by Katherine J. Collmer, M.ED., OTR/L
In Part 1 of this series, we discussed some of the legalities, competencies, and best practice research pertaining to telehealth as they relate to state laws, regulations, and licensing rules; competency issues; reimbursement matters, and professional standards and ethics. There was a great deal of information offered as a starting point to your research on this service modality. This segment will be presented as an outline of the questions I am typically asked by peers in the field and will include my answers, as well as some additional sources for your research.
Questions and Answers
How did telehealth become a option as service delivery model in your Handwriting With Katherine practice?
The provision of services through technology in my private practice was actually born out of a suggestion from my husband. After he retired, I wanted to continue the work I’d begun in my clinic but was torn between my professional passion and our dream to winter in a warmer climate. His experience with teleconferencing as a business meeting model led him to suggest its use as a service delivery model that would allow me to enjoy both. At the time, I was not familiar with the term “telehealth” and was unable to find information related to the delivery of professional services using technology such as Skype or FaceTime. I was on my own, making my business decisions as well as those regarding best practices and ethics based on my education and previous experiences. It wasn’t until a year later that I’d attend an AOTA Conference presentation that included Jana Cason, DHS, OTR/L, FAOTA, who was considered the guru on this emerging delivery model. And yet, after that presentation, I remained in unchartered territory since I’d learned that there existed very few guidelines or regulations addressing its use by occupational therapists.
2. Please describe the start-up process for adding telehealth into your service options.
The start-up process was exciting as it provided a new environment of creativity within which to use my clinical reasoning and planning skills. My previous experiences, both as a secondary education teacher and as a designer and presenter for training workshops, laid the foundation for building my service delivery model. At the time, AOTA had not yet published their position paper on telehealth; but I offer it here as a reference because despite the lack of its valuable input at the time, the information included in it is the crux of how I built my delivery model best practice guidelines.
Ethical Considerations: Informed Consent
Of course, the first items on my list were the ethical considerations regarding the delivery of services through technology. I had been corresponding with my clients’ parents through personal emails when they felt comfortable with that method. There were some parents, of course, that preferred to discuss their child’s rehabilitative services on the phone or strictly in person. Therefore, it was important to consider my approach to the parents whose children currently received services on site in my clinic and who would be involved in this change to a service that was restricted to technology. In addition, the technologies I was considering (e.g., Skype, FaceTime, GoogleChat) and the electronic devices we would be using (desktop, laptop, and tablet computers) were not secure lines of communication.
The 2013 AOTA position paper on Telehealth (Table 1) states that the practitioner must “fully inform the client regarding the implications of a telehealth service delivery model versus an in-person service delivery model,” matching this guideline with Strategies for Ethical Practice that concern informing clients, their parents, spouses, and caregivers about the “benefits, risks, and potential outcomes of any intervention;” and/or “any reasonable alternatives to the proposed intervention. (Principle 3A)”
And this was what I did in those early days of planning. In an effort to provide parents with the opportunity to review and completely understand this new development, I first discussed my consideration of a move to Arizona for four months that winter. In this conversation, I included the introduction of a new service delivery option that would allow their children to continue to complete their rehabilitation plan under my care. (It is important to note here that our decision to winter in Arizona that year was based on the acceptance of this new service on the part of my clients’ parents. My responsibility, of course, was to their children’s completion of their rehabilitation plans.)
During that conversation, I provided them with a written outline of my proposal for review at home with their spouses and children, giving them an opportunity to formulate questions for me. I must say that I received an overwhelming acceptance to the idea even at this stage. Most of the children had been working with me for a while and were happy and comfortable with my strategies. That held a great deal of weight for the parents since I was offering specialized services in handwriting development skills that were difficult to obtain in other clinical or even school-based practices.
Next I obtained formal, written consent from the parents. The 2013 AOTA position paper on Telehealth, Table 1, states that the practitioner will “obtain consent before administering any occupational therapy service, including evaluation, and ensure that recipients of service (or their legal representatives) are kept informed of the progress in meeting goals specified in the plan of intervention/care. (Principle 3B)” In the consent form, I also outlined the additional responsibilities that would be theirs or another designated adult should they consent to this new service. (These responsibilities will be discussed later in the article.) I was thrilled that each of my parents signed the consent and were looking forward to this new experience.
With the formal acceptance of the parents, I moved on to the challenge of creating my service delivery model. It’s difficult to imagine now but at the time there were no resources available on the internet to guide me through this. I was doing it the old-fashioned way by building it from the ground up using ingenuity to devise the least complicated yet most effective mode of delivery. Suffice it to say that in this day my methods may be considered unrefined; but they were effective and the process was exciting nonetheless.
