Telerehabilitation Of High Risk Patients In Home Health Settings: A Preliminary Report

1. Telerehabilitation Of High Risk Patients In Home Health Settings: A Preliminary Report Newman BC, Shaw DK, Sarchet PM, Mitchell CJ Department of Physical Therapy, Texas State University, San Marcos, Texas ; Beyond Faith Homecare & Rehab, LLC, Lubbock, Texas Thank you for allowing me to present this preliminary report, Telerehabilitation of High Risk Patients in HH settings. I have been a HH therapist for many years and am excited about the possibility of providing higher quality and safer therapy to the cardio-pulmonary patient in the home setting based on this technology. This is our future, in HH, especially with this population, and the results of this preliminary study conducted between the Texas State University Telehealth program in San Marcos and Beyond Faith HH in Lubbock are promising and exciting.Thank you for allowing me to present this preliminary report, Telerehabilitation of High Risk Patients in HH settings. I have been a HH therapist for many years and am excited about the possibility of providing higher quality and safer therapy to the cardio-pulmonary patient in the home setting based on this technology. This is our future, in HH, especially with this population, and the results of this preliminary study conducted between the Texas State University Telehealth program in San Marcos and Beyond Faith HH in Lubbock are promising and exciting.

2. INTRODUCTION Home health therapists are at a distinct disadvantage when treating at risk patients with underlying cardiac or pulmonary disease At risk cardiac and pulmonary patients present the therapist with many challenges in any setting. These patients present with complications or possible further exacerbations related to CHF, sp CABG, unstable angina, unstable arrythmia, unstable BP and unstable HR. In the HH setting these patients could be classifed with cardiac cripple syndrome - � due to the diagnosis and fears related to the diagnosis. In the inpatient setting the therapist has access to constant ECG monitoring, onsite trained medical staff, and state of the art equipment and access to medical staff trained to treat the cardiopulmonary patient in case of a crisis. During therapy sessions with these patients complications are highly possible and cardiopulmonary incidents are looming and waiting to happen. At risk cardiac and pulmonary patients present the therapist with many challenges in any setting. These patients present with complications or possible further exacerbations related to CHF, sp CABG, unstable angina, unstable arrythmia, unstable BP and unstable HR. In the HH setting these patients could be classifed with cardiac cripple syndrome - � due to the diagnosis and fears related to the diagnosis. In the inpatient setting the therapist has access to constant ECG monitoring, onsite trained medical staff, and state of the art equipment and access to medical staff trained to treat the cardiopulmonary patient in case of a crisis. During therapy sessions with these patients complications are highly possible and cardiopulmonary incidents are looming and waiting to happen.

3. Now imagine this same patient in the home health setting, especially in the rural community. The patient may have in home oxygen and the therapist may come equipped with a BP cuff. But generally in the HH setting therapists do not have access to technology to provide safe and effective monitoring during the exercise session for the at risk cardiopulmonary patient. Now imagine this same patient in the home health setting, especially in the rural community. The patient may have in home oxygen and the therapist may come equipped with a BP cuff. But generally in the HH setting therapists do not have access to technology to provide safe and effective monitoring during the exercise session for the at risk cardiopulmonary patient.

4. THE PROBLEM IS THIS� The home health patient population is increasingly OLDER The home health patient population is increasingly SICKER Therapists are OFTEN NOT ADEQUATELY TRAINED NOR EQUIPPED to assess and treat the at risk cardiopulmonary patient in the HH setting Thanks to DRG�s and changes in reimbursement for inpatient stays patients are going home much sicker. We know the population is aging and also thanks to improvements in medical care living longer. And patients want to be at home and as independent as possible in their home. Home therapy and exercise intervention is key to providing a safe and independent environment for these patients. My experience is that most therapists in the HH setting must be strong generalists and therefore are not trained to meet the challenges of the at risk cardiopulmonary patient. Also HH agencies are not equipping the HH therapist with the necessary training and supplies needed to provide safe and effective HH therapy. Therefore many of these patients are either not receiving any HH therapeutic exercise or therapeutic exercise is being provided under high risk conditions. Thanks to DRG�s and changes in reimbursement for inpatient stays patients are going home much sicker. We know the population is aging and also thanks to improvements in medical care living longer. And patients want to be at home and as independent as possible in their home. Home therapy and exercise intervention is key to providing a safe and independent environment for these patients. My experience is that most therapists in the HH setting must be strong generalists and therefore are not trained to meet the challenges of the at risk cardiopulmonary patient. Also HH agencies are not equipping the HH therapist with the necessary training and supplies needed to provide safe and effective HH therapy. Therefore many of these patients are either not receiving any HH therapeutic exercise or therapeutic exercise is being provided under high risk conditions.

