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Teleprehabilitation during COVID-19 pandemic: the essentials of “what” and “how”
brief-report
Author(s):
Genevieve Lambert
1
,
2 ,
Kenneth Drummond
1
,
2 ,
Vanessa Ferreira
1
,
3 ,
Francesco Carli
1
,
2
,
Publication date (Electronic):
12 September 2020
Journal:
Supportive Care in Cancer
Publisher:
Springer Berlin Heidelberg
Read this article at
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Abstract
In view of the COVID-19 pandemic and recent global events, the healthcare system and its services have been negatively affected, contributing towards extensive surgical backlogs. Oncological surgical candidates have been the most impacted by these changes and recommended self-isolation practices, which could result in emotional distress, sedentary behavior, and poor lifestyle habits. Preoperative supportive intervention, prehabilitation, has been proven to improve patients’ functional status and clinical trajectories. Presently, there is a critical need for prehabilitation to optimize patient health, as they experience extended wait times. However, in-hospital delivery may not be an ideal approach due to public health and safety measures. Telehealth is a field of research and practice, which has grown and evolved significantly in the last two decades, allowing for the remote delivery of health services. Therefore, the current commentary addresses the different modalities of telehealth delivery in perspective of their known feasibility and potential application in prehabilitation.
Related collections
Most cited references12
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Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care
Eddie Donaghy, Helen Atherton, Victoria Hammersley … (2019)
Background People increasingly communicate online, using visual communication mediums such as Skype and FaceTime. Growing demands on primary care services mean that new ways of providing patient care are being considered. Video consultation (VC) over the internet is one such mode. Aim To explore patients’ and clinicians’ experiences of VC. Design and setting Semi-structured interviews in UK primary care. Method Primary care clinicians were provided with VC equipment. They invited patients requiring a follow-up consultation to an online VC using the Attend Anywhere web-based platform. Participating patients required a smartphone, tablet, or video-enabled computer. Following VCs, semi-structured interviews were conducted with patients (n = 21) and primary care clinicians (n = 13), followed by a thematic analysis. Results Participants reported positive experiences of VC, and stated that VC was particularly helpful for them as working people and people with mobility or mental health problems. VCs were considered superior to telephone consultations in providing visual cues and reassurance, building rapport, and improving communication. Technical problems, however, were common. Clinicians felt, for routine use, VCs must be more reliable and seamlessly integrated with appointment systems, which would require upgrading of current NHS IT systems. Conclusion The visual component of VCs offers distinct advantages over telephone consultations. When integrated with current systems VCs can provide a time-saving alternative to face-to-face consultations when formal physical examination is not required, especially for people who work. Demand for VC services in primary care is likely to rise, but improved technical infrastructure is required to allow VC to become routine. However, for complex or sensitive problems face-to-face consultations remain preferable.
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COVID-19: maintaining essential rehabilitation services across the care continuum
Summary box Rehabilitation services are essential: They need to continue during a pandemic and after as they are an essential component of high-value care offered for individuals across the lifespan to optimise physical and cognitive functioning to reduce disability. Rehabilitation care is affected: Globally, the response to COVID-19 is shifting rehabilitation services provided in all settings, introducing new burden on patients, families and healthcare workers. Measurement needed: A core set of measures needs to be adopted to monitor the health and functional outcomes for COVID-19 and other patients at risk for functional decline and to assess the quality, availability and accessibility of services today and as our nations recover. Telerehabilitation is necessary: Remote delivery of care and the necessary rapid scale-up of telehealth could be optimised if financial, infrastructure, resource, training and cybersecurity barriers were addressed. Collaboration can support needs in the home: Novel partnerships that include the rehabilitation community could enhance communication and delivery of safe and effective home-based rehabilitative strategies to mitigate the consequences of COVID-19 and reduced service capacity. Direct care providers need personal protective equipment: Rehabilitation providers in all settings should be ensured personal protective equipment and training to use it effectively. Introduction COVID-19 is overwhelming healthcare services and healthcare workers globally. The response, appropriately, is on the ability to