My main focus in this beginning stage was on my young clients (ages ranging from 5 to 16) and the effectiveness of the telehealth delivery model for engaging them and their parents as effectively as I had during an in-person session. Skype and FaceTime were familiar to me; but I had not used them beyond chatting with friends or relatives and, even then, on a limited basis. Even this level of experience with video technology had revealed that there occurred many glitches caused by slow internet speeds and older device capabilities, as well as difficulties connecting or maintaining the connection. These types of technological interferences in a therapy session would most likely affect the engagement and experience of both the client and parent, as well as the clinical outcomes. There was much to be learned about the different modes of audio technology that were available to my parents. But the learning began with me. So my husband and I set up practice sessions between my place in the clinic and his spot in the living room upstairs. There soon came about many areas where the learning would be concentrated.
— Mastering the Technology: Each video technology had its own Help Line. This information was recorded in a notebook placed next to my phone. In the event of a glitch that couldn’t be solved in a timely manner, the session could be closed and rescheduled and I could call the Help Line to inquire about a solution. This information could then be added to the notebook for use in similar situations.
The first and most critical aspect of an audio session proved to be the ability to link up and to receive and send both visual images and sound. This required my becoming familiar with the screen prompts and visual cues provided by each video technology. This information went into the notebook as well to help prevent delays in the beginning of the session. It was important to become familiar with the tool that closes out the session both audibly and visually to ensure privacy after the session is ended.
We positioned my iMac such that the relevant clinical areas behind me would be visible to the clients and their parents. For example, the chalk board was an important tool in my work and therefore would need to be visible, as well as the floor space behind me that would allow me to demonstrate gross motor activities.
The computer positioning also addressed the location of my image on the screen of the receiving device. It was important for the clients and their parents to be able see both my face and my hands while keeping the chalkboard and floor space behind me remain visible. My chair was the correct height to display my face well, but I needed to maintain my hands off the desk in order for them to be visible.
–Practicing the Service Delivery: At this point, I engaged the services of one of my clients and her mother in completing practice therapy sessions. This proved to be an important step in the process.
—Organization: I quickly realized that my session materials needed to be well organized and within reach during the session. Where I could move about the clinic freely during an in-person session to retrieve items that I would use for therapy, this proved to be a visual distraction as I moved out of the camera’s range during a video session.
—Communication: Engaging with the children and parents while maintaining the children’s attention were the next hurdles to practice. I would be utilizing the parents or caregivers in the role of assistants who would provide the hands-on interaction that was unavailable from my end. Therefore, it would be necessary for me to communicate with both of them at the receiving end without causing confusion by talking too fast, talking over their voices, or not providing enough visual guidance. Slow, deliberate speech patterns combined with visual demonstrations proved to be the best technique, as well as frequently asking for questions and feedback.
—Hands-Off Critical Thinking: It quickly became apparent that the most important role I played on the screen was a natural one – a therapist. The same strategies that I utilized in the clinic to engage my clients remained the same ones I’d utilize in the session: laughter, engaging in conversation, turning work into play, and providing time for client feedback and questions throughout the session. But as I came to realize that this method of service delivery defined “hands-off” care, I began to understand how important all of my other senses would be now. During our practice sessions, I honed my visual skills to avoid distraction and maintain eye contact with the parent’s movements as well as the reactions of the child in response to guided movement or the sensations provided during interaction with the tools. In combination with my visual skills, I relied upon my vestibular skills to assist me in verbally guiding the child through gross motor and postural activities, relying of course on her verbal and vestibular responses as well. But most important were my communication skills and my approach toward giving directions to both the parent and the child and offering feedback from a distance.
—Finding the Right Space: The area and environment you choose for providing your telehealth services should be considered very carefully. These are some of the considerations that worked for me:
Be sure that the area respects patient privacy and confidentiality. It should have a door that closes securely; be in an area of the building that does not allow others to hear the conversations between you and your clients; and provides an environment that affords clear communication, free from noise and poor audibility. Place a sign on the door during your session to alert others that privacy is needed.
Limit the distractions behind you such as cluttered bookshelves, busy wallpaper, mirrors, or solar glare from a window behind or beside you.
Position your stored materials close by in a well-organized manner in case you need to retrieve a forgotten article or want to try a different activity in the session.
Be sure to have a comfortable seat and room to stretch your legs. Fidgeting can be distracting to the client and the parent or caregiver.
Be sure that any communication devices (e.g., land lines, computers, fax, or copy machines) are turned off or will not be needed by others during your session. Silence phones and other computer equipment. And, of course, refrain from accepting any form of communication during your session.
At this point, I began working on parent engagement. This facet was perhaps the most important one relative to the success of my service. I would be relinquishing my cherished role as a hands-on therapist and entrusting it to my parents and caregivers. This of course is what we’d see as an ideal transition from therapy to home programs; but most often I found that parents, no matter their dedication to their children’s rehabilitation efforts, felt more comfortable observing than interacting for most of the session. This, of course, would not be an option and would definitely serve to enhance engagement of the parents.
