By Rebecca Matalon, PT, DPT
As a physical therapist, people are always asking me what to do about the pains they have or how to quickly address a strain or a “thrown-out” back. We all need physical therapy (PT) at some point in our lives, whether because of an acute injury or a chronic condition. Thankfully, these days physical therapy can address nearly every movement condition, anywhere the patient is located.That’s right. There are ways of making telehealth work for you and your patients.
“Tele physical therapy,” “telerehab,” “virtual physical therapy,” “telehealth,” and “remote physical therapy” are all common terms referring to physical therapy services conducted remotely, utilizing video AND audio connection between a patient and a licensed physical therapist. Many physical therapy clinics began offering this service in response to the COVID-19 pandemic. Insurance payors quickly pivoted to permit the allowed use of telehealth practices in PT. Prior to the pandemic, telehealth was not a covered service by Medicare and many private payors. However, in order to stay in business and treat our patients, we all needed to flex.
In 2020, my clinic in the San Francisco Bay Area was shut down and people were prohibited from traveling beyond 5 miles from their residence. In order to stay afloat and to safely see our patients, I kickstarted the use of tele PT in our clinic. Our staff quickly learned how to practice therapy over the internet, through apps, and over FaceTime. Though most clinics have opened back up for in-person care, telehealth remains a feasible and convenient option.
Staying Safe and Productive
With tele physical therapy, patients do not need to worry about hurrying to the clinic. They may be ill, busy, stuck at work, unable to find a babysitter, or have some other extenuating circumstance; regardless of the situation, they can still access the care they need. Telehealth is a remarkable opportunity in the field of medicine, allowing patients and practitioners to stay safe and productive.
For practitioners, making telehealth work as part of our toolbox helps us to retain patients, to create a more personalized plan of care, and to showcase the aspects of our practice that set us apart from other health fields. Clinically, we are able to maintain patient volume by offering telehealth services to patients who are thinking of canceling an appointment at the last minute. We educate the patient on the benefits of telehealth versus missing out on therapy and disrupting their progress. Patients may be canceling for many reasons: unable to leave their home, too much pain to drive, feeling unwell, not having enough time between appointments, or work responsibilities. Telehealth takes very little time, is convenient, and provides skilled therapeutic services to mitigate pain and inflammation.
Range of Accomplishments
I have quickly learned how much can be accomplished online. I can diagnose through active listening to the patients’ history, viewing their range of motion, analyzing their quality of movement, and performing functional screening. Regarding treatment, I educate my patients in practicing self-mobilizations, correcting their posture, and improving their form with activities of daily living and recreational skills. I can guide patients in effectively performing therapeutic exercises and activities that utilize body weight or any piece of exercise equipment or home goods they have available.
As physical therapists, we are movement experts and are trained to identify compensations, points of stiffness or weakness, and more efficient and safe movement patterns. The routines and regimens we create are of the utmost importance for our clients to reach their movement and physical rehabilitation goals.
Whether seeing patients who are post-op, who are looking for a health maintenance plan, or who are recovering from chronic injuries, we can evaluate, educate, and treat patients over the computer within a 20- to 40-minute session, depending upon case complexity. Often, telehealth appointments only require a 1/week frequency of visits, which makes care convenient and accessible, and helps to maximize patients’ health insurance benefits.
However, please check with your state laws and regulations prior to offering telehealth services. Physical therapy is not typically approved by Medicare and some private payors for telehealth practice. The rules did change during the COVID-19 pandemic, and Medicare put into place an exception for physical therapists to offer tele services. Since 2020, the rules and billing practices have been under constant flux.1 Though there are not any CPT codes for telehealth services in physical therapy,
Some therapists use codes in the 97000 series that best describe the services being provided and then use the place-of-service code 02 to indicate that the services were provided remotely. Because the CPT codes are direct contact codes it is important to verify that the payer allows you to use these codes when services are provided via telehealth, or if you must use a specific modifier. We also encourage you to check with each payer about using place-of-service code 02 when billing for telehealth services to specify the entity where service(s) were rendered (APTA).2
Evaluations in the Client’s Environment
Evaluations may seem like a daunting task for telehealth. However, one of the biggest differences in telehealth compared to clinic-conducted evals, is that you can see the patients’ unique environments and living situations. You get to see their workstation set-ups, their preferred couches, the exercise gear available to them, and how they use the equipment. You can assess nearly everything you need to from their gait pattern, neuro skills, balance, ADL performance, symptom management, compensation patterns, ranges of motion, and postures in their typical environment. With this information, you can make appropriate corrections and give the most accurate education, based on the patient in front of you, right then and there. That immediate and specific feedback goes a long way.
Challenges to Making Telehealth Work
Conducting physical therapy sessions via telehealth is not without its challenges—one issue being the aforementioned lack of insurance coverage or certainty. Second, there are clinical cases that may warrant an in-person visit. These may include appointments with patients who are post-operative and of high complexity, if a patient is alone in their home and is not safe to be left without in-person guarding and monitoring, or if manual therapy is an essential element to the plan of care. There is also the issue of the technology required for both the client and the therapist. For a session to be considered a true telehealth appointment, the session needs to include video AND audio. Sometimes, the technology goes on tilt, and we need to get creative and troubleshoot.
