In 2019, telehealth continued to be labeled as an “emerging” practice area in occupational therapy. The American Occupational Therapy Association (AOTA) published telehealth position papers dating back to 2005 (AOTA, 2005, 2010, 2013, 2018), and occupational therapy and occupational science had a foundation of research to draw from to inform practice (e.g., Proffitt et al., 2021). Yet, barriers to widespread use of telehealth persisted, which included a lack of payment structures and insurance reimbursement for occupational therapy (OT) services in many settings, attitudes, and perceptions related to decreased efficacy and personalization of telehealth delivered services, and a lack of technology and internet access in many communities. When the COVID-19 pandemic unfolded in March 2020, an “emerging” service delivery model quickly became part of everyday practice. Due to rapid uptake of telehealth across practice settings and populations, research on all aspects of telehealth are required to further bolster occupational therapy and occupational science evidence. In this special issue of OTJR: Occupational Therapy Journal of Research, we highlight recent scientific contributions to the growing body of research supporting the use of occupational therapy services delivered via telehealth.
The PACE Framework (Little et al., 2021) serves as a guide for the measurement and evaluation of occupational therapy services delivered through telehealth and includes (1) Population and Health Outcomes, (2) Access for All Clients, (3) Costs and Cost Effectiveness, and (4) Experiences of Clients and Occupational Therapy Practitioners. In this editorial, we provide descriptions of the scientific contributions of studies within this special issue as they fall within each category of the PACE Framework. This allows us to understand the strength of evidence within each category and where gaps exist for future research.
Population and Health Outcomes
To assess intervention effectiveness on population and health outcomes, we must have psychometrically sound instruments validated for telehealth delivery. Three studies explored instrument development and delivery. First, Guzmán & Grajo used Rasch analysis to validate TeleWrite, a telehealth-based writing assessment. Results indicated that TeleWrite shows strong construct and internal validity, and may be a promising tool for handwriting assessment in elementary school age children. Second, Sinvani & Gilboa evaluated the acceptability, inter-rater reliability, and concurrent validity of the Gliboa Functional Test (GIFT-Online) among children 3–7 years old. Results showed that the GIFT-Online demonstrates concurrent validity with other validated measures of handwriting, and is an acceptable, valid, and reliable measure for assessing handwriting through videoconferencing. Third, Phillips and colleagues investigated the extent to which parents met administration fidelity of an autism screening tool, finding that 82% of parents adhered to fidelity criteria when administering an autism screening tool via telehealth. To better understand what instruments are currently used, Tkach & Earwood conducted a scoping review on caregiver outcome measures in pediatric rehabilitation delivered via telehealth. The authors found that caregiver measures consisted of questionnaires, standardized measures, electronic tracking, and interviews.
Early-phase evidence supports interventions delivered via telehealth among a variety of participants, including teachers, those with autism, individuals with cancer, and those with chronic conditions. Halperin and Waldman-Levi evaluated a telehealth delivered teacher training program focused on playfulness in the classroom and stress management. Teachers reported increased knowledge and skills as well as reduced stress following 6 weekly sessions. Little et al. investigated the efficacy of a synchronous and asynchronous parent coaching intervention delivered via telehealth to improve toileting skills for young children with autism. Parents reported the intervention as highly acceptable and reported significant improvements in children’s toileting skills; however, parents accessed the asynchronous materials at a low rate. Radomski et al. investigated the feasibility of providing a purpose in life renewal intervention to breast cancer survivors via telehealth. The group-based intervention was acceptable; however, pre-post changes in purpose of life were not significant. Kang et al. evaluated the feasibility and preliminary efficacy of MyGoals, a goal setting and goal management system for individuals with chronic conditions. Findings showed that telehealth and hybrid (i.e., telehealth and in-person) resulted in client satisfaction, engagement, and changes in goal achievement.
Five studies provided stronger evidence for effects of telehealth delivered interventions on health and participation outcomes among individuals with various conditions through randomized controlled trials (RCTs). Dursun and colleagues evaluated a 5-week CO-OP intervention delivered via telehealth for children with organic acidemia as compared to a home program. Children in the CO-OP group showed significantly more gains in occupational performance and satisfaction as compared to controls. Mitchell et al. analyzed data from 2 RCTs of Lifestyle Redesign® for young adults with diabetes, comparing engagement and attendance between in-person to telehealth delivery. Telehealth delivery resulted in increased occupational performance, satisfaction, and health management. Intervention engagement and attendance was similar across telehealth and in-person delivery. Grinblat et al. used a tailored, metacognitive intervention (Work-MAP) delivered via telehealth to improve work performance among adults with attention deficit hyperactivity disorder (ADHD). Over the course of 11 weeks, the intervention group showed efficacy in improving work performance, executive function, and quality of life as compared to waitlist controls. Ellington and colleagues evaluated the effectiveness of the Glove Rehabilitation Application for Stroke Patients (GRASP) virtual reality home exercise program among individuals with stroke delivered asynchronously and synchronously. As compared to usual care controls, the GRASP group demonstrated significant improvements in upper extremity function. In another study with individuals having experienced a stroke, Lee et al. evaluated the effects and perceptions of a motivational interviewing and group-based self-management program to treatment as usual. Participants in the intervention group reported emotional benefits, new insights, and a moderate effect for perceived recovery.