–Defining the Parents’ Responsibilities: My concern for the parents’ level of engagement in light of the increased responsibility they would be facing was a strong motivator for creating a well-organized system for communication between us during all phases of the sessions. The success of the program relied a great deal on their understanding and acceptance of their roles, as well as my expectations before, during, and after the sessions; their sense of competence in their ability to perform that role and their confidence in my support toward their success; and their ability to sustain their placement in this role for the duration of their children’s rehabilitation plans. Therefore, my delivery model structure was specific in defining the role of assistant that would ask them to
—become familiar with and maintain the video technology and device of their choice, including sharing Help numbers for the video technology with me;
—communicate with me before each session through emails to receive documents and a list of materials that would be needed for the session;
—provide a quiet and accessible treatment area that allowed both the child and myself to be seen and heard through their chosen device;
—plan and set up the treatment area prior to the session;
—review the session plans and gather materials prior to the session;
—scan and email their children’s competed homework before the season;
—provide guidance to their children through tactile or verbal cues during the session;
—interact with me during and after the session to allow for questions, feedback, and goal review; and
—spend time following the session to scan and email the work their children completed during that session.
I considered this transition from our interactions in an in-person session to one that relied on a shared responsibility for the success of the treatment session as a chance to review what my relationship might look like with the parents after the change. I understood that maintaining our strong relationship was a key element in the level of their engagement. They have taken on an important and unfamiliar role in their children’s therapy. I took this opportunity to take an assessment of my responsibilities in this challenge and I came up with a few guidelines to help me:
—First of all, express appreciation for their taking on these additional responsibilities for the children’s therapy success.
—Practice long-distance patience for myself, the parents, and the children as we navigate this change together.
—Be understanding of the parents’ limitations and take note of their learning styles to help guide them in their role as an assistant.
—Give them support by listening to their feedback about their participation in the sessions and their management of the administrative duties. Take their suggestions when I can.
—Remember that “They are my hands” and that this change could not be completed successfully without them.
As you can see, the parents were now fully engrossed in the sessions as participants versus observers. I was concerned about their perception of the telehealth service model’s effectiveness, although I was inclined to believe that this deeper level of engagement would reap benefits both in the accomplishment of home exercise programs and their sense of involvement. But, in then end, I understood that the media would be the determining block in the structure I was building. If it was a weak link, then the level of engagement would suffer on both ends. And although I was going into this venture without a clear sense of the effectiveness of the media we would utilize, there was no precedent for me to consider in my decision. I had to make the choice for myself and go forward with it.
Currently, similar concerns have risen regarding patient engagement and their perceptions of the effectiveness of telehealth as a service modality. Professional service models that shoulder the client, or in my case the clients’ parents, with more responsibility while providing them with increased accessibility to the practitioner place the client/parent into a “self management” role. A 2015 article reported that this element of patient care has been utilized “to guide higher-quality chronic illness management in primary care” resulting in “favorable health outcomes.” It also reported that initiatives designed to increase the clients’ role in their medical care through technology “have led to reductions in hospital visits, decreased morbidity and mortality, and improvements in treatment adherence and quality of life associated with chronic diseases such as heart failure, ulcerative colitis, and asthma.” These results indicated that while costs were reduced with the introduction of technology, quality of care was not sacrificed. As I noted with my clients’ parents, not everyone is familiar and/or comfortable with technology for medical purposes. But according to this article, 79% of respondents in a 2010 study stated that they “were more likely to select a provider who allows them to conduct healthcare interactions online, on a mobile device, or at a self-service kiosk,” while additional study results showed that some respondents would pay for online services of this type.
It has also been noted that a poorly constructed telehealth environment could lead to confusion and frustration on the part of the clients and their caregivers. WebPT reports that studies and accomplished program statistics have shown that “when done correctly, telehealth can strengthen the patient-provider relationship and better engage patients with their care — thus improving outcomes.” Positive results such as these were felt to be the result of the development of a strong healthcare team that shares information with patients that allows them to see what’s happening in their healthcare plan, assist in determining what needs to be done and in the development of a plan. Programs that include clients in making their own health care decisions have seen improved compliance and in clinical outcomes over time. WebPT also shared a recent study of knee and hip replacement patients at a hospital in Virginia that reported results indicating that “more than 90% of the participants said that telehealth improved their episode-of-care experiences, helped them better understand and set expectations, and improved their satisfaction with the care they received.”
At this point, I felt comfortable with the audio portion of the set-up and with my expectations and guidelines for the parents. I was ready to move on to developing an efficient method for coordinating the mechanics of the sessions with the parents, such as the tools they would need on hand, and adapting therapy strategies I’d used in the clinic to facilitate the accessibility of those tools for the parents.
—Therapy Tool Boxes: Since I was familiar with the children for this first experience and had the luxury of working with them up until the day I left for Arizona, I had some fun crafting Tool Boxes for them as starter sets for their sessions. This is a strategy that I continued to use with new students using telehealth, mailing it to them after the evaluation. Each was individually crafted, much the same as in an any individual rehabilitation plan, including simple and inexpensive items that would cover gross motor, visual motor, and fine motor skill areas, and a culmination activity that most likely would include handwriting. Depending upon their ages and needs, the items might have included:
Gross Motor Warm-Up Materials: Balloons, a small nerf ball, a visual list of yoga or core body exercises;
Vision Warm Up Materials: Bubbles, whistles; small, soft ball with a string to use as a tether ball; cotton balls and straws;
Fine Motor Warm-Up Materials: therapeutic putty, marbles with golf tees, a small selection of small snap together blocks, q-tips to use with water to trace; and
Culmination Activities: paper and pencil activities or games that addressed the child’s specific handwriting development skill needs.
