Telehealth and Occupational Therapy: Integral to the Triple Aim of Health Care Reform

Care Experience

Health systems usually quantify and measure the care experience through patient satisfaction surveys and system-level analysis of key dimensions of care: safety, effectiveness, timeliness, efficiency, equitability, and patient-centeredness (Stiefel & Nolan, 2012). Telehealth improves access to care and specialists; prevents delays in care caused by personnel shortages, travel, and other barriers; facilitates care coordination and communication; reduces hospital admissions and readmissions through telehealth-delivered health and wellness services, chronic disease management, and prevention of secondary complications of chronic diseases; and fosters care in the community (Cason, 2012; Clawson et al., 2008; Darkins, 2014; Darkins et al., 2008; Hopp & Hogan, 2009).

High levels of satisfaction have been reported among patients receiving services through telehealth technologies (Darkins et al., 2008; Kairy, Lehoux, Vincent, & Visintin, 2009; Steel, Cox, & Garry, 2011); some patients even preferred videoconferencing to in-person contact (Steel et al., 2011). Factors that influenced patient and caregiver satisfaction with telehealth included positive perceived benefits, convenience, and usefulness of the telehealth program (Kairy et al., 2009; Taylor et al., 2009); reduced travel requirements (Clawson et al., 2008; Finlayson & Holberg, 2007; Robinson, Seale, Tiernan, & Berg, 2003); and improved care coordination (Clawson et al., 2008; Hopp & Hogan, 2009). Kairy and colleagues’ (2009) systematic review of 28 telerehabilitation studies revealed “consistently high” patient satisfaction with telerehabilitation and clinical outcomes comparable with in-person interventions.

Population Health

The term population health refers to the health outcomes of a defined population. Population health is often affected by the social processes and public policy that influence these outcomes. Stoto (2013) conceptualized population health along a spectrum:

The ACA underscores population health as a means and an end to achieve the goals of health care reform. Several initiatives are under way to improve population health: increased access to health care through the ACA’s insurance mandate and Medicaid expansion, health care quality improvement initiatives (e.g., National Strategy for Quality Improvement, Center for Medicare and Medicaid Innovation [CMMI]), enhanced prevention and health care promotion measures, and incentives for community- and population-based health promotion activities (Stoto, 2013). In the IHI white paper A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost, Stiefel and Nolan (2012) identified physiological factors (blood pressure, body mass index, cholesterol, blood glucose), behavioral factors (tobacco use, alcohol consumption, physical activity, nutrition), and health-related quality of life (QoL) as indicators of population health. Other factors that influence population health include “social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services” (Public Health Agency of Canada, 2013, para. 2).

Affordability of Care

Improved access to care in the home versus in a more costly institutional environment (e.g., hospital, long-term care [LTC] setting) may reduce health care costs overall and contribute to positive health outcomes and effective patient self-management of chronic diseases (Darkins, 2014; Jones et al., 2014). Jones et al. (2014) reviewed 137 articles related to home telehealth for chronic disease management and concluded that home telehealth was equivalent or superior to usual care (as defined by each study’s authors) in improving disease state, symptoms, and QoL in patients with chronic diseases.

Providing services where people live, work, and play is a foundation of occupational therapy. Systematic reviews and comparative efficacy studies of occupational therapy using telehealth yield similar outcomes when compared with in-person services for treatment of chronic conditions (Steel et al., 2011), wheelchair assessment (Barlow, Liu, & Sekulic, 2009; Schein et al., 2011), preadmission orthopedic occupational therapy home visits (Hoffmann & Russell, 2008), assessment of activities of daily living (ADLs) and hand function in people with Parkinson’s disease (Hoffmann, Russell, Thompson, Vincent, & Nelson, 2008), rehabilitation and adaptive equipment recommendations for older adults with mobility impairments (Sanford et al., 2007), ergonomic assessment (Jacobs, Blanchard, & Baker, 2012), and skill development (e.g., completing novel household activities) in adults with intellectual disabilities living in integrated community settings (Taber-Doughty, Shurr, Brewer, & Kubik, 2010).

Research funded by the Agency for Healthcare Research and Quality (2008) demonstrated that telehealth can improve patient safety, quality of care, and care coordination. By providing the “right care in the right place at the right time” (U.S. Department of Veterans Affairs, 2014, para. 6), telehealth may lead to improved efficiencies within the health care system. Because occupational therapy has always worked toward the “right care in the right place at the right time,” the profession’s underpinnings are compatible with the positive potential of telehealth. The profession must now move forward to fully integrate telehealth to optimally achieve these objectives. Further research, including comparative effectiveness studies and cost-effectiveness analyses, is needed to evaluate the impact of telehealth on the dimension of affordability of care.

Center for Medicare and Medicaid Innovation

Established by the ACA, the CMMI is charged with engaging a broad range of stakeholders in identifying and testing innovative payment and service delivery models and advancing best practices aimed at reducing costs and improving quality of care for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program (Centers for Medicare and Medicaid Services [CMS], n.d.). Lamb and Metzler (2014) encouraged occupational therapy practitioners to advocate for inclusion in CMMI-funded research when the potential for occupational therapy involvement exists. In July 2014, CMMI announced the second group (“Round Two”) of prospective award recipients for the Health Care Innovation Awards program. The significant number of funded programs incorporating telehealth technologies indicates that telehealth will be an integral factor in health care reform (CMS, 2014). Occupational therapy practitioners must become aware of and involved in projects such as these to increase awareness of the true value the profession can bring to these efforts. In several of these studies, occupational therapy, if included, could be recognized as a key component of any broad telehealth expansion:

These studies demonstrate the growing interest in telehealth technologies as a means to achieve the Triple Aim. Other CMMI Round Two studies do not explicitly include telehealth or occupational therapy, although they would benefit from the inclusion of both. For example, the Coaching and Comprehensive Health Supports Program, designed to improve outcomes for young adults transitioning out of foster care, will use a coaching model and interprofessional support team to improve healthy behaviors; reduce hospitalizations through better management of behavioral health conditions; increase access to primary care physicians; and positively influence pregnancy-related outcomes, employment, and education attainment (CMS, 2014). The role of occupational therapy in physical and behavioral health, wellness and health promotion, employment, and education is well established (AOTA, 2014). Inclusion of occupational therapy and telehealth technologies could greatly augment this study.

