Providing Occupational Therapy Intervention using Telehealth

The Research on the Efficacy of Telehealth

With occupational therapy intervention where services are provided using telehealth, research shows that improvements are seen in upper extremity function, parental stress levels, motivation, carryover with home programs and engagement in daily tasks such as ADLs and IADLs (Hung & Fong, 2019; Sarsak, 2020).

There is also feasibility with utilizing online resources to engage in therapeutic exercises to improve upper extremity function (Sarsak, 2020) and completing a home safety assessment using a telehealth model with the assistance of dementia caregivers (Gately et.al, 2019). Research also indicates that involving caregivers with interventions that improve care recipients improve both the care recipient’s functional outcomes and the caregiver’s stress levels (Family Caregiver Alliance, 2000; Vance, 2016). Along the same lines, caregivers are more likely to complete tasks that involve the care recipient and tasks that fit in their daily schedule (Family Caregiver Alliance, 2000; Vance, 2016).

Overall, telehealth intervention positively impacts the functional outcomes of clients in addition to improving the skills and mental health of caregivers. However, telehealth is a practice area that requires a large amount of treatment planning and exploration of resources available to provide effective intervention. So, let’s get started on how to implement interventions using telehealth!

Adult Population

  1. Telehealth Tools for Therapists This site has resources for therapists made by therapists.
  2. Sanitized therapy kits.

Working with adults that have physical disabilities, it becomes important to guide therapeutic exercises. As therapists, we know the outcomes of not following a good exercise program on strength, flexibility, and ultimately function. Working with clients using telehealth, can be as simple as providing the client with a large Ziploc® bag (gallon size or larger) of activities that can be used during a telehealth session.

With permission of the client, items can be delivered to the client’s home and at every scheduled session, the therapist and the client can work together to complete an exercise session using the items in the bag. The Ziploc® bag can be labelled. This bag would be the client’s and will not be returned. Therefore, items provided must be cost effective. Purchasing items for the purposes of work can be tracked to ensure that overspending does not occur. An example of a kit that can be prepared is provided below:

Links to items in Therapy Bag:

Ziploc® type bags can be purchased at Dollar Store—roughly 10-gallon size bags or 5-6 larger bags. *affiliate links

Theraband*: TheraBand Resistance Band Set Cost: 14.49

Hand Exerciser*: Hand Exerciser Cost: 10.00

Beads*: Medium and Large Beads Cost: 6.99

Hand Exercise Webs: Hand Exercise Web Cost: 32.75

Pillbox*: Pillbox Cost: 4.99

Weights*: 1lb weights Cost: 8.98

Total: $78.00 which can make about 3 or more kits, roughly $25 per kit, less if material can be distributed in smaller amounts. Alternatives include using water bottles as 1lb weight for further savings. There is also the opportunity to use what the client has in his or her home to organize a therapy kit. Beads can be used to mimic pills for medication management task or for fine motor skill task. Be certain if beads are provided, there are not your children at the home. Using a budgeting sheet will help with tracking spending.

Link to spreadsheet here: Telehealth Budget Excel Spreadsheet

3. Caregiver education

Research has shown that caregivers prefer to have interventions that allows for incorporation of the care recipient (Family Caregiver Alliance, 2000; Vance, 2016). Therefore, caregiver education that includes care recipient will be beneficial. Caregiver education is one area where the right approach and tone needs to be set early on.

As occupational therapy practitioners, we need to consider the other roles of the caregiver, level of education, overall health, and level of access to the client. One resource that meets the needs of the client and caregiver is the OT Toolkit. This resource breaks down an activity or strategy in a manner that can be easily understood. The use of simple pictures, and wording, helps the caregiver to understand and serves as a tool that the clinician can use to present information in a manner that is not overwhelming to the client or caregiver.

If you have the e-book version (https://www.ottoolkit.com/individual), the client can screen share to provide education or to walk the caregiver through the training.

Use this link: https://www.ottoolkit.com/samples to get some samples to see the usability of this resource.

4. Therapeutic exercises

Sanitized therapy kits can be used for exercise programs. Setting up an exercise plan with the client with what is available in the home is also an option. This can be bottles of water or cans for weights. Having a caregiver make theraputty (this link has an easy to follow recipe: DIY Theraputty )to use as part of an exercise program.  

5. Adaptive equipment recommendations and training

Toolkit: https://www.ottoolkit.com/samples  can also be used to show equipment. A great You Tube video I have used: Adaptive Equipment Training at Home shows possible equipment and usage for families to review as a screen share option. Also providing clients and caregivers with local stores that carry items and are knowledge about reimbursement for equipment: Local AE Store Problem solving for space, cost, utilization can also be a client and caregiver education session.

6. Screen share activities

There are many apps that are available online through Apple, Android, and Microsoft. AOTA provides a list of apps (https://www.aota.org/Practice/Manage/Apps.aspx )that can be used to positively impact therapeutic outcomes. The list of the apps is available for access to AOTA members. Using a video conferencing platform such as Zoom, either the therapist of client can share the screen for interaction.

Some examples of apps that can be used for intervention:

Medscape—this app can be used for a health literacy session with a client to teach about condition, safety, and medication management.

ReHand Hand Rehabilitation—This tool can be used for prescribing and conducting exercise programs for the hand. There is also a monitoring tool to view progress over time.

Pain Diary—This app can be used to track pain to develop a plan for pain management and an objective tool to track progress.

ptpal—this platform allows clinicians to send a home exercise programs, surveys, and activities directly to the client’s mobile device with the ability to track progress.

