intended to establish a strong working relationship with the PGAP consultant through disclosure and validation techniques, but the focus then moves to developing a structured activity schedule. When combined with physical therapy the program focus and activity schedules encourage safe reintroduction into the workforce.
4. A focus on return to work
Unlike other rehabilitation interventions, PGAP’s main objective is not symptom reduction, but reduction of disability. Research shows that symptom reduction is not a precondition for successful return to work. In fact, an overt focus on symptom reduction may reinforce the patient’s belief that symptoms must be eliminated before work activities can resume.
In one study, the addition of PGAP to a functional restoration physical therapy program increased return-to-work rates by more than 50%, and in a sample of 70 individuals with chronic disability caused by cervical sprain injury, 75% of clients were able to resume work following PGAP completion.
MedRisk’s solution for delayed recovery cases incorporates these proven treatment strategies, combining evidence based treatment guidelines, early identification of psychosocial barriers, PGAP and physical therapy to deliver a more direct road to rehabilitation, and an improved quality of life for your workforce.
Bibliography
Sullivan,M. J. L., Adams, H., Rhodenizer, T., & Stanish,W. D. (2006). A psychosocial risk factor-targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy, 86(1), 8–18.
Sullivan, M. J. L., & Adams, H. (2010). Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiotherapy Canada, 62(3), 180–189.
Sullivan, M. J. L., Adams, H., & Ellis, T. (2013). A psychosocial risk-targeted intervention to reduce work disability: Development, evolution, and implementation changes. Psychological Injury and Law, 6, 250–257.
University Centre for Research on Pain and Disability (2013). A Community-Based Intervention for the Prevention of Pain-Related Disability [PowerPoint slides]. Retrieved from http://indep.ca/wp-content/uploads/2013/11/PGAP1.Presentation.pdf.
Feb 2, 2016 | Insights
By Kevin Basile, PT, OCS, MTC, Director of Provider Relations Physical Medicine
As more Americans postpone retirement, employers are taking steps to optimize working conditions for their employees.
Companies across the country are embracing their senior workforce, recognizing the expertise, loyalty, and mentorship experienced employees bring to the table. However, the unprecedented demographic shift has employers and payers alike wondering whether workers’ compensation loss costs will also experience an upward swing.
In 1964, baby boomers made up a staggering 40 percent of the population. Fast-forward half a century and boomers are surprising the census yet again—this time with a surge in the workforce. Between 2004 and 2014, the number of active American workers age 55 or older skyrocketed by 47.1 percent. According to the Bureau of Labor Statistics, this group’s share will increase to one-quarter of the workforce by 2024.
In 2012, the National Council on Compensation Insurance (NCCI) stated that the impact of an aging workforce on loss costs may be less negative than previously believed. In a report released that same year, the NCCI revealed that injury rates for workers age 45 and older dropped by 50 percent between 1994 and 2009, due at least in part to workplace safety initiatives.
Unfortunately, the positive trend in frequency rates was counterbalanced by an increase in severity. Rotator cuff and knee injuries top the list of workers’ comp claims among the 55+ crowd. On their own, these injuries can be difficult to bounce back from, but common effects of aging such as muscle deterioration, respiratory inefficiency, and comorbidities like diabetes, obesity, and osteoporosis can further lengthen the road to recovery.
So, what can employers do to set up older employees for success – and safety – on the job?
CLOSE GAPS
The aging process makes certain tasks, such as those requiring exceptional flexibility and balance, harder for us to do. As a result, gaps between a job’s demands and a worker’s capabilities may form over time.
To close these gaps, employers should review the distribution of work at their company and consider how they might capitalize on the expertise and strengths of aging employees while keeping their physical, psychological, and physiological needs in mind. Here a few options to consider:
- Offer more frequent breaks throughout the workday.
- Minimize shift work and increase morning hours to allow older workers to punch the clock at optimal times
- Institute a job rotation system so an older worker is alternating tasks (rather than overexerting the same muscles throughout the day)
RETOOL YOUR EQUIPMENT
Although employees come and go, it is not uncommon for workstations to go unchanged for many years. It is important to periodically review workspace configurations to ensure they are not exacerbating workplace injury.
