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Can Telehealth Make Physical Therapy More Effective?

A new study launched by Duke University will analyze whether e telehealth platform can reduce costs and improve clinical outcomes for knee replacement patients.

- Duke University’s Clinical Research Institute has launched a new study to determine whether telehealth-based physical therapy works better than traditional therapy.

Called VERITAS (Virtual Exercise Rehabilitation In-home Therapy: A Research Study), the program will evaluate patients undergoing total knee replacement (TKR) surgery who use the VERA virtual exercise rehabilitation platform developed by San Diego-based Reflexion Health, both before and after surgery. They’ll be compared to a control group who receive traditional home- and clinic-based PT.

“Physical therapy is often a critical component of care for patients who have TKR surgery,” Janet Prvu Bettger, ScD, an associate professor with the Duke Department of Orthopaedic Surgery and principal investigator for the study, said in a press release announcing the study. “Digital health technology, including virtual and telehealth options, may increase access, improve quality and lower healthcare costs.”

“Extending the reach of physical therapists into the home using a digital healthcare platform like VERA can provide remote guidance and supervision for a home-based therapy program,” she added. “However, implementation in the U.S. has not been widely evaluated until now.”

The Centers for Disease Control and Prevention estimates roughly 700,000 total knee replacements are done each year, the most frequent hospital procedure in the U.S. With an aging population, growth in the number of younger adults diagnosed with knee osteoporosis and more people remaining active later in life, that number is expected to top 3 million by 2030.

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With the shift to value-based care and the Centers for Medicare & Medicaid Services’ interest in including joint replacement in its bundled payment models, healthcare providers are looking at telehealth and mHealth platforms that can improve outcomes and cut into a procedure that can cost upwards of $33,000.

They’re also looking for platforms that improve patient engagement. A 2014 study found that seven out of every 10 patients assigned to physical therapy don’t follow their doctor’s orders, particularly in attending PT sessions at a clinic or scheduling sessions with a therapist at home.

Physical therapy is "one of the few areas in healthcare where patients have to be engaged themselves," Naveen Khan, whose Physical Therapy Pal app and platform, launched in May 2013 and used by health systems like Cedars-Sinai, Kaiser Permanente and UT-Southwestern, said in a 2014 interview.

Khan is one of several mHealth companies looking to make physical therapy more engaging by connecting the patient at home with the PT trainer at the hospital or clinic. Others have looked to combine PT with the rapidly growing telerehabilitation field, which encompasses everything from stroke recovery to prosthetic training.

The American Telemedicine Association has long supported telerehabilitation – including physical therapy delivered via telehealth – as a means of reducing expensive follow-up care, including painkiller prescriptions and additional doctor appointments, reducing rehospitalizations and improving a patient’s overall health and wellness.

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“(A)dvances in rehabilitation care have been made in the recent decade by relying on using telehealth technologies that include measuring for and generating wheelchair prescriptions; neurological assessments; adaptive equipment prescriptions and home modifications; ergonomic assessments; functional exercise programs; activities of daily living (ADLs) skills training; self-care training; caregiving support; adjustment and clinical support of prosthetic devices; school-based services, including handwriting performance; early intervention (IDEA Part C services); health and wellness programming; and rehabilitation for individuals who have experienced stroke, breast cancer, traumatic brain injury, polytrauma, Parkinson’s disease, and other neurological and orthopedic disorders,” the ATA wrote in a January 2016 letter to CMS calling for more reimbursement.

When CMS’ Comprehensive Care for Joint Replacement (CJR) bundled payment initiative took effect this past April, Reflexion Health’s Ben Torres said healthcare providers would turn to telehealth to meet those CJR benchmarks and improve their outcomes beyond discharge.

“While there are many questions that still need to be answered with CJR, what is crystal clear is that providers will have to critically examine their joint arthroplasty care pathways and implement new methods to meet CJR benchmarks,” Torres said in a blog. “This, in particular, holds true for post-acute care, where the majority of cost variability exists. Any effort to rein in spending, should it be required, will likely come from this setting.”

“(P)hysicians will look to develop strategic partnerships with ‘preferred providers’ who will be able to optimize both clinical outcomes and healthcare costs,” Torres added. “These ideal providers will likely be those who have been able to leverage certain remote monitoring and tele-rehabilitation technologies and have been able to transition to value based care models. Post-acute care facilities that have implemented these new practices could be very attractive to physicians, who will be having an even greater influence on how post-acute care is delivered.”

The VERITAS study will encompass roughly 300 participants at six U.S. health facilities. Officials say the study will examine costs, health service use and clinical outcomes before and up to three months after TKR surgery.

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