Abstract
BACKGROUND:
Telerehabilitation, or the delivery of rehabilitation services through telehealth platforms, has existed since the late 1990 s. Telerehabilitation was characterized by unprecedented, exponential growth at the beginning of the novel coronavirus-2019 (COVID-19) pandemic. Medical systems sought to reduce the likelihood of disease transmission by using telerehabilitation to limit physical proximity during routine care. This dramatic change in how medical care was delivered forced many professions to adapt processes and practices. Following the change, debates sparked regarding the best path to move forward for the betterment of patients, clinicians, systems, and society. Long COVID has emerged as a complex chronic health condition arising from COVID-19. The unique needs and dynamic disease process of Long COVID has incentivized medical systems to create equitable ways for patients to safely access interdisciplinary care.
OBJECTIVES:
The purpose of this commentary is to describe what medical systems must consider when deploying high-quality telerehabilitation to deliver rehabilitation through asynchronous (e.g., text, portal) and synchronous modalities (e.g., phone or video). We highlight lessons learned to help guide decision-makers on key actions to support their patients and clinicians.
METHODS:
Not applicable.
RESULTS:
Not applicable.
CONCLUSIONS:
Key action steps from our lessons learned may be used to address complex chronic health conditions such as Long COVID and prepare for future challenges that may disrupt medical systems.
Telerehabilitation provides both opportunities and potential unintended consequences to accessing, delivering, and receiving rehabilitation services [1, 2]. We define telerehabilitation as rehabilitation interventions delivered through virtual care platforms and technologies by licensed rehabilitation clinicians [3–5]. Emerging evidence shows that telerehabilitation uptake is multi-factorial and influenced by an individuals’ local environment and the broader sociopolitical climate [6]. In addition, many medical systems and clinics are face challenges when determining how to implement telerehabilitation effectively and equitably. In this commentary, we highlight the challenges medical systems experienced with Long COVID rehabilitation care and describe how telerehabilitation offers a solution.
Long COVID is a complex chronic condition affecting 5–30% of individuals after coronavirus-2019 illness (COVID-19) [7–9]. Long COVID is broadly defined as the emergence or persistence of symptoms approximately three months post infection, affecting multiple body systems [9]. Symptoms include post-exertional malaise, profound fatigue, and cognitive dysfunction [10–19]. Rehabilitation clinicians are integral members of the Long COVID care team as they address function, health-related quality of life, and participation in societal roles impacted by Long COVID symptoms [10–19]. Patients with Long COVID require dynamic approaches to long-term interdisciplinary care, including rehabilitation, to continually address the episodic nature of the disease [6, 19]. One emerging approach to address complex patient needs is using telerehabilitation to deliver rehabilitation assessment and interventions for Long COVID.
Telerehabilitation introduces additional complexity to medical systems, especially those that did not have the infrastructure to support telerehabilitation prior to the COVID-19 pandemic. These systems face challenges at multiple socioecological levels. Much literature has described patient-level factors—such as cognitive impairment, technology literacy, and scheduling need [1, 20–22]—that have important implications for whether and how clinicians may successfully implement telerehabilitation. However, less attention has been given to key upstream determinants for telerehabilitation adoption by medical systems and clinicians. In the subsequent sections, we use the novel medical case of Long COVID to describe the unique challenges of delivering telerehabilitation services. Our shared experiences treating this population unmask deficiencies in our current medical care delivery model and provide opportunities to dismantle ineffective systems.
What do clinicians need to deliver effective rehabilitation services via telerehabilitation?
Clinicians require mentorship and telerehabilitation-specific training to successfully adapt and implement telerehabilitation into practice [22–28]. Clinicians also need autonomy and flexibility in implementing and scheduling telerehabilitation in practice [23, 29]. From our experience, each clinician has different processes for working with patients to decide when to be seen in-person versus virtually, and varying levels of autonomy for managing their telerehabilitation practice. As a result, clinicians range from zero telerehabilitation visits on a given day to hybrid clinic days (mix of telerehabilitation and in-person appointments on the same day) to full telerehabilitation days mixed with full in-person clinic days. Clinicians also require program leaders to advocate for appropriate and equitable telerehabilitation use [6, 24].
How has Long COVID further challenged pre-existing needs and what have we learned?