5. Guidelines American Heart Association American Association of CardioVascular and Pulmonary Rehabilitation American College of Sports Medicine The AHA, AACVPR, and ACSM, provided us with the guidelines we used to categorize the patients in this study and also provided safe guidelines on supervision and ECG monitoring requirements for this population in general. The AHA, AACVPR, and ACSM, provided us with the guidelines we used to categorize the patients in this study and also provided safe guidelines on supervision and ECG monitoring requirements for this population in general.

6. Guidelines Examining the guidelines from AHA and AACVPR you will see how we classified the patients in this study as at risk for a cardiac event and supported the need for cardiac monitoring during therapeutic exercise. AHA guidelines Our patients fell into classes C and D Class C � continuous monitoring until safe,� conditions may flare during exercise Class D- no exercise � in uncompensated CHF with unstable angina, medically unstable arrythmia, cardiac arrythimia, persist and do not respond to meds AACVPR Our patients fell into the internedicate and high risk categories Intermediate - at least initial and intermittent monitoring, 40�49% ejection fractions High � constant monitoring, low EF ( less than 40) these patients EF or stroke volume lie outside of normal, with normal being 50-70 EF (ejection fraction � stroke volume) � volume of blood ejected from a ventricle into the main artery by each ventricular beat- normal 50-70Examining the guidelines from AHA and AACVPR you will see how we classified the patients in this study as at risk for a cardiac event and supported the need for cardiac monitoring during therapeutic exercise. AHA guidelines Our patients fell into classes C and D Class C � continuous monitoring until safe,� conditions may flare during exercise Class D- no exercise � in uncompensated CHF with unstable angina, medically unstable arrythmia, cardiac arrythimia, persist and do not respond to meds AACVPR Our patients fell into the internedicate and high risk categories Intermediate - at least initial and intermittent monitoring, 40�49% ejection fractions High � constant monitoring, low EF ( less than 40) these patients EF or stroke volume lie outside of normal, with normal being 50-70 EF (ejection fraction � stroke volume) � volume of blood ejected from a ventricle into the main artery by each ventricular beat- normal 50-70

7. PURPOSE The purpose of this study was to evaluate the efficacy of providing enhanced cardiopulmonary monitoring for at risk patients in the Home Health setting using telerehabilitation technology The purpose of this study was to evaluate the efficacy of providing enhanced cardiopulmonary monitoring for at risk patients in the HH setting using telerehabilitation technologyThe purpose of this study was to evaluate the efficacy of providing enhanced cardiopulmonary monitoring for at risk patients in the HH setting using telerehabilitation technology

8. TERMINOLOGY I have been asked � what is telerehabilitation�? Telerehabilitation falls under the umbrella term of telehealth, as does telemedicine and teleconferencing, among others. Telehealth is defined as �electronic information and communication technology - activities such as health professional education, community health education, public health, research, and administrative services fall in this category�. We probably most often come in contact with the term �telemedicine� which refers to the use of electronic communication and information technologies to provide and support clinical care at a distance� � replace the term �clinical care� with rehabilitation care and we get �telerehabilitation�.I have been asked � what is telerehabilitation�? Telerehabilitation falls under the umbrella term of telehealth, as does telemedicine and teleconferencing, among others. Telehealth is defined as �electronic information and communication technology - activities such as health professional education, community health education, public health, research, and administrative services fall in this category�. We probably most often come in contact with the term �telemedicine� which refers to the use of electronic communication and information technologies to provide and support clinical care at a distance� � replace the term �clinical care� with rehabilitation care and we get �telerehabilitation�.

9. Therefore, through this electronic communication The therapists at the telehealth program at Texas State University in San Marcos was able to monitor the at risk cardiopulmonary patient during their home exercise therapy session in the HH setting in Lubbock Texas, 450 miles away. Our role during the exercise session was to communicate directly with the treating therapist and make recommendations to the therapist based on the patients ECG readout, BP, PR and the patients report of perceived exertion using the BORG scale. Therefore, through this electronic communication The therapists at the telehealth program at Texas State University in San Marcos was able to monitor the at risk cardiopulmonary patient during their home exercise therapy session in the HH setting in Lubbock Texas, 450 miles away. Our role during the exercise session was to communicate directly with the treating therapist and make recommendations to the therapist based on the patients ECG readout, BP, PR and the patients report of perceived exertion using the BORG scale.