The items were stored in an inexpensive canvas bag that included a laminated list of its contents explaining which were to be retuned to me when I arrived back from Arizona, as well as a list of the paper copies of activities that I initially provided to give us a smooth start once we began the telehealth sessions. This list also included inexpensive items that the parents might wish to purchase or might have on hand that would be useful in our sessions. These included items such as tweezers, scissors, small playing cards, and chalk and small chalkboard (which I provided to the initial children because I had them on hand and they could be returned when I came home).
In order to maintain consistency and reliability for some aspects of the handwriting development portions of our sessions, I provided copies of handwriting paper or activities designed on specific handwriting paper through email communication. I also shared online resources that provided free downloadable copies of the handwriting paper we were using.
—Session Outlines: Effective parent engagement included keeping them well informed during every step of their involvement in their children’s telehealth experience. Their success in meeting my expectation that they would provide guidance to their children and interact with me during the sessions would depend on my sharing information beforehand. My responsibility would be to prepare an outline of each session’s activities and share it with them well in advance of the session. I created a typical session outline that resembled my daily treatment plan organizer that could be filled in on the computer or by hand. I emailed it to the parents about 3 days before the session, along with any activity sheets they would need for the session or for their home program. The latter included instructions for the home work, which I would discuss with the parent before the end of the session.
After the consent forms were signed and returned and the payment options explained and agreed upon, it was time to test the technology with each parent. This was by far the second most important facet of the program development. Each video technology worked in different ways and had its own tools for engagement. This opportunity also gave us time to discuss some shared technology guidelines for times when the video equipment does not cooperate, such as an inability to connect, the screen freezing up, or unexpected internet shut downs. We came up with a written plan to address:
–Who calls to reconnect?
–How much time is allowed for correcting the situation before considering the session canceled?
–What are the rescheduling options?
All in all, this part went smoothly and we were ready to begin our new adventure once I arrived in Arizona.
The last step in my preparation process for the transition to telehealth addressed the children’s level of engagement. In-person therapy sessions typically involve a lot of tactile, vestibular, auditory, and visual engagement between the therapist and the child. While the auditory and visual engagement facets would continue to exist between us, I knew that they would be filtered by the long-distance impression of the video technology. I would be relying on the parents to provide the tactile and vestibular input, for sure; but I recognized that their proximity to the children would override most of my input if I wasn’t creative. I didn’t have difficulty adapting my therapeutic strategies for the screen and found in the end that I was able to conduct the same interactive activities as I’d done in the clinic. But in my practice sessions conducted with my client and her parent before I left for Arizona, I found these simple guidelines worth noting:
–Ask the parent and child if they can hear and see you well enough and if there are any distractions that you need to address before you get started. This avoids hampering the child’s or parent’s engagement or creating disruption during the session to make changes.
–Ask the parent to keep the work area clear of all items except those which are going to be used in the activity.
–Provide the child with an opportunity to manipulate the materials, listen to your labels for them, discuss the directions and purpose for the activity, and ask questions or give feedback before starting.
–Speak slowly and provide instructions clearly. Sometimes a slight time delay in the transmission of information across the internet or phone lines can be distracting or result in the child misunderstanding your directions.
–In the case of long-distance conversations, it is even more important to ask the parent and/or child to repeat your directions in order to determine their level of understanding.
–If the family’s environment becomes noisy or the parent is interrupted during the session, be flexible and understanding. Have a plan to work on a simple fine or visual motor activity while the situation is resolved. This helps to keep the child engaged and to prevent him or her from getting distracted. This works well if the parent is unprepared with disorganized or unavailable activity materials or the unavailability of downloaded materials. If this occurs often, you and the parent can discuss these events and options for remediation on the phone later.
–If the materials or downloaded items are not available, be creative and utilize previous activities or similar ones that include what is on hand and will meet the child’s needs.
–If the child gets fidgety or distracted, suggest a short break for a gross motor activity or to get a drink and/or non-messy snack that can be brought back to the therapy session.
We were ready to go! For additional information about the process for setting up my telehealth practice you can download my handout from the 2014 AOTA National Conference by clicking on the picture below. This will direct you to my Handwriting Development Skills Resources Page. Scroll down until you see this picture there.
