Questions and Answers
The following are questions submitted in connection with the April 2 webinar titled “How to Evaluate and Treat PT Patients via Telehealth” with answers.
What are the ranges for self-pay telehealth sessions? $50-$125 per session; pricing should reflect value and quality and not just pricing.
Is there a patient population/health profile that you would be hesitant to treat due to safety concerns? CVA/Neuro, advanced geriatrics, wound care.
What platforms use closed caption? Google Meet.
Can you describe how to go about assessing strength during initial evaluations? Using against-gravity motions for screen, self-applied pressure.
Any recommendations for pediatrics? Make everything a game. Wheeldecide.com is a fun way to build your own program and let the child spin the wheel. Of course, caregiver is super important.
Can PTAs do treatment sessions? Yes, for the commercial and work comp insurers that are allowing telehealth. Typically, PTAs can provide telehealth for treatment visits on the same basis as in clinic visits.
Are/should the sessions be recorded? Optional. But only under strict guidelines including signed waiver and the question online and have the patient recording with their approval.
What about equipment substitutes? Most patients will not have what we use in the clinic. Look around the house, be super creative. My gym is holding online Zoom training right now and the trainers are very good about coming up with substitutes like milk jugs, canned goods for weights, etc. Or open your own branded Amazon shop and have them purchase from you. Or buy it yourself on Amazon and drop ship it to the patient for free but roll the cost up in the service (i.e. cash pay).
How am I liable if a patient is injured while performing a task, I have directed them to do during a digital session? You just said it. You directed them to do it. As the professional, your advice comes with risk and responsibility. [CBE INSERT]
What group did you use on YouTube for the test? Physiotutors, The Prehab Guys.
What is TNE? Therapeutic NeuroScience Education. Very useful for telehealth.
How do you explain to the patient the best place to set themselves up so you can see their movements? Give them a small space depending on pathology. For example, with a shoulder, they can sit close to the screen. But for lumbar, they may need to lie on the floor, stand away from the camera to see the feet to the head.
For cash pay, do you charge less than an in-person visit? No. You should place some value for what you do based on an exclusivity of price. For example, if you charge $15 for PT service when massage is $75, you are only competing on price, not value (quality). I have a cash PT friend who started out charging $75 then $125 to $150 and now charges and gets $195/visit.
What is the mechanism for assessing vitals, including pox and activity-tolerance assessment? The only way to do that is to use Wi-Fi-enabled equipment or self-administered vitals.
What technology vendors do you utilize? IT support? Anywhere.healthcare, intakeQ, Google Meet.
Any advice for technical aspects? Keep high-speed internet at home, keep all streaming devices off, use a secondary microphone. Close all windows except what you will be using and increase your RAM to at a minimum 8 GB — 16 is optimal.
Can you provide us with some examples of digital consent forms using G Suite? We use G Suite and this would be a great tool. You have to create these in Google Forms.
Where did you buy your background?
What system do you recommend that works well for telehealth (that has closed captioning)?
Anywhere Healthcare has closed captioning as well as Google Meet.
If I am a contract worker, can I do telehealth as independent PT? The payers that are paying for telehealth are typically only including providers who are in their network. So, you would need to be credentialed with the specific payer.
Biggest question is how to bill. Different codes for Medicare vs private ins. Also, E-visit vs telehealth billing? This webinar covered clinical issues relating to telehealth. We did another webinar that was entirely devoted to billing for telehealth and E-visits. You can find a recording of the telehealth and e-visit billing webinar at: https://pt-management.com/purchase-recorded-webinars/
I like the HEP aspect of MedBridge that you showed us, but are you using MedBridge for the actual telehealth session or another telehealth service such as Doxy.me? We are not using MedBridge’s telehealth system.
Simpler and fewer exercises are safer and better, don’t you think? Agreed.
What about treating state-to-state? I work at a high school/college setting. Now that they are home, they are out of state. You need to have a physical therapy license in the state in which the patient is located. You may be able to easily obtain a license to treat in another state that is a member of the multi-state compact. You can find this out at: http://ptcompact.org/.
What is the best way to perform muscle testing? Gravity and patient self-resistance.
What would you recommend to assist with taking vitals? Vitals can be a challenge. I would have a patient take their own or provide them with Wi-Fi-enabled equipment.
Would you feel comfortable treating a patient with balance issues? In most cases, only if a person with the patient is able to help study the patient and prevent a fall.
If I am licensed in Ohio, could I treat from my home in Pennsylvania? If you are licensed in Ohio, you can treat a patient who is located in Ohio via telehealth regardless of where you are located.
How do you incorporate telehealth in place of home health visit? We could do HEP, but what about balance and gait training? I would definitely break down balance and gait to basic parameters and then use SAFE and basic concepts. Once the patient masters those, if you feel like they are not safe on their own, someone must be at home to assist. You should note that home health agencies that are billing under part a of Medicare, which is typically the case, are not authorized to bill Medicare patients for telehealth or e-visits.
How long are your typical treatment sessions? 30-60 min.
How are you taking ROM measurements? Percentage compared to other side.
You have discussed self-pay a lot, how does this relate to insurance claims or is it self-pay only? During the COVID emergency, many insurers will pay for telehealth or e-visits. You have the option of using self-pay, but typically not for patients covered by health insurers that you are contracted with.
Advice for mental health crisis during session? Try to screen for that. Arroll, et al. 3-question depression screen and you need to have a digital emergency policy and procedure in place.