care for people who become critically ill, protect their carers and keep people physically distanced. However, this response has shifted what is considered and how to provide essential healthcare services. Rehabilitation services, which optimise physical and cognitive functioning to reduce disability, are a core component of high-value care.1 The decisions to shift, transform, delay or discontinue rehabilitation care are complex. These decisions have societal implications for today and the future. This commentary describes adjustments to the continuum of rehabilitation services across 12 low-income, middle-income and high-income countries in the context of national COVID-19 preparedness responses (table 1) and provides recommendations for decision makers on the provision and payment of these essential services. Table 1 Continuum of rehabilitation services across 12 low-income, middle-income and high-income countries in the context of national COVID-19 preparedness recommendations Country National government mandated COVID-19 response Rehabilitation services during COVID-19*(inpatient, redeployment/bed shift, outpatient/home and telehealth) Stay-at-home order 2020 National response Guidance for ‘non-essential’ healthcare services Argentina 20 March National lockdown:essential trips for cleaning supplies, medicines and food. Outpatient suspended. Inpatient rehabilitation still offered in reduced capacity.Other inpatient bed types converted to increase acute hospital bed capacity.Patients are not attending day rehabilitation programmes despite programmes being open.All outpatients clinics in all public and private hospitals closed.Physicians and therapists cannot get reimbursed for video telehealth visits (neither video nor telephone). Belgium 17 March Containment and mitigation: school and retail closures, ban on all gatherings, movement only for essential needs and ban on non-essential international travel. Non-essential services suspended. Inpatient rehabilitation operational but discharging more quickly to prevent spread; all activities in patients’ room.Rehabilitation personnel but not beds have shifted to support acute care.All outpatient rehabilitation services discontinued.Government-approved renumeration for telerehabilitation for all provider types (expanded for COVID-19). Brazil By state Containment and mitigation: national guidance defined essential services and recommendations for social distancing and foreign entry restricted. Non-essential services suspended. Reduced operations for inpatient rehabilitation.Shift in rehabilitation personnel and outpatient services, encouraged to use telemedicine.Federal Council of Medicine acknowledges use of telemedicine for teleorientation (distance guidance, training and patient referral), telemonitoring under medical supervision or guidance and teleinterconsultation (between physicians for diagnostic or therapeutic assistance). China 23 January Lockdowns across country: suspension of travel, banned public gatherings, early detection and isolation, mobility restrictions and quarantine for returning migrant workers. Non-essential services suspended. Inpatient rehabilitation for all non-urgent patients suspended.Shift in rehabilitation hospital beds or rehabilitation personnel to help with COVID-19 response.Outpatient rehabilitation suspended.All home care discontinued.Teleconsultation/virtual rehabilitation provided mostly free of charge. Germany 22 March Containment and mitigation: travel restrictions, school closure, closing non-essential businesses and banned public gatherings. All elective surgeries and non-essential services postponed. Acute hospitals continued early acute rehabilitation.Rehabilitation hospitals discontinued care for chronic, non-acute problems; acute patients (eg, surgery and stroke) stay as long as needed.Some rehabilitation hospitals could be designated as overflow hospitals. Rehabilitatation personnel supporting acute hospitals.Outpatient rehabilitation is reduced but available for high need patients/essential care.Telerehabilitation for physicians and health professionals in the acute COVID-19 phase possible and reimbursed. Guyana 16 March Encouraging social distancing and hygienic practices.Established health emergency operations centre.Curfew and stay-at-home policy implemented and all non-essential business ordered closed. All elective surgeries and non-essential services postponed. Inpatient rehabilitation continued in acute hospitals.Outpatient rehabilitation therapists reassigned to acute hospitals.All community-based rehabilitation suspended in hinterland regions.Phased approach to cancelling/closing all outpatient rehabilitation services; patients receive self-led home-based programme.Telerehabilitation via telephone, Zoom, WhatsApp and emailing exercise programs. Also using MedBridge. India 24 March National lockdown: exceptions medical and pharma services, groceries, banks, telecom, gas stations as essential services, school closures and restriction of international and most domestic travel. Non-essential elective surgeries postponed Hospitals discharging stable patients at earliest possible.Inpatient rehabilitation continued for patients who cannot return or travel home.Rehabilitation personnel considered part of human resource mobilisation for training and