Similarly, occupational therapy and telehealth technologies could be a positive addition to CMMI-funded pediatric studies. The Improving Child Well-Being Through Integrating Care in a Community School Setting study aims to promote health through health risk assessment and interprofessional services targeting physical and behavioral health, wellness, and personal health management. In this and other CMMI-funded studies, occupational therapy practitioners could incorporate telehealth technologies to evaluate all factors in a client’s life that may promote or hinder health, participation, occupational performance, and QoL and then analyze those factors to facilitate intervention, consultation, and monitoring to promote healthy living and prevention of disease and disability.

Patient-Centered Outcomes Research Institute

The ACA established the Patient-Centered Outcomes Research Institute (PCORI) to fund comparative efficacy research to assist health care providers and consumers in making informed decisions related to treatment options (Lamb & Metzler, 2014). As in CMMI-funded research, telehealth is a prominent delivery model in PCORI-funded research. A study by the University of California–Los Angeles will determine whether telehealth is an effective, efficient, and family-centered method to deliver developmental, behavioral, and mental health services to children in low-income communities. Outcomes to be studied include improved access to developmental, behavioral, and mental health services; quality measures including timeliness, family-centeredness, coordination, and parent experiences of care; parent satisfaction; clinical outcomes associated with the children’s developmental, behavioral, and mental health; and the children’s QoL (PCORI, 2013a).

This study, which is aligned with the Triple Aim, would benefit from the inclusion of occupational therapy to evaluate and remediate limitations in areas of concern including ADLs, instrumental ADLs, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014). By evaluating client factors, performance skills, performance patterns, and the influence of context and environment, occupational therapy practitioners could design interventions and provide recommendations for enhancing the children’s occupational performance; promoting their health and wellness, emotional well-being, and mental health; increasing their participation, role competence, and social competence (e.g., coping skills, making and keeping friends, solving problems, understanding social etiquette, following rules); and improving their QoL (AOTA, 2011).

Another PCORI-funded study, titled Telehealth Self-Management Program in Older Adults Living With Heart Failure in Health Disparity Communities, aims to use telehealth technologies to enable weekly interactions with health care providers via videoconference and daily patient self-monitoring to reduce higher cost care (i.e., emergency room care, hospitalization) and facilitate patient-led improvements in health, satisfaction, and quality of life (PCORI, 2013b). Occupational therapy practitioners could contribute to this study in the areas of prevention, lifestyle modification, and physical and psychosocial rehabilitation. Interventions may include assessment for fall risk and home modification to improve performance and safety; provision of home exercise programs, adaptive strategies, and assistive technology to enhance occupational performance and participation; and activity modification techniques and patient education on energy conservation. Additionally, occupational therapy practitioners may teach techniques to facilitate stress management, pain control, and coping skills to support physical and psychosocial health and well-being (AOTA, n.d.-a).

Challenges and Call to Further Action

Of concern in the studies outlined in this article and in other PCORI-funded studies is the apparent omission of occupational therapy practitioners as members of the studies’ health care teams. For example, a $30 million national study for fall injury prevention will deploy “nurses or nurse practitioners trained as ‘falls care managers’ to provide older adults with individually tailored, evidence-based care plans to help them avoid falls and related injuries” (PCORI, 2014, para. 1). Occupational therapists are trained to administer standardized balance, cognitive, and visual assessments and evaluate the interplay of intrinsic (person) and extrinsic (environment) factors contributing to fall risk (AOTA, 2012; Roberts & Robinson, 2014). Occupational therapy interventions including environmental modification, exercise programs, and patient education promote safety during daily routines and activities and reduce fall risks (Roberts & Robinson, 2014). The distinct skills of occupational therapy practitioners would be of great value in this fall intervention study, yet nurses and nurse practitioners are the “falls care managers” identified in the study.

Lamb and Metzler (2014) identified fall prevention programming as an area in which evidence supports the value of occupational therapy; occupational therapy practitioners can use this evidence for “assertive and focused actions to ensure that the new system and all its components fully use the skills and benefits of occupational therapy” (p. 13). The ACA created opportunities for expanded roles for occupational therapy in primary care, patient-centered medical homes, ACOs, behavioral health, prevention, and wellness. Unfortunately, the role (and value) of occupational therapy in these nontraditional practice settings is not well understood by stakeholders (Goldberg & Dugan, 2013). We must take action to fulfill our potential in service of these larger needs by articulating the distinct value of occupational therapy and the evidence supporting our expertise in these nontraditional practice settings.

Stoffel (2013) issued a call to action for occupational therapy practitioners to “collaborate closely with behavioral health professions, advocacy groups, and the community to ensure that quality essential services include the expertise of occupational therapy practitioners” (p. 144). We must take this call to action even further. Occupational therapy practitioners must educate stakeholders and articulate occupational therapy's distinct benefits in relation to what patients, health care teams, organizations, policymakers, and society value (Lamb & Metzler, 2014). This message must include attention to the role of telehealth in health care and, more specifically, the role of telehealth in the delivery of occupational therapy services.