A national survey of brain injury rehabilitation providers and internal survey by Centre of Neuro Skills indicates the success of telehealth in dosing therapy sessions during the COVID-19 pandemic, with most providers planning to continue telehealth services. To learn more about the topic, we conducted an interview with Dr. Gary Seale, PhD, LPA, LCDC, CBIS-T, Regional Director of Clinical Service – Centre for Neuro Skills.
1. Can you tell us more about Centre for Neuro Skills (CNS)?
Centre for Neuro Skills is an experienced and respected world leader in providing intensive rehabilitation and medical programs for those recovering from all types of brain injury. CNS covers a full spectrum of advanced neurological treatment from residential and assisted living to outpatient/day treatment. Founded by Dr. Mark Ashley in 1980, CNS has seven locations in California and Texas.
2. What was the motivation behind conducting your national survey?
One consequence of brain injury is compromised immunity and increased susceptibility to infection, particularly respiratory infection. Following a brain injury, many people develop co-morbidities that are risk factors for COVID-19, including hypertension, diabetes, and obesity. Individuals with brain injury, therefore, are most at risk for contracting COVID-19. When stay at home orders were issued nationwide in March, 2020, individuals with brain injury were forced to stay at home or in other residential settings, and their ability to access rehabilitation services was severely restricted. This placed individuals with brain injury at risk for regression, isolation, and depression. Brain injury programs across the nation were faced with a dilemma – how to provide necessary rehabilitation services to this vulnerable population, while at the same time reducing exposure to COVID-19. Telehealth provided an option for continuing contact and providing therapy for this vulnerable population. Given a large majority of post-acute programs employed some form of telehealth to provide therapy, we wanted to know: how many providers used TeleHealth technology to deliver medical, nursing and/or therapy services during the COVID-19 Pandemic; what platform was most popular and was it stable enough to allow for the delivery of a quality therapy experience; what therapies or specific interventions worked with well with this technology; which did not; which patients appeared to benefit most; were therapists able to collect and report objective data, including therapy outcomes; how did progress/outcomes using telehealth technology compare to in-clinic therapy; are providers planning on continuing to employ Telehealth technology in the future, and if so, in what ways?
3. Who participated in the survey?
408 providers of post-acute brain injury rehabilitation (PARIR) services from across the US participated in the survey.
4. When did you start using telehealth in rehabilitation therapy? Why?
CNS began experimenting with Telehealth technology about 4 years ago, primarily as a way to increase access to treatment for individuals that were not able to present to a clinic for therapy. Telehealth, or Telemedicine technology, was also being piloted by CNS physicians as a way to increase access to medical services. Because of this work that began roughly in 2017, CNS was able to quickly pivot to telehealth as a platform for delivering therapy when stay at home orders were issued in March, 2020. CNS began delivering therapy via telehealth technology, company-wide, on or about March 30, 2020. As mentioned above, the rationale for using telehealth technology as a platform for therapy was to reduce exposure to COVID-19 while providing necessary therapy, nursing and medical services to reduce risk of isolation, depression, and regression.
5. How did telehealth serve patients and staff amid the COVID-19 pandemic?
The telehealth technology platform served patients and staff very well. Many staff and patients were initially skeptical about the technology platform, but comfort levels increased within one week. The large majority of patients and staff reported satisfaction with the platform, reporting a high quality therapy experience, in most cases.
6. Why did telehealth service sessions more than doubled after the COVID-19 pandemic?
In my opinion, telehealth sessions more than doubled for a couple of reasons. First, there was really no other viable option. While some “talk therapies” (i.e., counseling and some aspects of speech therapy) can be delivered effectively via the telephone, other therapy modalities (physical therapy, occupational therapy, some aspects of speech therapy and education therapy, as well as nursing and medical services) require a visual component. Telehealth allowed both auditory and visual presentation of instructions, modeling, guidance, etc. Secondly, the Trump administration reduced regulations that restricted access to telehealth and telemedicine services, allowing programs to deliver therapies via this modality and to bill for those services.
7. Why do you think that telehealth has been well-received and effective for both patients and staff?
Therapies delivered via Telehealth technology have been effective for patients and staff for a variety of reasons: 1) as mentioned above, a number of therapy modalities and specific therapeutic interventions lend themselves well to this technology platform, such as counseling, speech therapy, and educations therapy. Certain aspects of Physical and Occupational therapy also work well with this therapy modality, including some aspects of vestibular therapy and vision therapy; 2) patients are able to access therapy from the comfort of their home or other residence. That is, there was no need to travel long distances to/from the clinic. This was particularly helpful for patients that experience pain or stiffness following a long car ride, or who may have anxieties about vehicular travel; 3) therapists were able to deliver therapy in the patients home. That is, they were able to teach strategies and develop skills as they worked with patients in the actual physical context in which the skill or strategy will be used. This increased generalizability or carry over; 4) staff were able to work directly with care givers as they delivered therapy to the patient. Family training and education occurred simultaneously with the therapy session; 5) humans are very visual – we are attracted to light, color, motion, etc. Additionally, we are programmed from a very young age to look at a screen – Iphone screen, tablet screen, computer screen, television screen, etc. So looking at a screen for therapy purposes was very natural, particularly for younger patients.
8. What CNS therapeutic treatments are offered via telehealth?
All therapies offered by CNS were delivered via telehealth technology – Occupational therapy, Physical therapy, Speech/Language therapy, Counseling, Education therapy, Nursing services, Medical services, and Case Management. Additionally, CNS developed ways to conduct pre-admission assessments, Admission intake sessions, family conferences, and some aspects of Behavior therapy via Telehealth Technology. The marketing and sales departments “went virtual” as well, “visiting” contacts in hospitals and rehabilitation units, providing continuing education to referral sources, and conducting virtual tours of CNS facilities. The CNS Communications department actually conducted the grand opening of a new clinic facility in Los Angeles via telecommunications technology!
9. CNS deftly pivoted to telehealth from the beginning of the COVID-19 pandemic. What new things did you learn from such experience?
CNS learned so much – how flexible the telehealth platform is; the resilience and creativity of staff; how effective the telehealth platform is (i.e., able to collect and report objective clinical data, able to collect and report clinical outcomes), etc., etc.
10. Where do you see CNS in the next 5-years?
I see CNS continuing to execute its growth strategy, adding more clinics in various locations across the country in the coming years. I also see CNS continuing with the treatment philosophy and therapy model that has, over the last 40 years, earned the organization a respected reputation as an experienced and progressive leader in brain injury treatment. This treatment philosophy and therapy model involves clinic-based, hands-on therapy employing an neuro-developmental approach with highly trained staff. However, CNS will use TeleHealth as an adjunct to in-person treatment, allowing flexibility in scheduling, increased access to treatment, as a power tool for family training and education and home evaluations, and for in-depth follow-up to ensure the durability of treatment outcomes. I’m sure other uses of the technology will surface as we move forward – very exciting to think about!
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