Physical therapists and occupational health consultants can work with employers to conduct an ergonomic assessment and make suggestions which might include:
- Raise work surface areas or countertops
- Reconfigure at-hand work materials to minimize repetitive squatting, kneeling or twisting
- Reposition overhead equipment to waist-to-chest level
- Replace thin handles with thicker handles for better control
- Redesign equipment for more efficient exit/entry to minimize contortion
EMPOWER YOUR EMPLOYEES
A comprehensive occupational training and education program is critical to workplace safety, but more and more companies are also prioritizing health and wellness off the clock. After all, a more physically fit worker has better success in recovering from an injury.
Here are just a few ways employers can encourage workers to take health and safety into their own hands:
- Initiate an on-site strength and conditioning program to minimize workplace injury
- Offer partial or full payment for a local health club membership, contingent upon a minimum number of visits
- Build a culture of wellness in the workplace by offering healthier food options and opportunities for light physical activity (e.g., walking meetings) throughout the day
These operational changes should not be viewed solely as interventions, but as investments with long-term returns. By looking out for the well-being of our aging workforce, we effectively create safer work environments and reduce costs while securing a tried-and-true source of wisdom, dedication, and leadership in our industries for years to come.
Dec 29, 2015 | Insights
Claims professionals have long known that some injured workers don’t recover, and not because their injuries are catastrophic or intrinsically unrecoverable.
By Ruth Estrich
In recent years, the managed care industry has focused on pain management solutions to address these delayed recovery cases.
However, recent studies show that while pain is an obstacle to returning to meaningful work and life roles, it is not as significant a deterrent as many assume. In fact, some symptom-based interventions, e.g., programs that only focus on pain, can actually increase disability duration rather than minimize it.
Increasingly, research is pointing to psychosocial barriers as a more important variable than pain, accounting for more than three times the variance in the magnitude of disability (Journal of Occupational Rehabilitation). Psychosocial factors, also commonly referred to as “yellow flags” arise from behavioral traits that reflect the relationship between the injured workers’ personal attributes and their social environments. Yellow flags can reflect personal, environmental and/or occupational work barriers and may be unrelated to the accident or presenting injury. Additionally, studies have identified the psychosocial barriers that have the greatest impact on delayed recovery and that can be mitigated by behavioral interventions:
- Catastrophic Thinking: The tendency to ruminate about irrational worst-case outcomes. Clearly, this can increase anxiety and prevent the injured worker from taking action, e.g., successfully completing their rehabilitation treatment program.
- Perceived Injustice: The injured worker’s belief that nothing will ever make up for what happened to them, and that they didn’t do anything to deserve their situation. Recent studies show that the combination of pain and perceived injustice increases depression significantly.
- Fear/Avoidance: The avoidance of movement and activity in an attempt to reduce pain. Studies show that this barrier generally results in both chronic pain and a disengagement from meaningful activities, which prolongs disability and also often leads to depression.
- Disability Beliefs: Injured workers’ expectations about recovery and their ability to manage returning to work. Studies in the Netherlands found that individuals’ perceptions of the impact of their condition had more influence on lost time, levels of impairment and activity levels than did actual physical or medical indicators.
Programs that identify injured workers who are at high risk for these critical psychosocial barriers and that deliver interventions that integrate behavioral and physical treatment approaches have been shown to be highly effective in 10 countries worldwide. Results from various studies led by Dr. Michael Sullivan, one of the foremost experts on psychosocial issues, cite a 77 percent enrollment success, a 33 percent reduction in the ongoing use of pain medications, and a 60 percent return-to-work outcome.
Of course, the earlier psychosocial issues are identified and addressed, the better. The American Physical Therapy Association has long noted that physical therapists are the providers who spend the most time with injured workers on the road to recovery, making them well positioned to observe – and if trained properly – mitigate these complicating factors. So it is not surprising that innovative new solutions are looking to physical therapists to provide psychosocial as well as musculoskeletal rehabilitation.