Pediatric Population

Providing interventions to the pediatric population has an additional layer of ensuring parental involvement. With school-aged children, setup by a parent may be all that is needed for the child to engage in a telehealth session. However, with a younger child or a child that has greater physical or cognitive needs, parental assistance may be needed during the entire duration of the intervention. There are options available below for both scenarios.

  1. Telehealth Tools for Therapists This site has resources for therapists made by therapists.
  2. Sanitized therapy kit

Like an adult therapy kit, a pediatric therapy kit provides the parent/caregiver with a Ziploc® bag of new items for therapy sessions. Important considerations with the items are the age of the child, amount of parental support that is needed to use the tools, and others that are in the house (beads would be great for a school-aged child to work on fine motor coordination, but if a 3-year old sibling gets in the bag, the beads are a choking hazard). Here is an example below of a therapy kit that can be provided to a child that consists of inexpensive items that have great therapeutic used.

All of these items can be found at your local Dollar Store. Putting a kit together is as simple as looking at your client’s goals, what is available locally, and delivering the completed kit to your client’s caregiver. The budget tracking sheet below can also be used to track spending. Cost: between $5-10 per kit.

3. Homework for parents

Related to a therapy kit that is provided, use a session to make a concrete list of items that can be used from what the child has available.  A scan of the toys can net some great toys that can be used for therapy sessions. With each toy that has great therapy potential, make a note of the toy and provide homework for the parent to have the toys available for the therapy session for use. The toys can be categorized—Fine Motor Toys or Gross Motor Toys. The categorization could be simpler such as ‘Toys for hands’ or ‘Toys that help with calming down’. The goal is to focus on terminology works for the caregiver. This would also be a great teaching opportunity for the parent to show how to use the toy to work on OT goals.

4. Caregiver education

Provide opportunity with parents to provide coaching with intervention. Coaching has been found to be beneficial with the pediatric population (Little et. al, 2014). Telehealth allows for caregiver support sign technology. If mealtime is an issue, conferencing during breakfast, lunch, or dinner allows for opportunities to problem solving sensory, adaptive tools, and feeding needs. Conferencing during bedtime routine allows for problem solving for sensory, routines, and equipment needs to support sleep.

5. Screen share activities

Tools to Grow resources: Tools to Grow Teletherapy Resources –One can easily go down the rabbit hole looking for telehealth resources and end up 1-2 hours later without many resources that meet your needs. This site is well-organized, it takes a minimal amount of time to put together intervention plans for your clients with the resources from this site. There are free resources for telehealth and a wealth of resources for subscribers. Here is member pricing: Tools to Grow Pricing I have an individual membership and I never have a shortage of activities for students.

 Your Therapy Source: Your Therapy Source Telehealth Resources The Therapy Zone is also a great resource.

The Telehealth Bundle: Telehealth Therapy Bundle is great for conducting evaluations using telehealth. Though you pay per resource, each resource has quite a bit of activities.

6. Activity calendars

Tools to Grow: Activity Calendars Having a schedule helps immensely. This resource can be used to organize a set of activities for a child. This works great for the therapist, child, and parent because there is a concrete plan of what will happen on a certain day. Another option would be to use a general calendar and organize the activities using resources such as toys or materials that are available. This resource can be used to organize a calendar of activities for the child. This is fillable pdf file that can be done online or printed and filled out.

Billing

Billing is based on insurance. Medicare billing is the federal insurance agency. Reimbursement codes can be found here: Medicare Telehealth Coverage, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth. With Medicaid, reimbursement codes can be found here: NY Medicaid Telehealth Medicaid Guidelines. Within each level of documentation, stating the provision of services using a telehealth model along with the correct CPT® coding ensures proper billing and reimbursement.

As occupational therapy practitioners, creativity is at the heart of what we do. With telehealth, it is important to be creative and think outside the box when providing intervention. There are a wealth of resources available to provide the best intervention possible, positively impacting outcomes.

I hope you found these ideas and resources helpful!

Citations:

Family Caregiver Alliance (2006). Caregiver Assessment: Principles, guidelines and strategies for change. Report from a National Consensus Development Conference (Vol. I). https://www.caregiver.org/sites/caregiver.org/files/pdfs/v1_consensus.pdf

Gately, M. E., Trudeau, S. A., & Moo, L. R. (2019). Feasibility of telehealth-delivered home safety evaluations for caregivers of clients with Dementia. OTJR: Occupation, Participation and Health, 40(1), 42-49. doi:10.1177/1539449219859935

Hung KN, G., & Fong, K. N. (2019). Effects of telerehabilitation in occupational therapy practice: A systematic review. Hong Kong Journal of Occupational Therapy32(1), 3–21. https://doi.org/10.1177/1569186119849119

Little, L. M., Pope, E., Wallisch, A., & Dunn, W. (2018). Occupation-based coaching by means of telehealth for families of young children with autism spectrum disorder. American Journal of Occupational Therapy, 72, 7202205020. https://doi.org/10.5014/ajot.2018.024786

Sarsak, H. I. (2020). Telerehabilitation services: a successful paradigm for occupational therapy clinical services? International Physical Medicine and Rehabilitation Journal, 5(2):93‒98. DOI: 10.15406/ipmrj.2020.05.00237

Vance, K. (2016). Home Health Care: A Guide for Occupational Therapy Practice. Bethesda: AOTA.

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