10. MATERIALS & METHODS So, how did we do it? In San Marcos in the Telehealth lab we had an electronic system specifically designed for this intervention consisting of a hard drive, touch screen, printer, ECG strip chart recorder, monitor and keyboard. In the home the therapist was equipped with a bipolar ECG home unit, a junction box, modem and headset. Through pre-arranged scheduling between the HH agency therapists and the Telehealth lab therapists the HH therapist spent the first few minutes setting up the patient on the home ECG unit, contacted us when ready and we begin our monitoring. We provided monitoring and recommendations' before, during and after the exercise session. So, how did we do it? In San Marcos in the Telehealth lab we had an electronic system specifically designed for this intervention consisting of a hard drive, touch screen, printer, ECG strip chart recorder, monitor and keyboard. In the home the therapist was equipped with a bipolar ECG home unit, a junction box, modem and headset. Through pre-arranged scheduling between the HH agency therapists and the Telehealth lab therapists the HH therapist spent the first few minutes setting up the patient on the home ECG unit, contacted us when ready and we begin our monitoring. We provided monitoring and recommendations' before, during and after the exercise session.

11. DOCUMENTATION The software at the telehealth lab provided a report easily interpreted by the HH therapist and ready to send to other healthcare staff. Although this is not easy for you to read, this document contains the following information: Patient demographics Patient vital signs, including BP, PR, RPE, respirations and O2 sats- all collected during pre-exercise, exercise, at rest, and post exercise. The monitoring therapist SOAP note summary of the session A represented selection of ECG strips from the full disclosure monitoring. The software at the telehealth lab provided a report easily interpreted by the HH therapist and ready to send to other healthcare staff. Although this is not easy for you to read, this document contains the following information: Patient demographics Patient vital signs, including BP, PR, RPE, respirations and O2 sats- all collected during pre-exercise, exercise, at rest, and post exercise. The monitoring therapist SOAP note summary of the session A represented selection of ECG strips from the full disclosure monitoring.

12. DATA ANALYSIS Descriptive data were obtained to assess changes in workload from initial session to discharge Appearance or changes in signs and symptoms were treated qualitatively and documented from patient and/or therapist reports For this study we looked at data collected on four patients. Descriptive data were obtained to assess changes in workload from initial session to discharge Appearance or changes in signs and symptoms were treated qualitatively and documented from patient and/or therapist reports For this study we looked at data collected on four patients. Descriptive data were obtained to assess changes in workload from initial session to discharge Appearance or changes in signs and symptoms were treated qualitatively and documented from patient and/or therapist reports

13. SUBJECTS AN algorithm developed at the Texas State Telehealth program guided the HH admitting RN during the admission process to identify candidates for the STEP program, which stands for Safe Transtelephonic Exercise Program. This is a summary of those 4 patients. All four patients resided in the Lubbock area and were monitored from Texas State University in San Marcos. All met the criteria for at risk cardiopulmonary patients as defined by the AHA and AACVPR guidelines. Subject 1: 67, female, CAD, stents, CABG, angina: C/intermediate Subject 2: 86, female, CAD, stent, angian: C/intermediate Subject 3: 76 female, COPD, GI bleed: C/High Subject 4: 85 female, CHF, unstable angina, COPD: C-D/High The AHA recommendation for class C patients is continuous monitoring, for class d recommendations are for no exercise; the AACVPR recommends patients in the intermediate range be monitored continually initially and for high risk constant monitoring during exercise (PAF � paroxysml atrial fib, uncontrolled arrythmia) AN algorithm developed at the Texas State Telehealth program guided the HH admitting RN during the admission process to identify candidates for the STEP program, which stands for Safe Transtelephonic Exercise Program. This is a summary of those 4 patients. All four patients resided in the Lubbock area and were monitored from Texas State University in San Marcos. All met the criteria for at risk cardiopulmonary patients as defined by the AHA and AACVPR guidelines. Subject 1: 67, female, CAD, stents, CABG, angina: C/intermediate Subject 2: 86, female, CAD, stent, angian: C/intermediate Subject 3: 76 female, COPD, GI bleed: C/High Subject 4: 85 female, CHF, unstable angina, COPD: C-D/High The AHA recommendation for class C patients is continuous monitoring, for class d recommendations are for no exercise; the AACVPR recommends patients in the intermediate range be monitored continually initially and for high risk constant monitoring during exercise (PAF � paroxysml atrial fib, uncontrolled arrythmia)