possible role assignments.Outpatient and home-based rehabilitation suspended.Telerehabilitation via phone, Whatsapp and Zoom carried out by certain tertiary care and independent rehabilitation clinics especially for the neurologically ill patients. Singapore 7 April National lockdown: temp. screening, hospital and home quarantines, extensive tracing, social distancing, bans on large gatherings, schools closed and travel restricted. Non-essential appointments, including elective procedures and outpatient rehabilitation, deferred. Inpatient rehabilitation continued but location shifted outside of acute hospitals into stand-alone rehabilitation (community) hospitals. Focus on intensive care, cardiopulmonary and severe, new onset disability.A significant proportion of outpatient providers shifted to inpatient.Limited outpatient rehabilitation personnel focused on postacute and shifted to small teams for physical distancing.All group and community-based rehabilitation activities suspended including day rehabilitation and senior activity centres.Home rehabilitation requests subject to review by health authorities, restricted to patients with significant new-disability and limited caregiver support.In-hospital rehabilitation consults and multidisciplinary team meetings through teleconference.Providers trained to deliver teleconsultations with national regulatory guidance for quality and cybersecurity. Spain 14 March National lockdown: exceptions medical and pharmacy services, groceries and banks. School closures and restriction of international travel. Non-essential services suspended, non-urgent surgeries postponed and outpatient clinics closed. Inpatient rehabilitation offered in reduced capacity.Rehabilitation beds shifted to extend capacity of acute care.Outpatient rehabilitation programmes suspended. All outpatient clinics in all public and private hospitals closed.The majority of home-based rehabilitation (but not completely) suspended.Physicians and therapists cannot get reimbursed specifically for telehealth visits (neither video nor telephone as of 23 April). In some contexts (eg, Catalonia) the Board of Physical Therapists organised a task force of volunteer physical therapists who can deliver some telephone-based rehabilitation. (Provision of healthcare is regulated and reimbursed regionally.) Tanzania Local only Containment and mitigation: public gatherings ban, 30-day closure of schools, universities, training institutions, health screening at points of entry, 14-day quarantine for travellers from high-risk countries. Local KCMC. Example: care for older adults suspended unless an emergency, outpatient block appointments, reduced elective surgeries and prioritised emergency surgeries. Inpatient rehabilitation offered but length of stay and visitors reduced to prevent hospital acquired infection (affecting amount of time therapists have to evaluate and treat patients+train family for home-based rehabilitation).Shift in rehabilitation personnel with those age >55 years exempt from patient contact.Outpatient rehabilitation appointments scheduled in blocks to avoid overcrowding and congestion especially in waiting areas.Telehealth not a standard of practice for rehabilitation (and not covered by insurance); patients discharged early and appointments delayed/cancelled have limited access to care. USA By state or city Stay at home orders, school closures, bans of mass gatherings and non-essential business closures. Recommendations to postpone all elective surgeries and non-urgent procedures and visits. Fewer rehabilitation beds; beds converted for acute care.Shift in rehabilitation personnel to acute inpatient and telemedicine follow-up.Outpatient rehabilitation available only for high need patients following. CDC recommendations for essential care.Rehabilitation teleconsultations. Slow scale to virtual visits. Physicians reimbursed. Therapists reimbursed by some private insurers but not reimbursed by government insurance until 30 April. UK 23 March National lockdown: only leave home for food, health reasons, work and other travel restrictions.Social distancing and personal hygiene guidelines. Non-urgent surgeries postponed. Hospital inpatients medically fit discharged early; inpatient rehabilitation offered in reduced capacity.Shift in rehabilitation hospital beds to maximise inpatient capacity; shift in rehabilitation personnel to provide greater acute hospital and community service support.Outpatient rehabilitation at reduced capacity.Telephone and digital/video-based consultation. *Authors provided reports of rehabilitation practice in the absence of national policies. CDC, Centers for Disease Control and Prevention; KCMC, Kilimanjaro Christian Medical Center. Changes to rehabilitation care across settings Rehabilitation addresses health and functioning for individuals across the lifespan. The immediacy of care needs varies by condition.2 Services are provided in every setting—acute hospitals, rehabilitation hospitals, outpatient clinics, in the community and in people’s homes—and resources vary by region. Guidance for the delivery of rehabilitation during COVID-19 is available for physiotherapy but not yet all rehabilitation professions.3 Several regions reported fewer non-urgent rehabilitation patient admissions in order to expand acute