You can view a sample session from my clinic here:
3. What types of services do you provide?
Let me begin with the types of services I provided specific to my private practice mission statement. Handwriting With Katherine was created to meet the needs of an ever-growing population of children who were experiencing handwriting challenges that could not or were not being met through a structured, organized instruction program or with the benefit of an occupational therapy remedial plan. The focus of my practice is to assess and remediate the underlying developmental skills that affect learning, in this case handwriting. So although the end goal of my clients and their parents was to master handwriting skills, their rehabilitation plans addressed those developmental skills (gross motor, vision, fine motor, visual perceptual, sensory) that were identified in their initial assessment as the culprits standing in the way of their success.
Primarily, our work was done on an in-person basis at my clinic. The live videoconferencing telehealth service model was later offered as a synchronous modality that allowed me to expand my services to meet both the needs of my clients and myself. I found this to be an efficient way to conduct evaluations, provide treatment, and confer with parents while I was away and to provide services to clients who were unable to meet in the clinic.
A note about the conduction of an evaluation using the telehealth delivery model: My initial telephone or in-person consultation with the parents is designed to determine if a handwriting development skills assessment is the appropriate starting point to address their concerns and their children’s needs. The information gathered during this conversation would also assist me in deciding if a telehealth method of service delivery would be appropriate for the evaluation, if the parents desired this option. The evaluation process that I conduct follows a standardized format that allows for the inclusion of specific adaptations during its presentation. In addition it utilizes basic, inexpensive items that were most often available to the parents or that I could mail to them inexpensively or email to them for downloading. This facilitated the evaluation through telehealth as I was able to utilize the parent as the assistant in providing the child with any tools and adaptations that were need during its administration. The greatest drawback to this plan, however, was the additional time that the set up took in order to practice with the technology and ensure success with the session. This was not my preferred method for conducting an evaluation and I would make every attempt to travel to the child’s home when possible.
For my service model, I chose “Live Videoconferencing,” though we now know that there are other modalities that serve additional client and practitioner needs. There are a small number of sites that are addressing the pressing need to set standards and policies and to develop a framework for the delivery of telehealth services. One such organization is the Center for Connected Health Policy (CCHP). CCHP is a non-profit, private organization working toward the integration of “telehealth virtual technologies into the health care system through advancing sound policy based on objective research and informed practices.” One of it’s major accomplishments was the research report they published that was the basis for the California Telehealth Advancement Act of 2011 (AB 415), which “allows all licensed health professionals to utilize telehealth, removes restrictions and barriers to providing telehealth, and expands the locations where telehealth can take place.” Their site is a valuable resource for telehealth information, such as the definitions of the various technologies that encompass the telehealth service delivery model.
The CCHP page, “What is Telehealth?” provides definitions for and descriptions of the use of the 4 telehealth modalities. The links in the left column of that page provide more extensive information about the modality, as well as their uses in various capacities.
4. Based on your clinical experience, what are the pros and cons of providing services via telehealth?
Cons: The excitement over this emerging service method as a solution for reducing costs and reaching clients in remote areas where services are not available has begun to push policymakers and state licensing boards to create definitions and regulations in an effort to set some type of standard that will allow healthcare professionals to include telehealth as a service model into their practices. For a number of years, the consideration of telehealth as an option sat in the background of the discussions that were taking place to improve healthcare delivery. A small amount of groups and professionals were writing papers and delivering presentations designed to create awareness and garner interest in telehealth; but for the most part, those discussions led to the discovery that there was very little support by professional organizations or state licensing boards relative to our legal and ethical use of this model in our occupational therapy practices. It was frustrating and confusing and often resulted in a reluctance by therapists to consider it. Currently, we are finding more information on the internet, most importantly from AOTA, that provides definitions, guidelines, and ethical considerations based on our professional standards. And that is fortunate. However, I remain cautious about the rush on the part of therapists to become a telehealth provider. My concerns include:
–Provider Competence: A current small internet search I conducted did not reveal an occupational therapy program that advertised telehealth as a course selection. Of course, this is not conclusive but it does suggest that telehealth courses are not currently prevalent in occupational therapy curriculums, or at the least that colleges are not advertising them. Using the key words “telehealth course,” the search did reveal a number of introductory training workshops designed to focus on various elements of telemedicine and telehealth offered by allied health, medical, and supplier organizations. However, I was not able to locate a reference to an occupational therapy curriculum that included telehealth. With the excitement and push for the advancement of this new delivery method, as well as the growing desire for therapists to enter into private contractual or private practice therapy enterprises, my concern is for the new graduates who are looking toward utilizing telehealth as a way to enter these job markets. These concerns about educational needs for new endeavors were voiced as far in the past as 1998, by Mary Foto, in her AJOT article titled, “Competence and the Occupational Therapy Entrepreneur.” The concern at the time was the increased desire for new graduates to want to assume a wider scope of responsibilities versus the once traditional goal of “entering into and becoming successful at hands-on clinical practice (p. 765)” relative to the question, “How will occupational therapy entrepreneurs be judged competent?” Although her article discussed the “knowledge, skills, traits, and habits required of any occupational therapy practitioner contemplating a career as an entrepreneur (p. 765),” her thoughts relative to competency coincide with those being discussed here. She states that:
“the American Occupational Therapy Association (AOTA) and its members are obligated to protect the health, safety, and welfare of the persons we serve. Certification – and recertification – is but one means of meeting this obligation. My views on this topic are based on three premises:
1. Assuring continuing competence is an obligation, not an option, so the question is how to assure the continuing competence of occupational therapy practitioners.