On occasion, I have needed to call patients just before our session and instruct them in how to set up the telehealth website or app. Most telehealth procedures are as simple as opening a website, typing in your name, and clicking the “Start” button. However, even if the system may be easy, technology issues may persist with poor internet connection, fuzzy images, or delayed audio. In these situations, relay the problem to the patient and request that each of you simply allow more time after something is said or done for the message to be received on the other side. However, you may also abandon the website option altogether and switch to a video call on a smartphone. Of course, be sure to gain permission from the patient for using a different method, as some platforms do not allow for HIPAA privacy.
Overcoming Challenges
Yes, tele evaluations and follow-ups may be challenging to fully assess and test the patient to collect all the necessary information. You really have to put your creative hat on with telehealth services to visually determine ranges of motion and strength testing, instead using more functional screens and outcome measures. You can clearly see if someone is able to move against gravity or lift a full bottle of water. In my experience, the patient becomes so impressed and surprised by how much can be conducted over the internet, that the buy-in and the retention comes quickly. Patients become so excited to adjust their environments, to try new movements, and to put the new education into practice that the success rate of telehealth is high.
There are studies that show patient outcome success to be equal to or even greater than clinical rehabilitation success. Part of the reason may be that patients are quickly placed into a more independent position and are able to see how much they can accomplish on their own. The motivation and education in telehealth are large components of patient success and are integral to long-term benefits.
Try educating for self-mobilization techniques to account for the lack of manual therapy in telehealth services. Self-mobilizations often produce a quick change in symptoms. When patients see quick results, they gain the self-determination needed to progress rapidly through functional skills and achieve their goals.
Long-Term Benefits of Making Telehealth Work
Making telehealth work is also instrumental in carrying out long-term maintenance health plans. Scheduling patients once a month or annually for a check-up allows a therapist to make any needed updates to home exercise programs, re-evaluate posture and mechanics, and educate for the patients’ most current needs. Check-ins are quick and effective ways to continue to progress your patients’ health and wellness and to promote patient retention.
Pro tip: Always be sure to stress the importance and value of the home exercise program. Through proper education and motivation techniques, we can promote patient compliance and increase treatment efficacy.
Building Rapport for Patient Retention
Once you show patients that you can efficiently and positively influence their symptoms, you gain their trust. That trust is fortified through your personal confidence, connection, and compassion. This can be even more important via telehealth, serving as a way to bridge the physical distance between you. This is one way of making telehealth work for you and your patients.
Confidence is more than your personal confidence; it is also the patients’ confidence in you. Using your technical knowledge and insight, you can provide the essential education that motivates and supports your patients’ therapeutic success and helps them feel confident in your skills.
However, proving your knowledge is not always enough to create a solid rapport with your patients. Gaining a connection with your patients involves finding common ground; demonstrating an authentic interest in your patient and being willing to take time to actively listen to their story and concerns and respond with kindness and understanding.
Demonstrating heartfelt compassion for every person you encounter earns you loyal patients who will continue to seek your care and provide word-of-mouth referrals. Every individual can teach you something, just as much as you can teach them. Be approachable, genuine, and kind, giving each person the time and dignity they deserve. In therapy, we see people at their most vulnerable; they are in pain, they are fearful, and they are in need. Put yourself in their shoes, meet them at their energy level, and speak in terms they can relate to. PTP
Benefits of Tele-Physical Therapy:
- Diminish the risks associated with external exposure to viruses, illnesses, and hazards
- Convenient appointments without the commute
- Care brought wherever the client is located
- One-on-one care and treatment
- Education that kickstarts health goals
- Greater access to PT for those unable to leave their homes
What Can Be Accomplished Tele-Remotely:
- Evaluations to watch for body mechanics, compensation movement patterns, and collect subjective histories
- Conduct check-up appointments and re-assessments
- Conduct consultations and quick screens
- Guide and progress therapeutic exercises and activities for functional gains, strength training, and mobility improvements
- Education for wellness and self-care: post-op, after injury, in maintaining rehabilitative gains
- Prevention planning to maintain a healthy future
Rebecca Matalon, PT, DPT, is the clinic director at California Rehabilitation and Sports Therapy in Camarillo, California. She takes a holistic approach to healing by incorporating her background in Reiki, yoga, Pilates, dance, and trauma release. Matalon holds a copyright for her method of Therapeutic Motor Imagery and has practiced neuroplasticity training in California, Alaska, and North Carolina. She is passionate about health and wellness for the mind, body, and soul. For more information, contact [email protected].
References
- The Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS. (2021, March). Billing for telehealth encounters – An introductory guide on fee-for-service. Center for Connected Health Policy. Retrieved July 29, 2022, from https://cdn.cchpca.org/2021/04/2021BillingGuideFINAL.pdf
- APTA- News Now Staff. (2020, March 16). Telehealth in physical therapy in light of covid-19. APTA. Retrieved July 29, 2022, from https://www.apta.org/news/2020/03/16/telehealth-in-physical-therapy-in-light-of-covid-19
CAPTION: One of the benefits of telehealth sessions is that they allow PTs to see clients in their own environments, including the exercise equipment they are using at home. PHOTO: California Rehabilitation and Sports Therapy, Physical Rehabilitation Network