care bed capacity. Lengths of inpatient stays for patients who receive rehabilitation are now shorter in several countries including Belgium, India, Tanzania and the UK. Shorter inpatient stays reduce the time available to assess and treat patients and train family. Any need for continued home-based care has implications for caregivers particularly while social distancing. In addition to shorter lengths of inpatient stays, all 12 countries report outpatient and home-based rehabilitation care suspended or operating at reduced service capacity. These inevitable decisions for protection of both healthcare workers and the general public may result in increases in disability and morbidity from a lack of necessary rehabilitation care to those with continued care needs. Patients at home with limited ability to move independently or facilitate their own self-care activities, and patients with prolonged hospitalisation for COVID-19 who have returned home, are at high risk of several adverse health effects. Skin breakdown, muscle weakness, joint stiffness, reduced range of motion, changes to bowel and bladder functioning, venous stasis, oedema, decreased rate of metabolism and respiratory movement, lowered mood and depression are measurable in the first week of limited mobility. It is critical that public health communication continue to address the significance of daily activity and movement while uniquely considering limitations of individuals with significant physical or cognitive disability. Guidance needs to also ensure the safety of caregivers involved and be provided for households without available caregivers. Protecting providers of direct care While there is concern for people with unmet rehabilitation needs, it is important to protect all direct care providers, paid and unpaid, during a pandemic response. Many components of rehabilitation care require patient contact, for example, treating patients weaning from mechanical ventilation, developing patients’ balance techniques after stroke and fitting a new limb after amputation. Furthermore, rehabilitation personnel from Guyana to Singapore are being redeployed to meet needs in care settings different than their usual work environment. In Spain, health workers represent 15% of all COVID cases and, in response, the country has mobilised retirees, medical residents or other health personnel. In Singapore, private sector and retired rehabilitation staff may join frontline healthcare. In planning for adequate personal protective equipment and training for its use, governments need to include all direct care providers in their calculations to adequately protect people in homes and community-based settings when direct-patient contact is still necessary. Telerehabilitation Telephone consultation for care is an option in some regions but is dependent predominantly on the availability of personnel. Use of video visits and other forms of virtual care, although preferred for rehabilitation over telephone consultation alone, requires widespread and stable internet connectivity, availability of technology for both the rehabilitation provider and the patient, ‘tech literacy’ or the ability to use a device, the availability of ‘tech support’ to troubleshoot or first get connected and payment for provider time. Although rehabilitation in some countries such as Guyana, Germany and the UK is a component of universal healthcare coverage (UHC), governments and health insurers of other non-UHC countries need to pay therapists, in addition to physicians, to equitably provide care via telehealth. Use of telehealth under usual circumstances in all forms—text, telephone and video—requires planning, training and iterative improvement. It is imperative that experienced telehealth providers share protocols and become champions to support their peers with rapid scale-up in this challenging environment. Publications are emerging, and some professional societies are sharing guides for remote consultations.4 5 China and the USA have live webcast sessions with national experts to train rehabilitation providers and online communities to empower caregivers. Creative solutions to use free and commercially available communication tools like WeChat and WhatsApp are being used in Brazil, China and Guyana. These approaches are limited in Tanzania and likely other low-income countries due to costs for data plans and limited in-home internet access. With the majority of rehabilitation care provided remotely during a pandemic response, telehealth strategies need the infrastructure and to be resourced and financed appropriately. Measuring the impact of COVID-19 Enhanced measurement and monitoring are desperately needed at the individual, health system and national levels. With the release of the WHO Rehabilitation Guide for Action only this past year,6 few countries had fully completed a systematic assessment of the rehabilitation situation and developed a strategic plan to adequately meet rehabilitative needs prior to this pandemic or to activate during pandemics. Yet, today, we need alignment on a measurement strategy. Longitudinal assessments of health and functional outcomes are needed to monitor individual and population health and support clinical decision making for allocation of scarce resources in all settings. The global significance