2. The assurance of continuing competence and quality of care is desirable not only for the protection of the public, but also for the protection and advancement of the occupational therapy profession and the protection and financial well-being of occupational therapy practitioners.
3. The manner in which we assure continuing competence must appropriately balance the needs and interests of all stakeholders including referral sources, clients, payers, and practitioners. A one-size-fits-all approach would be inconsistent with the diversity of occupational therapy practitioner roles and practice specialties found in our profession.
Foto addresses competency but sadly not entry-level education that would provide a baseline knowledge for introducing new therapists to, in her case, entrepreneurship. However, her remarks relative to our obligation toward continued competence as well as competence in our progression toward a specialty area continue to reflect my concern about this recent transition into telehealth as an additional scope of our practices. And although strictly speaking entrepreneurship and telehealth are not actually specialties but more delivery models, their use demands specialized knowledge, skills, traits, and habits that require competence.
Foto further writes on this topic:
“Just as occupational therapists move into certain roles over time, they also move from being general practitioners to being specialists. Thus, although the use of a general practice certification examination is appropriate to assure the competence of persons entering occupational therapy practice, it would be inappropriate to use this examination, which was designed to measure a broad range of knowledge, to determine the competence of those practicing a specialty. Just as competency assessment must take into consideration our occupational roles, it must also be relevant to one’s specialty area.
We must recognize that successfully passing a certification examination or recertification examination does nor assure competence. Demonstration of didactic knowledge should not be confused with consumer protection. Competence and consumer protection—whether entry level or continuing—must be viewed and measured within a broader framework. A certification examination and its criterion of successful passage set forth a minimal competence standard. Our profession’s Code of Ethics (AOTA, 1994a) sets forth the highest standard. In my view, competence is based on a body of knowledge and a set of skills that, when provided to consumers, are guided by our Code of Ethics, shaped by our profession’s values, and driven by our 10 standards of practice (AOTA, 1994b). A certification examination should address only one of these components of competent practice–knowledge. (p 769)”
My experience with the development and inclusion of a telehealth service into my practice at a time when guidelines and information resources were scant included those very concerns. I was entering into unchartered territory in an environment where I was my sole judge of competency. I had concerns about the quality and consistency of care provided using this method, as well as the outcomes that my clients would achieve with it. In my case, however, I had been a member of therapy teams across the country in diverse environments for over 14 years. These experiences culminated in the development of continued competence in the standards for continuing competence set by AOTA in the areas of: Knowledge, Critical Reasoning, Interpersonal Abilities, Performance Skills, and Ethical Reasoning. These skills form the knowledge base and core values “to perform current and future roles and responsibilities within the profession (p. 661).” I was able to draw upon my trials and errors in each of those environments as well as my successes to form a plan and create a working model for using telehealth within my practice. Competence in those areas takes time, practice, and patience. AOTA defines continuing competence as “a dynamic, multidimensional process in which the occupational therapist and occupational therapy assistant develop and maintain the knowledge, performance skills, interpersonal abilities, critical reasoning, and ethical reasoning skills necessary to perform current and future roles and responsibilities within the profession (p. 661).” My concern remains that new graduates will choose this intriguing and cost effective method of service delivery, without even an introduction to its benefits or contraindications in college or during formal training, only to find themselves entering the same unchartered territory as I did but lacking the awareness of that.
–Appropriate Environments: My second concern is that of a general rush to assume that this delivery model will fit into any area of our profession and can be considered a suitable alternative for all treatments within a therapists’ practice. AOTA clearly states in its 2013 paper titled, “Telehealth,” that although telehealth is supported as a service modality within each major practice area within occupational therapy, this is not an indication that it is appropriate for all situations. The fact is that telehealth as a service modality “has potential” and should be utilized only after each case has been evaluated individually based on “the variability of client factors, activity demands, performance skills, performance patterns, and contexts and environments using clinical judgment, client’s informed choice, and professional standards of care (p. P S70)”
In the case of my business model, the majority of my clients’ needs could in theory be met with telehealth services. However, it would not be appropriate for children with high sensory needs because hands-on treatment that addresses the child’s individual sensory needs is a vital factor in gathering information relative to his or her reactions and progress. In my professional opinion, there could be no substitute for that. This was not a concern for me, however, because I referred children whose needs centered around sensory issues to a clinician specializing in that area because mostly likely the focus on handwriting development needs would be more successful once the children had had success with a sensory plan. In any case, I would be reluctant to offer services through the telehealth model to children who would benefit from my services but whose sensory needs ranked high in my handwriting development assessment. In this case, as well as in most areas of our practice, our ability to use touch and to learn about our clients’ needs through tactile input is invaluable. It’s one thing for my parents to provide hands-on techniques per my instructions, but it’s a whole other issue about their being able to understand and convey the tactile sensations they are receiving back from the children. While touch provides both the therapist and client with valuable information, touch also offers the therapist a unique learning experience that shapes his or her expertise. And that comes only from experience and practice. This is especially true for building competency in a new therapist.