Finally, a scoping review assessed evidence related to telehealth utilization on health outcomes. Washington et al. assessed evidence related to telehealth for older adults; many studies included older adults with chronic conditions. Findings revealed themes of telehealth-based interventions for older adults, including, but not limited to, cognition, home modification, and occupational engagement and performance.
Access for All Clients
Research suggests that individuals from low socioeconomic status areas and backgrounds, cultural and linguistic diverse communities, older adults, and those with disabilities experience difficulties in accessing telehealth (Ortega et al., 2020). To address accessibility of telehealth, Taylor and colleagues tested the extent to which training modules influenced older adults’ perceptions of competency in using telehealth. Findings showed that structured trainings may increase user competence in accessing telehealth services among older adults.
Costs and Cost Effectiveness
Telehealth may be a cost-effective method of service delivery for occupational therapy services, and research is needed to understand specific elements of service provision and utilization that contribute to costs of services. Tanner et al. examined electronic health records from pre- to post-COVID and found that average visit length varied by diagnosis during COVID, not during COVID. During COVID, telehealth visits were longer. The authors also found a decrease of Black and Hispanic clients in accessing telehealth delivered services, related to accessibility of care.
Experiences of Clients and Occupational Therapy Practitioners
To understand components that lead to long-term adoption and effectiveness, we need evidence related to client, caregiver/care partner, and provider satisfaction. In this special issue, there are 7 studies that investigated client and practitioner perspectives of telehealth intervention creation as well as telehealth intervention delivery. Several investigators explored practitioner perspectives of telehealth interventions to optimize intervention content and delivery. Using a qualitative approach, Pineda et al. evaluated health care perceptions of a telehealth-delivered Baby Bridge program, an implementation strategy to improve access to early therapy services post-neonatal intensive care unit discharge. Findings from this study showed that providers viewed telehealth delivery as acceptable, not preferable to in-person delivery, and suggestions for optimization of the Baby Bridge program. Lamash and colleagues used interviews with clinician stakeholders to conduct a formative evaluation of a telehealth delivered social participation intervention for adolescents with autism, Social Participation and Navigation (SPAN). Stakeholders described participant benefits, intervention goals, and program content, and findings informed the development of an intervention website and intervention manual. Angell et al. interviewed clinic administrators, occupational therapists, and parents to evaluate perceptions of telehealth-delivered therapy services for autistic children. Researchers found themes related to specific barriers and facilitators and outlined specific strategies to support engagement over telehealth. Sleight et al. studied the prevalence and perceptions of telehealth among occupational therapy practitioners that served individuals with cancer. Overall, occupational therapy practitioners (OTPs) in oncology settings supported the use of telehealth, and identified treatments best suited for telehealth, including education, quality of life, and psychosocial interventions.
Investigators also explored perceptions of telehealth interventions from client perspectives. Smith and colleagues used a mixed-methods approach to evaluate telehealth delivered parent coaching among children with special health care needs. Their findings showed that telehealth was an effective method of enhancing parent-provider connection and fostered parent involvement. Hladik et al. also used a mixed-method approach to evaluate parent perceptions of a mealtime intervention. This study unveiled benefits and challenges to telehealth delivered mealtime intervention, and family characteristic differences supported increased accessibility of the intervention. Donnelly et al. used a qualitative approach to evaluate the acceptability of a complex, muscle biofeedback system (Tele-REINVENT) for stroke survivors. Individuals reported that features of the asynchronous telehealth intervention that promoted agency and control were highly acceptable.
Conclusion
We hope that this issue highlights the important and timely work being conducted in telehealth for occupational therapy and occupational science. Much of the evidence supports the use of telehealth-based interventions for improving client and practitioner experiences as well as improving client outcomes. We hope that researchers and OT practitioners are inspired by the findings presented in this Special Issue and ask new questions to grow the dearth of evidence in “Access for All Clients” and “Cost and Cost Effectiveness.” The contributions in this Special Issue have significantly contributed to the evidence for telehealth in occupational therapy and occupational science.
Authored by:Lauren M. Little, PhD, OT/LAssociate Editor, OTJR: Occupational Therapy Journal of Research
Associate Dean of Research & Associate Professor, Department of Occupational Therapy, College of Health Sciences, Rush University, Chicago, IL, USA
Rachel Proffitt, OTD, OTR/LAssociate Editor, OTJR: Occupational Therapy Journal of Research
Associate Professor, Department of Occupational Therapy, University of Missouri, Columbia, MO, USA