of measurement on practice and policy was evident in the release of COVID-19 outcomes assessments of intensive care unit patients7; similar data are needed on the functional recovery of patients with COVID-19. Service-level records need to be monitored to ensure adequate quality and equity with constrained resources. In the longer term, greater attention to national census and cohort surveys will be needed to detect changes in population health that can inform policy decisions on rehabilitation service needs and geographic disparities. The rehabilitation community needs to unite to consider a core set of measures to monitor recovery of patients with COVID-19, health of persons with disability and chronic conditions, and the quality, availability and accessibility of services today and as our nations recover. Recommendations Rehabilitation care is at a unique turning point. In 2017, the WHO had already noted ‘substantial and ever-increasing unmet need for rehabilitation services worldwide’.8 Today, we are faced with a new population of patients at risk of functional decline in addition to the disability pandemic already present among one billion people globally. We are providing care in new ways and standards of care are changing. The following recommendations are provided to mitigate the consequences of COVID-19’s impact on rehabilitation care and support continued health with reduced risk of disability. Governments need to include rehabilitation and other direct care providers in home-based and community-based settings in their plans for personal protective equipment acquisition and training. Global collaboration across rehabilitation professionals needs to accelerate the sharing of resources, instructional tools, education and training packets for how patients and families can continue rehabilitation at home during a pandemic response. Public health messaging on mental and physical health while social distancing needs to expand with input from rehabilitation professionals to provide guidance for persons living with physical and cognitive limitations, with and without caregivers. Public–private partnerships are needed to better support rapid scale of telehealth today and in the future to ensure effective use, financing, cybersecurity, access and increased reliability of broadband networks to reach people in low-resourced areas. The rehabilitation community needs to unite on measurement of care and outcomes because the evidence established in real world practice today could transform care and lives tomorrow. Conclusions The WHO called on nations to ensure continuity of essential services in parallel to scaling public health preparedness and response measures.9 Our shared experience is that national agencies did not issue specific guidance for the provision of rehabilitation. Considerations for service delivery balanced risk of transmission with both the availability of resources to provide care and the patient’s acuity, level of urgency and potential for harm if services were postponed or altered. Rehabilitation service providers mobilised quickly to provide the best, safest care possible to those in greatest need; decisions were in many cases made locally. Looking beyond the pandemic, rehabilitation needs to remain at the forefront of discussions for UHC; barriers to infrastructure, implementation and financing care via telehealth and alternative approaches need to be eliminated. Strong leadership for inclusion of rehabilitation in public health and healthcare policymaking is acutely needed to ensure high-value care and reduce the global burden of disease.
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Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2)
Seewon Ryu (2012)
Information systems and communication technologies (ICTs) gave us new and innovative wave of communication life such as living in cyber space, instant messaging, and communications with whom anyone in anywhere. These are changing not only life-style, but also mode of business in every industry. Health care service industry is resource-intensive, process-oriented, and doing business traditionally by method of confrontation between medical professionals and patients. ICTs have great potential to address some of the challenges faced by both developed and developing countries in providing accessible, cost-effective, high-quality health care services. Telemedicine uses ICTs to overcome geographical barriers, and increase access to health care services. These are particularly beneficial for rural and underserved communities in developing countries - groups that traditionally suffered from lack of access to health care. In light of this potential, the World Health Organization (WHO) established the Global Observatory for eHealth (GOe) to review the benefits that ICTs can bring to health care and patients' wellbeing. The Observatory is charged with determining the status of eHealth solutions, including telemedicine, at the national, regional, and global levels, and providing WHO's Member States with reliable information and guidance on best practices, policies, and standards in eHealth. In 2005, following the formation of WHO's eHealth strategy, the Observatory conducted a global eHealth survey to obtain general information about the state of eHealth among Member