Jana Cason, DHS, OTR/L, in her 2012 article, “Telehealth Opportunities in Occupational Therapy Through the Affordable Care Act,” shares insight into the aspects of the ACA that align with therapy roles supported by AOTA and provides research study results that support the use of telehealth in certain areas: early intervention and school-based pediatric therapy; productive aging/health and wellness, mental health; rehabilitation, and disability, and participation.
Pros: There are a number of situations that I consider excellent candidates for telehealth and look forward to its implementation within them as appropriate:
—providing services to communities that are underserved due to their remote location and/or lack of occupational therapists on site;
—offering services to clients who have difficulty meeting at a clinic due to financial or transportation constraints;
—assisting clients in the incorporation and use of assistive technology and adaptive techniques (e.g., caregivers serving a patient with dementia for Alzheimer’s Disease, parents of children who rely upon assistive technology to communicate or perform ADLs);
—assessing and assisting in the modification of home, work, or school environments to increase accessibility and level of independence;
—providing therapy designed to improve skills after clients return home post surgery or hospital visit to facilitate carryover to a functional environment;
—providing assessment and therapy designed to promote the creation and maintenance of healthily habits and routines.
Cason, in her 2012 article, concludes that, “by removing barriers to accessing care, including social stigma, travel, and socioeconomic and cultural issues, the use of telehealth as a service delivery model within occupational therapy leads to improved access to care and ameliorates the impact of personnel shortages in underserved areas (p. 132-133).”
An additional benefit of using the telehealth service delivery model in my practice was the opportunity for the enhanced experience it provided the parents as they were formally involved in the delivery of services. This was the single-most positive outcome in that it resulted in improved participation and completion of the children’s home program, which is a key element of a rehabilitation program.
5. What has been the overall response from the clients (i.e. parents, children) you serve?
As I mentioned, the introduction of the program was met with an overwhelming positive response from both the initial parents and children. The children were happy, of course, because they were entering into a new adventure with me! The parents were excited about continuing their children’s therapy with me and recognized the benefits of this service delivery method. They dove into the project and worked with me to ensure its success throughout those initial 4 months. I have to say that we encountered very few snags because of the many months that we’d taken planning the program and practicing with it.
Telehealth continued to be a service I offered when I traveled to Arizona in subsequent winters as well as when my clinic was open. The parents who elected to utilize the program in lieu of in-person therapy did so because of transportation issues, scheduling barriers, or family responsibilities. But when chosen, they viewed it as an interesting and appropriate method and one that they felt they could implement with a bit of planning and practice.
Although telehealth was offered as a service option in my business model, the decision to choose it for a child was decided on case-by-case basis. Whenever possible, I opted for an in-person evaluation and would consider the appropriate service delivery options for the child’s treatment strategy at that time.
In all instances, both the parents and I considered our relationship to be stronger because we had much more contact with each other while we managed the mechanics of the program. I continued to request feedback from parents throughout the completion of the children’s rehabilitation plan and was often rewarded with ideas and suggestions for improving the program.
From my standpoint, I was very pleased with the continued engagement displayed by the parents as they maintained communication with me by email, downloaded materials in a timely manner, collected materials and set up the space before the session began, and worked with me throughout the session, limiting any absence away from the therapy set up. This was time consuming for them and it added responsibility to their time at home. Their sustained involvement humbled me as they became “my hands” and acted as my assistant.
6. What is the typical structure of an online session?
It was important to me that the services I provided through the telehealth delivery model were consistent in quality and efficiency with those that I offered in person. Therefore, during the planning and creation of the project, I spent a considerable amount of time evaluating the impact that long-distance delivery would have on the length of my session; assessing the therapy tools and activities that would work well in this environment; determining strategies for providing adequate guidance to the parents for implementation of the therapeutic activities; and, finally, the feasibility of conducting an evaluation with this model. When I’d determined that these facets could be accomplished, I designed my sessions in the same manner as an in-person session, with the exception of the additional 10-15 minutes of Parent Time. During in-person sessions, the parents would typically sat in the therapy room with us and I would discuss progress and demonstrate activities for the home program during therapy. Any discussions that addressed other areas of the children’s therapy were conducted on the telephone. A typical telehealth session was conducted as follows:
—Gross Motor Warm-Up: 5-10 minutes (more if enhanced gross motor skills were a goal in the child’s remedial plan)
—Vision Warm-Up: 10-15 minutes
—Fine-Motor Warm Up: 15-20
—Culmination Activity: 15 minutes (This would be an activity that addressed handwriting at an appropriate skill level.)
—Parent Time: 10-15 minutes
I wrote an article that outlines a day in the life of an occupational therapist and you can see how my day usually went. This day had one telehealth session in it. It also includes a video of a portion of one of my sessions.
