Clinical Considerations and Practical Strategies in Implementing Telerehabilitation by Veterans Health Administration Rehabilitation Providers

The COVID-19 pandemic accelerated innovations within the Veterans Health Administration (VHA) healthcare system and forced a sudden shift to telerehabilitation for those in need of rehabilitation services. However, there exist few data-driven guidelines regarding the clinical practicalities of implementing telerehabilitation. Gains in practical knowledge for implementing telerehabilitation were accelerated during the VHA healthcare systems’ rapid shift from out-patient rehabilitation services to telerehabilitation during the COVID-19 pandemic. This study examines implementation of telerehabilitation within the VA healthcare system during COVID-19 and describes VHA Telerehabilitation Enterprise-Wide Initiative (TR-EWI) rehabilitation providers’ experiences of and practical strategies for implementing telerehabilitation—whose uptake was accelerated in response to the COVID-19 pandemic. The purpose was to identify key considerations, supports, and practical strategies for engaging patients in rehabilitation services via telehealth technologies for VHA rehabilitation providers. A qualitative design was used to examine, in-depth, VHA rehabilitation provider’s implementation of telerehabilitation. Group and individual interviews with 12 VHA rehabilitation providers were conducted to examine, in-depth, the providers’ implementation of telerehabilitation. An interview guide was developed by the TR-EWI evaluation team and piloted with a VHA clinical rehabilitation manager who is a physical therapist. The open-ended questions and probes developed for the interviews were used as a guide to ensure that all domains of interest were asked about. Interviewees were five occupational therapists, three rehabilitation clinical psychologists, two physical therapists, one speech-language pathologist, and one telehealth medical service assistant. Following the thematic analysis, data were analyzed for content specific to practical strategies, considerations, and supports that had applicability across the rehabilitation disciplines represented in the sample. Emergent conceptualizations were regularly discussed and verified by team members with VHA content expertise. Group and individual interviews were conducted using video conferencing software (i.e., Zoom, Microsoft Teams) with use of video, chat, transcription, and recording functions agreed to by participants and used in all interviews. Transcripts were verified from the video recordings immediately after each group and individual interview and used for analysis. Thematic analysis yielded nine themes: Willingness to Give Telerehabilitation a Chance: A Key Ingredient; Creativity and Adaptability: Critical Attributes for Telerehabilitation Providers; Adapting Assessments; Adapting Interventions; Role and Workflow Adaptations; Appraising for Self the Feasibility of the Telerehabilitation Modality; Availability of Informal, In-Person Support Improves Feasibility of Telerehabilitation; Shifts in the Expectations by the Patients and by the Provider; Benefit and Anticipated Future of Telerehabilitation. Telerehabilitation requires multi-faceted clinical reasoning when deciding what patient is appropriate for what types of telerehabilitation care. Safety considerations include both physical and mental safety considerations. Therapeutic activity and safety considerations were often made in consideration of family member availability. Novel findings contribute in-depth understanding of clinical reasoning considerations, supportive strategies, and practical approaches for engaging adult Veterans in rehabilitation care through telehealth modalities. VHA telerehabilitation has the potential to substantially transform Veterans’ rehabilitation care delivery and maintain or improve rehabilitation outcomes.

References

American Occupational Therapy Association (2021). Telehealth resources. American Occupational Therapy Association. Available from: https://www.aota.org/Practice/Manage/telehealth.aspx

Hale-Gallardo, J. L., Kreider, C. M., Jia, H., Castaneda, G., Freytes, I. M., Cowper Ripley, D. C., Ahonle, Z. J., Findley, K., Romero, S. (2020).Telerehabilitation for rural Veterans: A qualitative assessment of barriers and facilitators to implementation. Journal of Multidisciplinary Healthcare,13, 559-570. https://doi.org/10.2147/jmdh.S247267

Richmond, T., Peterson, C., Cason, J., Billings, M., Terrell, E. A., Lee, A. C. W., Towey, M., Parmanto, B., Saptano, A., Cohn, E. R., Brennan, D. (2017). American telemedicine association’s principles for delivering telerehabilitation services. International Journal of Telerehabilitation, 9(2), 63-68. https://doi.org/10.5195/ijt.2017.6232