14. RESULTS All four patients participated in a monitored exercise program developed by the treating HH therapist in Lubbock with recommendations from the monitoring therapist in San Marcos. All 4 were able to exercise on a 2inch step bench brought into the home by the treating therapist. METS (metabolic equivalent, or amount of oxygen required to sustain an individual in a seated, upright position) was used as a quantitative measure of patient progress. 2 of the 4 subjects increased their METS during the treatment session from start to finish ; 2 remained the same from start to finish, but these 2 had a shorter course of treatment. Visits ranged from a low of 4 exercise sessions to a high of 19 exercise sessionsAll four patients participated in a monitored exercise program developed by the treating HH therapist in Lubbock with recommendations from the monitoring therapist in San Marcos. All 4 were able to exercise on a 2inch step bench brought into the home by the treating therapist. METS (metabolic equivalent, or amount of oxygen required to sustain an individual in a seated, upright position) was used as a quantitative measure of patient progress. 2 of the 4 subjects increased their METS during the treatment session from start to finish ; 2 remained the same from start to finish, but these 2 had a shorter course of treatment. Visits ranged from a low of 4 exercise sessions to a high of 19 exercise sessions

15. SUBJECT #1 Strips were obtained while the patient was at rest prior to exercise in order to establish a baseline and also to determine if the patient was safe to exercise during that session. Even if you are not trained to read and interpret ECG strips you will see that these strips are not normal. This resting strip shows a wide QRS complex. If you will recall subject #1 is a 67 year old female with a dx of CAD, 3 stents, 2 CABG�s, stable angina and by AHA guidelines defined as a class C requiring continuous monitoring during exercise. AHA recommendations note that this category of patient may flare during exercise. The second strip demonstrates how continuous monitoring of this category of patient is important. During this exercise session the second strip was recorded. The ST segment is elevated and consistent with infarction. Based on our guidelines the recommendation was made to the treating therapist to stop the exercise session. The HH agency nurse was contacted and the patient was transported to the ER. A potential serious cardiac event was avoided due to the constant monitoring offered by telerehabilitation. Based on the AHA guidelines the patient was changed to a Class D AHA category and further exercise was not recommended. Based on our recommendation the treating therapist changed the treatment plan to energy conservation techniques and discontinued the exercise portion of the treatment program.Strips were obtained while the patient was at rest prior to exercise in order to establish a baseline and also to determine if the patient was safe to exercise during that session. Even if you are not trained to read and interpret ECG strips you will see that these strips are not normal. This resting strip shows a wide QRS complex. If you will recall subject #1 is a 67 year old female with a dx of CAD, 3 stents, 2 CABG�s, stable angina and by AHA guidelines defined as a class C requiring continuous monitoring during exercise. AHA recommendations note that this category of patient may flare during exercise. The second strip demonstrates how continuous monitoring of this category of patient is important. During this exercise session the second strip was recorded. The ST segment is elevated and consistent with infarction. Based on our guidelines the recommendation was made to the treating therapist to stop the exercise session. The HH agency nurse was contacted and the patient was transported to the ER. A potential serious cardiac event was avoided due to the constant monitoring offered by telerehabilitation. Based on the AHA guidelines the patient was changed to a Class D AHA category and further exercise was not recommended. Based on our recommendation the treating therapist changed the treatment plan to energy conservation techniques and discontinued the exercise portion of the treatment program.

16. CONCLUSION The present telerehabilitation system appears to be efficacious in facilitating safe exercise for at risk patients with underlying cardiac or pulmonary disease We recognize that this sample was small and that this is just a preliminary study, but we believe that the present telerehabilitation system appears to be efficacious in facilitating safe exercise for at risk patients with underlying cardiac or pulmonary disease We recognize that this sample was small and that this is just a preliminary study, but we believe that the present telerehabilitation system appears to be efficacious in facilitating safe exercise for at risk patients with underlying cardiac or pulmonary disease

17. RELEVANCE Telerehabilitation technology is seen as pivotal in reaching a wide variety of home health patients especially those at risk for exercise-induced cardiopulmonary complications Telehealth, telemedicine, telerehabilitation, and the ability to use electronic communications and information technologies to provide and support therapy care is our future. In our homes, where most patients want to be if possible, telerehabilitation offers the patient the opportunity to a safe and effective exercise program, the ability to live at home as independent as possible, and the HH therapist the confidence to provide the safest and highest quality of care possible to the patient at risk for cardiopulmonaryy events.Telehealth, telemedicine, telerehabilitation, and the ability to use electronic communications and information technologies to provide and support therapy care is our future. In our homes, where most patients want to be if possible, telerehabilitation offers the patient the opportunity to a safe and effective exercise program, the ability to live at home as independent as possible, and the HH therapist the confidence to provide the safest and highest quality of care possible to the patient at risk for cardiopulmonaryy events.