MedRisk’s Chief Strategy Officer Ruth Estrich has more than 30 years’ experience in managed care, both in workers’ compensation and group health. Estrich can be reached at restrich@medrisknet.com.
Nov 11, 2015 | Insights
Knowledge is power – a point especially true for injured workers undergoing rehabilitation. Feeling comfortable and in control—or not—has a significant impact on treatment outcomes.
Two recent studies found a positive relationship between education and patient results—validating the importance of patient education in driving positive outcomes, efficient return to work and overall cost savings. However, understanding what effective patient education looks like and actually implementing it aren’t as widely reflected in industry policies and procedures as they could and should be.
Reducing Outliers, Speeding Recovery, Lowering Costs
Last year, Ohio researchers reported on the positive effects the educational aspect of preoperative physical therapy had on knee and hip replacement outcomes.[i] This year, Gallup researchers saw a similar trend when they looked at how pre-surgery education affected post-surgery results as measured by patient satisfaction, problem incidence and quality of life.[ii]
When you look at the actual numbers, it is clear that patient education can have far-reaching effects on patients’ lives and on carriers and carrier personnel burdened with delayed recovery cases and ever-increasing costs.
The Ohio researchers found just one to two physical therapy sessions in advance of surgery resulted in an estimated 29% reduction in postoperative care.[iii] Contrary to assumptions, it wasn’t so much the physical strengthening or range of motion benefits that drove the change, as that would have required multiple intensive sessions. Rather, the origin of the improvements was the fact that patients were receiving quality and knowledgeable instruction on what to expect from the procedure and recovery process in advance, improving patient satisfaction overall.
According to the Gallup research, patients that felt they were well educated in advance of their procedures—knew what to expect, were prepared for and followed post-procedure instructions—were 33 percent more satisfied with the results, experienced 19 percent fewer problems and reported a much higher level of contentment[iv]. They also had fewer readmissions indicating faster, smoother recoveries, and a potentially lower overall cost-per-patient.
What Does Effective Patient Education Look Like?
“Quality” patient education is a vague target—too subjective to drive real change. So what exactly does an effective patient education program look like?
Researchers posit that managing patients’ expectations in advance is key to improving their level of satisfaction with the results of their procedures, as well as the physical and emotional outcomes. A positive educational experience can even have beneficial effects beyond the procedures themselves, increasing patients’ feeling of personal well-being.[v] For delayed recovery cases, where the psychosocial and emotional barriers can be just as important to address as the physical, patient education has the potential to speed long-stalled recoveries.
At MedRisk, we’ve seen this research born out again and again. Patient education is of paramount importance to improving outcomes, and that’s why we believe that a patient-centric approach is a critical component of a successful managed care program. It not only improves the quality of patient care – it encourages compliance with treatment strategies, reduces the workload for busy adjusters and case managers and helps remove psycho social barriers to recovery. It’s why our managed physical medicine program includes one-on-one concierge service and patient education in advance of treatment.
The healthcare industry in general, however, has not yet realized much less adopted this revolutionary method to sustaining improved outcomes. For example, only 37% of respondents in the Gallup study felt they received enough information on the important aspects of upcoming procedures.
How can MedRisk help? By providing a comprehensive and managed approach to repair and rehabilitation involving clinical oversight, tailored communication, a superior educational component, integrated services and a continuum of care that ensures patients feel confident, comfortable and empowered.
The more the medical and insurance communities can incorporate higher levels of communication and education into their engagements with patients, the better the outcomes will be for not only the patients themselves, but the industry as a whole.
[i] http://www.apta.org/PTinMotion/News/2014/10/2/PreOperativePT/
[ii] http://www.gallup.com/businessjournal/183317/benefits-pre-surgery-education.aspx
[iii] http://www.apta.org/PTinMotion/News/2014/10/2/PreOperativePT/
[iv] http://www.gallup.com/businessjournal/183317/benefits-pre-surgery-education.aspx
[v] http://www.gallup.com/businessjournal/183317/benefits-pre-surgery-education.aspx