Long COVID has challenged pre-existing medical services because specialized Long COVID care may not be locally available. Thus, clinicians may rely on fully virtual modalities to reach patients who reside outside the boundaries of their specialty practice. This could be addressed through a “hub” model in which clinicians at a central location provide virtual specialty care to patients within the system’s catchment region. However, this model may be limited by challenges such as reduced broadband and language barriers, which often disproportionately affect underserved or marginalized populations [6, 31]. An alternative method is clinician-to-clinician telehealth. This format facilitates mentorship and consultation from a specialty-trained clinician to a general clinician who is located in an area where specialty healthcare is not available. The National Institutes of Health conducted a workshop in 2021 to help advance research on this topic [32], and there is a desperate need to include rehabilitation in this arena. Finally, the unpredictable nature of Long COVID can preclude patients’ ability to travel (e.g., post-exertional malaise exacerbation). Thus, clinicians must have the scheduling flexibility and technical support to quickly, thereby convert in-person appointments to telerehabilitation leading to better care continuity by reducing missed visits.
What do medical systems need to support telerehabilitation?
Medical systems must reimagine service and business models. For example, systems may advocate for novel reimbursement models, such as ones that support remote therapeutic monitoring. Advancements in virtual care technologies have created untapped opportunities for clinicians to remotely monitor patients and provide skilled services that facilitate long-term maintenance and enhancement of functional outcomes. Rehabilitation professional organizations may advocate for service and payment models that expand care beyond discrete episodes. Such a practice change would require a cultural shift in clinical care delivery that embraces virtual care as another tool to optimize patient health. Expanding into telerehabilitation will also require systems to examine their operational capacity to identify necessary changes to system culture, infrastructure, and personnel. Successful implementation of telerehabilitation may rely on leadership to champion the resources needed, including technical and scheduling support, private space, and technology equipment [23, 24]. Relatedly, systems must understand and evaluate connectivity constraints in their communities to address potential barriers to access to telerehabilitation care [22–24]. This issue calls for medical systems to partner with local communities to develop novel solutions. For example, the United States Veterans Health Administration coordinates with local businesses to create spaces where Veterans can receive telehealth care when they face barriers to participating in telerehabilitation from their homes [33].
How has Long COVID challenged medical systems and what have we learned?
The early phases of the COVID-19 pandemic highlighted many of the challenges associated with coordinating and optimizing interdisciplinary care [34, 35]. These challenges were further exacerbated by stressed medical systems operating in “survival mode,” which exposed a lack of collaborative infrastructure to support learning and problem-solving. Medical systems continue to face the need to integrate in-person and virtual care modalities across many clinical disciplines. Further research is needed to evaluate models of care (e.g., clinician to clinician) to understand what modality works best, when, and for whom, particularly to enhance access to care in low resourced areas. Collaborative infrastructure is necessary to keep up-to-date on the latest evidence, share lessons learned, and co-create knowledge to identify solutions to barriers in delivering complex care [27, 37]. So far, our collective experience with Long COVID underlines the need for safe, effective, and equitable rehabilitation that supports a growing demand for long-term interdisciplinary care. We must continue to address the challenges of telerehabilitation to optimize the health care needs of patients with Long COVID and other complex chronic conditions.
Ethical approval
Not applicable.
Informed consent
Not applicable.
Conflict of interest
The authors declare they have no conflicts of interest.
Footnotes
Acknowledgments
We thank Emily Hudson and Barbara Goodhart for their assistance in editing and formatting the manuscript.
Funding
Dr. Gustavson is supported by the Minneapolis VA Center of Innovation, Center for Care Delivery and Outcomes Research (CCDOR), grant CIN 13–406; Minneapolis VA Rehabilitation & Engineering Center for Optimizing Veteran Engagement & Reintegration (RECOVER), grant A4836-C; the Agency for Healthcare Research and Quality (AHRQ) and Patient-Centered Outcomes Research Institute (PCORI), grant K12HS026379; and the National Institutes of Health’s National Center for Advancing Translational Sciences, grant KL2TR002492. Dr. Rauzi is supported by the Denver-Seattle VA Center of Innovation for Veteran-centered and Value Driven Care through an advanced research fellowship. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government, AHRQ, PCORI, or Minnesota Learning Health System Mentored Career Development Program (MN-LHS).