A week after Boston University’s campuses closed and classes were shifted online due to COVID-19, physical therapist Tim Nordahl began videoconference sessions with patients at the Center for Neurorehabilitation. As Nordahl interacted with his clients, most of whom are dealing with physical limitations due to Parkinson’s disease, he realized that although he couldn’t touch his patients to guide a movement, he was gaining a more precise view into their lives.
After seeing inside a bedroom or kitchen, Nordahl found he could prescribe exercises tailored to those circumstances: how to gain leverage to rise from a mattress or use kitchen counters for support. “I have been pleasantly surprised at how much we can get done in this sort of format,” he says.
Therapists and nutritionists at the Ryan Center for Sports Medicine and Rehabilitation, Sargent Choice Nutrition Center, and the Speech-Language Hearing Sciences Clinical Centers are reporting similar benefits using telehealth. Appointments via a videoconference is an idea that healthcare providers have long considered but that wasn’t covered by health insurance. That changed in March, when Medicare announced coverage for telehealth services and other insurers followed. Congress is now considering a proposal to make the changes permanent.
Karen Jacobs, associate dean for digital learning and innovation, says the pivot to telehealth fits into a broader effort at Sargent to use online channels to connect practitioners. For example, her research has shown that virtual peer-to-peer mentoring helps postdoctoral occupational therapy students build resilience so they can finish their programs. That same lesson applies to therapists ensuring that they cultivate personal connections with patients when meeting via Zoom. “We’re understanding the natural context in which people live, and that is helping us to become even more client centered,” Jacobs says.
After the COVID-19 pandemic forced them to make a rapid transition to online services, leaders from all four centers and programs say they plan to continue virtual appointments as part of a hybrid care model, even after their facilities reopen.
NEW INSIGHTS
The first virtual appointment at the BU Physical Therapy Center in the Ryan Center occurred on March 16. By mid-June, the center was holding about 40 percent of its typical physical therapy sessions online.
James Camarinos, clinic director, says it’s forced his team to get creative. For example, he offered suggestions for easing one patient’s neck discomfort after viewing how he lay in bed. “It allowed for a real-life intervention in the moment,” he says. Without weights from the center at hand, Camarinos had another patient put books into a duffel bag.
—James Camarinos
“Perhaps the best thing that physical therapists do is they build meaningful relationships with their patients. And they help educate them and manage whatever condition is limiting them from doing the activities they want to do,” says Camarinos. “Through either modifying the activities or tailoring them differently or prescribing exercise, I can do all those things on telehealth.”
On June 3, the Ryan Center partially reopened. Patient visits were limited and staff wore gowns, masks, and gloves. But even as his team makes plans to broaden in-person services, Camarinos says he wants to see telehealth appointments continue. “There is a litany of research that supports the idea that early intervention is better than delayed intervention,” he says. “Telehealth is a really unique way that we could capitalize on that, if we’re smart and creative.”
A HYBRID SOLUTION
Terry Ellis, director of the Center for Neurorehabilitation, agrees telehealth sessions are here to stay. She predicts the emergence of a hybrid model, with patients visiting the center when the physical therapists need to measure walking and balance abilities. Ellis, an associate professor and chair of physical therapy and athletic training, says there are challenges specific to the work her center does with patients with Parkinson’s. For example, physical therapists need to perform an in-person baseline exam during intake, analyzing aspects of movement such as walking, balance, strength, and flexibility so they can measure progress or deterioration over time. The center resumed some of these appointments in July with staff wearing protective gear; by then, they’d already conducted 200 virtual visits with 50 patients.
“We can then see the advantage of having them do interim visits remotely, so that it would take some of the burden off of them of having to travel,” Ellis says. Such a model also means the center could attract out-of-state patients who would benefit from rehabilitation.
The telehealth experience builds on research that Ellis has conducted showing that Parkinson’s patients on average walk 10 percent more when they have an app on their phone or tablet that encourages regular exercise—a key to slow progression of the disease.
AN EXPANDED REACH
The expanded reach of telehealth has proven especially helpful for the Sargent Choice Nutrition Center, which provides counseling and support services for people with a variety of conditions, including food allergies and intolerances, eating disorders, and digestive ailments, and also offers nutrition and cooking classes.
Stacey Zawacki, director of the center, and a clinical assistant professor of health sciences, says Zoom calls provide easier access for clients. As a result, cancellations have decreased. Telehealth also ensures continuity of care for students who have moved back home.
If a client has recently learned they have celiac disease or is testing different foods to identify a food intolerance, it takes time to learn new dietary patterns. An eating disorder doesn’t stop for a pandemic. “There are a lot of people finding that eating in this changed world is very different and can be very challenging right now,” she says.
From March 15 to June 15, the center’s seven registered dietitian nutritionists conducted 730 telehealth sessions. That’s 8 percent more than the in-person visits they held over the same period in 2019.
Because dietitians, like other healthcare providers, often discuss personal issues, they have to ensure their clients have a private space for video calls, which for some is a challenge, Zawacki says. But there are also benefits, such as being able to look at a client’s food package label, or, if the client would like, strategizing around what’s in the refrigerator. There are even teaching benefits to telehealth sessions. “In person, you’re limited by the physical space,” Zawacki says. But online, multiple students can observe a session, with a client’s permission. And, after introducing themselves, they can shut off their cameras and mute their microphones, to observe unobtrusively. “It makes clinical training much more efficient,” Zawacki says.
The center reopened in September, but the staff also expects to continue offering videoconference appointments as a way to augment in-person visits for current clients and to expand future clientele beyond the Boston area.
“The world is recognizing how valuable these services are,” Zawacki says. “And a lot of the value is not just related to the pandemic.”
A STRATEGIC MOVE
Since March, graduate students in the speech-language pathology program have seen a range of clients via Zoom, including those with conditions like aphasia and language, speech-sound, fluency, and voice disorders. Michelle Mentis, MS program director and chair of the Department of Speech, Language & Hearing Sciences, says the move to telehealth has meant an increase in out-of-state clients.
The transition has also required that the students develop creative approaches for communicating with clients in video sessions, says Meghan G. Graham, a clinical assistant professor who supervises graduate speech therapy students.
“I was worried that this was not going to work with the little kids,” Graham says. “But our graduate students were incredibly innovative and creative and dedicated to making it work.”
Graham recounted one child who is a fan of basketball star LeBron James. His speech therapist used a basketball court as a Zoom background and had the child practice telling a story—a key skill for young children developing language—to images of James. “He would just light up when LeBron would appear,” Graham says.
Older clients, like those dealing with aphasia after a stroke, have found rewards participating in a speech therapy group via videoconference, Mentis says. The social ties of the group meeting have eased their sense of isolation.
“At the time of the pandemic, when everyone was at home and having to stay at home and had very little opportunity to socialize, these groups became even more important to some of the clients we were working with,” she says.
Speech-language pathologists are collecting data to better understand the differences between telehealth and in-person clinical services, but it’s too early to say if these sessions offer different benefits. Mentis says based on the experience so far, she expects that telehealth will continue after social distancing requirements ease. “This is not going away. This is going to be part of our arsenal of services that we can offer,” she says.