Advice for secure storage of video/ audio recording? Upload to HIPAA-compliant secure cloud-based storage.
What are the best platforms to use for telehealth? Doxy.me has been well received.
I do home health mostly focusing on joint replacement, stroke, and neurological injuries, and just deconditioning from prolonged hospital stay. What tips or advice would you recommend for my setting since most of this webinar was geared toward outpatient setting?
Joint replacement is fine, you treat those as you would at a clinic. In fact, a good deal of research currently supports telehealth use for joint replacements. Regarding neuro, etc., I really feel like you need to be the judge of your patient’s quality of movement level and environmental safety. If you are having doubts, it is imperative to have someone at home to help support you and the patient.
When documenting objective information, what is the verbiage that you use?
I like to use functional language and look for online sources of Oswestry, etc. to score the patient.
What is a preferred computer to use? Laptop? I use a MacBook Pro. 16GB RAM at least. I like solid state memory as well for speed.
I would recommend functional testing for the UE, e.g., they can lift 1 pound to shoulder height; they can perform 5 squats with proper form prior to fatigue; they can perform 10 SLR’s, shoulder ABD, 10# floor to waist, etc. Agreed!!
Do you need to state in the POC the # of visits planned as telehealth vs face-to-face? CMS has stated that e-visits do not need to be included in the POC.
Is contact made prior to a telehealth session to ensure the patient has what is needed prior to beginning that session? I think that is best practice and also lowers the risk of cancellation.
You said to be aware of red and yellow flags–examples? Red flags are any condition that warrants an immediate referral like cancer, cauda equina, heart attack. Yellow flags are psychosocial flags that warrant a referral either delayed or immediate for depression and thoughts of suicide.
Is your pre-payment set up on your website or do you use Square or similar platforms?
We use Stripe, but Square or anything similar will do.
What platform do you recommend for providing your telehealth sessions?
I have done some telehealth assessment; however, is this possible to do with someone who has some cognitive issues? I have used caregivers to assist but question accuracy of information provided. Any thoughts? I agree with your perception of accuracy but I like to look at this as a slightly inaccurate objective PT session with an assistant vs no PT at all.
I am an OT. I can see the education component. I can see the training for exercises, review some AD for safety, but how do you manage tasks such as transfers, toileting, bathing skills? Often, especially now, the caregivers are just as elderly in my home health setting as the client. True and telehealth is not for every patient. Can you observe the environment coach on functional tasks? Depending on the skill set, there are patients who do well with a hybrid model of home health and telehealth.
Do you save video of PT and add to chart? If you record a treatment, it becomes part of the patient record and needs to be added to PT record and saved with the chart.
Can you give a link to the bicycle tub mobs techniques?
With teletherapy, especially here in AZ, it has been allowed for Medicare and insurance to be covered just due to emergency with COVID, what do you suggest that we do as a professional to try and ensure that teletherapy can be covered after this epidemic is over?
Collection of data, outcomes, patient satisfaction and political lobbying should help. The goal is to not have this rolled back.
I am a PT in TX and just wanted to make sure that PTAs can do telehealth. Yes. You can find the TX PT Board’s guidance on this issue at: https://www.ptot.texas.gov/idl/7F9C31AC-EAD1-6635-405A-448E602C640A
What do we do if patient falls or has chest discomfort? You need to have an emergency protocol in place.
Do you call 911 for them? Is that what should be included in the emergency guideline?
Obviously, it is your responsibility to oversee the visit. What would you do in-clinic?
Is it possible to interchange between telehealth and in-person visits if the PT has to be out of town (but still in the same state)? Yes. It just counts as an OP visit.
I am concerned about how to maintain good ROM by delivering telehealth. How are we able to continue delivering good mobilization strategies when you are doing therapy virtually?
There are many ways in helping patients self-mobilize using repeated motions, mob belts, bands.
Is there a go-to objective outcome score index that you use for telehealth? Use all the standard outcome measures. Convert to fillable PDF.
Any tips on how to grade a muscle strength (e.g. 4+/5), or do you just write it up as patient is able to touch the top shelf? Yes. I use function vs MMT.
Do you write up the goals differently? Because usually we write goals for strength to be improved by 1 grade etc.? That is hard to test virtually. Goals in this domain should be objective, patient specific, and measurable via digital technology.
Do you use Zoom or Facetime, or different platform? Heavy Medicare population and they do not have great knowledge regarding technology. During the COVID emergency, HHS is allowing telehealth via audiovisual applications that are not hippo-compliant. You can use Zoom or FaceTime.
How do I have them see the exercises as I am treating? Screen share is the best option but other HEP programs have imbedded videos.
What is my liability if they fall? Your liability if the patient falls at home is no more than it would be if the patient fell in the clinic. Your professional liability coverage should protect you in this event, but it is a good idea to verify that you are covered for telehealth.
How do you receive payment for private pay? Some platforms have a payment option. Other options would be to send invoices to patients, imbed a payment option on your website like Square or Stripe. Definitely business dependent.
Where are you getting your patients? Marketing? Current patients, referring providers, social media ads are the main source of patients.
Can you send me a video of an ACTUAL session? I am sorry. Due to privacy concerns I cannot. There are some examples if you do a thorough Google search.
I work for 3 home health companies, and 1 outpatient company PRN. Am also willing to work for out of state companies that are flexible with licensure. I believe you said Pennsylvania was one state. What other states did you say are flexible with out-of-state licensure? You can find a list of these states at http://ptcompact.org/.