7. What recommendations or advice do you have for OT providers considering providing services via telehealth?
The start up of any project is an exciting and creative learning opportunity. It is time consuming and frustrating at times. But the most important part of any plan is the foundation upon which it is built. Therefore, the time spent on the areas I’ve listed below will result in a greater possibility of success and a more rewarding start up and business experience.
—Spend time researching this delivery method. Read every article you can find no matter the discipline it is directed toward in an effort to gather a diverse foundation of information and opinions. Contact experts in the occupational therapy field, such as Jana Cason, DHS, OTR/L, FAOTA. She has been very helpful to the many therapists I’ve sent her way.
—Determine if your practice area is an appropriate setting for the delivery of services with telehealth. Consult with other therapists in that area, asking for opinions and experiences with the modality.
—Determine your current level of competence within the area that you are considering for this delivery method. Take an honest assessment based upon your level of experience within that specific field and your level of comfort with the challenges that telehealth services can present.
—Consider courses that can offer an introduction to the general concept of telehealth or training courses that can address specific areas that may apply to your field. Check with occupational therapy programs in your area to get information on any of their experiences with telehealth, courses they may offer, or resources that they can forward to you.
—Contact the licensing board in your home state and request copies of their guidelines and state regulations, if any exist, so that you can review them in detail, asking questions if you need clarification.
—Collect information regarding the laws, regulations, and board guidelines for any state in which your clients will reside if it is outside your home state. Be clear on these before you engage in the delivery of services to these clients.
—Spend time researching information about the start up of small businesses regardless of the focus of their services. I cannot stress this enough. For many of you, this will be your first entrepreneurial endeavor and you will want to gather information about business plans and mission statements. It’s important to take the business management portion of a start-up company seriously no matter the size or scope of your practice. There are important decisions to be made about registering your business, applying for local permits, and maintain legal compliance. The Small Business Administration is a good pace to start, but there other online resources that can provide information about these and other business components such as accounting practices, business plans, and the legal requirements for working out of your home.
—Consider the time element inherent in providing telehealth services. The professional that I had consulted that offered vision therapy services through a much more sophisticated modality than I was planning to use indicated quite clearly that this method of providing services would consume much more of my non-billable time than an in-person session. And I did, indeed, find that to be so. The additional responsibilities that my parents would shoulder meant that my administration time would also be impacted by additional session preparation for items to sent to parents, preparing scanned items for the additional emailing required, receiving and printing items sent from the parents, and an additional accounting procedure to address long-distance parent payments. As a small business owner, it is often not feasible to purchase sophisticated technologies or additional personnel for simplifying some of these aspects of the business.
8. How do you feel technology in general has been able to support your practice as an occupational therapist?
In my Handwriting With Katherine practice, I actually utilized very little technology before the introduction of telehealth as a service delivery model. And the latter was done solely out of necessity. In my opinion and experience, the remediation of handwriting development skills are best addressed with a hands-on strategy, both for the therapist and the children. This type of specialized remediation benefits from the engagement of all of the senses, tactile in particular. As far as using apps or electronic games in my sessions, I have chosen not to include them. Although I appreciate them for what they are and the advantages they can offer children, I am happy with the results my clients make using hands-on activities such as board and card games, gross motor games, and paper-and-pencil activities. And I find I can tailor those activities to meet their needs much more effectively than I can with an electronic one. It is funny, though, that in all my years of working with children on their handwriting skills, not one of them has asked me where the technology is. Or their parents for that matter.
I recognize that some children will have needs that would best be addressed with adaptive technologies. The mission statement of my business does not expand my practice to address adaptive technologies for those children whose needs go beyond the services offered in my practice. For those who would benefit and require adaptive strategies and equipment, I refer them to the experts in that area. I have great respect for those who specialize in them.
Telehealth has the potential for becoming a useful service delivery method in occupational practice. There is still much research to be done and guidelines to be written, however, and I am looking forward to what it may hold in the future. I hope this series on telehealth has provided you with a starting point for considering this new service method. As alway, that you for reading. And I look forward to your comments.
The Handwriting is Fun! Blog is published by and is the property of Handwriting With Katherine.
Katherine J. Collmer, M.Ed., OTR/L, is a pediatric occupational therapist who specializes in the assessment and remediation of handwriting skills. In her current book, Handwriting Development Assessment and Remediation: A Practice Model for Occupational Therapists, she shares a comprehensive guide and consistent tool for addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.
Pictures above that are the property of the author must provide a link back to this article or her website.
1 Disclaimer: This article is provided for informational and educational purposes only and is not a substitute for legal advice or the professional judgement of health care professionals in evaluating and treating patients. The author encourages the reader to review and verify the timeliness of information found on supporting links before it is used to make professional decisions. The author also encourages practitioners to check their state OT regulatory board/agency for the latest information about regulatory requirements regarding the provision of occupational therapy via telehealth.
2 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.