In Part 1 of this blog post I share my thoughts on using telehealth in neuro occupational therapy and summarise the current UK guidance in telehealth. This section focuses on my own ideas for completing an initial assessment via telehealth.
In order to deliver a high standard of occupational therapy via telehealth consultation, I felt the need to rethink the structure of my initial assessments. I’m sure my approach will evolve the more I use telehealth, but for now I thought I would share some of my ideas:
Assessment before the assessment
In order to utilise telehealth to its potential, I would try to gather as much information as I can prior to the video call. Technology can be unreliable at times and in my experience people tend to fatigue quicker when talking via video conference when compared with an in-person conversation, particularly those with neurological conditions.
Functional task
I will ask the client to video record themselves completing two ADLS/ DADLS which they find problematic - either asking someone else to record them, or by setting up their camera on a tripod or stand within view of the task. This eliminates the risk of technical difficulties interfering with the assessment, and allows me time to review their functional ability in advance, allowing me to focus the interview on the most relevant areas. Additionally, I think clients may feel less self-conscious sending a pre-recorded video of task performance rather than performing via video chat. Of course, this method relies on you having a very secure file sharing and storage system as I do.
Self-reported measures
Depending on the individual case, one could send additional questionnaires for the client/ caregiver to complete in advance. For example, the Cognitive Failures questionnaire, Catherine Bergego Scale and many fatigue rating scales can all be completed in advance and help guide the video call.
Preparation for the video call
Based on the functional task recordings and questionnaires, the client would be asked to have some items ready for the video call for continued assessment. For example, a pen and paper to assess handwriting, or some jars and containers from the kitchen to assess various grips and upper limb function. If there are physical issues, asking for photographs of the house or a video walk-through could be helpful. Again, secure file sharing and storage is required for this.
The video call
COPM / Subjective Interview
I use the Canadian Occupational Performance Measure to structure my initial interview and gather additional subjective information. I did consider collecting subjective information in advance as well but decided against it because the initial interview is about much more than gathering data, particularly within a neurological population. The manner in which a client responds to my questions and follows the flow of a conversation allows me to assess their cognition, behaviour and insight in a way which a questionnaire would not show. For diagnosis with no cognitive component, however, collecting subjective history via a form/ checklist could further streamline the process for patient and therapist.
Further assessment
Although the focus of my assessment is functional ability, I have adapted some impairment-based assessment tasks for telehealth. For example, usually I assess proprioception by placing a clients limb in one position and asking them to copy the position with their other limb with their eyes closed. However, proprioception can also be assessed by asking the client to touch alternate fingers to their nose with their eyes closed and this method does not require another person to be present. In terms of impairment-based cognitive assessment, the Montreal Cognitive Assessment (MOCA) has been adapted for use via telehealth. Another option would be to use the blind version of the MOCA which can be completed via the telephone or video conference and is equally valid and reliable. Here are the instructions for using the MOCA via video conference:
The rater shows the patient the visual section of the MOCA (first 8 points)
Trails: “Please tell me where the arrow should go next to respect the pattern I am showing you”
Cube: “Copy the cube” (they need a pen and paper ready)
Clock: “Draw a clock. Put in all the numbers and set the time to 10 past 11”
Animal naming: “Tell me the name of these animals”
The rest of the test is done in the same way except the orientation:
Date: “Look straight at the camera and tell me today’s date, day of the week, month and year”
Place: “From what clinic/ institution am I calling you from?”
City: “What is the city in which our clinic/institution is located?”
The Software
There are lots of telehealth and video conferencing platforms available. I have decided to use Doxy.me (https://doxy.me) as a starting point because they are a purpose-built telehealth platform with HIPAA compliant security, and they are totally free. They have options for paid subscriptions with added features but for now the free version has all I need. The client does not need to download any software or make an account, they just paste a URL into any web browser and it takes them straight to the call.
My ideas are not thoroughly tried and tested as of yet, and like all of us, they will be rapidly evolving over the coming months in response to the changing social and healthcare context in the UK. Next steps in the area of telehealth need to include guidelines from our governing bodies including the RCOT and HCPC with heavy input and consultation from frontline therapists. In the meantime, sharing practice and supporting one another to navigate these new ways of working is vital, and I hope that sharing my thoughts here contributes somewhat to that.
Thank you for reading and please comment with any thoughts or experiences you have on the subject.
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