States. Based on the data from that survey, the GOe carried out a second global survey in 2009; it was designed to explore eight thematic areas in detail, the results of each being reported and analysed in individual publications - the Global Observatory for eHealth series. The telemedicine module of the 2009 survey examined the current level of development of four fields of telemedicine: teleradiology, teledermatogy, telepathology, and telepsychology, as well as four mechanisms that facilitate the promotion and development of telemedicine solutions in the short- and long-term: the use of a national agency, national policy or strategy, scientific development, and evaluation. Telemedicine - opportunities and developments in Member States discusses the results of the telemedicine module, which was completed by 114 countries (59% of Member States). There are comprehensive reviews about telemedicine in the world; Overview of telemedicine: definition, history, applications, and potential barriers to telemedicine diffusion Telemedicine in developing countries such as Mongolia, Mexico Barriers, Legal and ethical considerations, to realizing the promise of telemedicine in developing Implications for telemedicine development, implementation, evaluation, and sustainability GOe Second Global Survey on eHealth: Methods and process Telemedicine services in the world by groups Telemedicine initiatives occurring around the world Norway's teleECG initiative Factors facilitating telemedicine development: Governance, policy and strategy, scientific development, evaluation processes The Swinfen Charitable Trust Telemedicine Network Discussions and recommendations about factors facilitating and barriers to telemedicine development Following the analysis of the survey results, WHO recommends steps Member States can take to capitalize on the potential of ICTs. One such step is creation of national agencies to coordinate telemedicine and eHealth initiatives, ensuring they are appropriate to local contexts, cost-effective, consistently evaluated, and adequately funded as part of integrated health service delivery. Ultimately telemedicine initiatives should strengthen - rather than compete with - other health services. Korea has been implementing trial projects of telemedicine in limited service area and populations for more than twenty years from the late 1980s. The Korean Government continued trial projects to develop safe and efficient telemedicine model, and intended to economic buildup. However, medical professional groups think that telemedicine would not be safe, and they are worried about whether it would be beneficial to themselves and patients. Scientists and medical doctors in cooperation with ICTs companies and local governments have been tried various models of telemedicine for more than 20 years in Korea. Recently, effectiveness of telemedicine in public health care has been revealed: compliance and effectiveness of telemedicine of hypertensive patients in the underserved communities [1,2], and effectiveness of eHealth services of public area [3], factors to adoption of telehealth services [4], and the effect of eHealth services of managing metabolic syndrome in rural area [5]. There are also accumulated and structured experiences and technological and managerial systems in participants of telemedicine projects. In Korea, a bill about telemedicine to the limited underserved populations and communities was made and submitted to the national assembly in May, 2010. The Ministry of Health and Welfare should have more interest and be active to realize the needed and safe telemedicine services. We recommend this report to those persons or groups interested about telemedicine in Korea and other countries that do not think about telemedicine, and are hesitating to adopt actively. Especially, we should understand what were successful service models and technological systems of eHealth in view of their culture and healthcare policy, and consider those factors facilitating and barriers of telemedicine recommended in the last of report. We expect that the report would be contributed that telemedicine be an alternative and useful solution to the communities underserved, and the general public, in case of limited and indispensible case.
Author and article information
Contributors
Francesco Carli: franco.carli@mcgill.ca
Journal
Journal ID (nlm-ta): Support Care Cancer
Journal ID (iso-abbrev): Support Care Cancer
Title:
Supportive Care in Cancer
Publisher:
Springer Berlin Heidelberg
(Berlin/Heidelberg
)
ISSN
(Print):
0941-4355
ISSN
(Electronic):
1433-7339
Publication date
(Electronic):
12
September
2020
Pages: 1-4
Affiliations
[1
]GRID grid.63984.30, ISNI 0000 0000 9064 4811, Department of Anesthesia, Montreal General Hospital, , McGill University Health Centre, ; Montreal, Quebec Canada
Article
Publisher ID: 5768DOI: 10.1007/s00520-020-05768-4
PMC ID: 7486157
PubMed ID: 32918606
SO-VID: 891d613b-8c52-4c87-b0f2-4f57e303c15f
Copyright © © Springer-Verlag GmbH Germany, part of Springer Nature 2020
License:
This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.
History
Date
received
: 16
June
2020
Date
accepted
: 8
September
2020
Categories
Subject:
Commentary
ScienceOpen disciplines: Oncology & Radiotherapy
Data availability:
ScienceOpen disciplines: Oncology & Radiotherapy