ANNUAL HEALTH CARE ISSUE

TELEHEALTH AND INDIVIDUALS WITH DISABILITIES: IMPACTS AND STRATEGIES

BY JOHNNY PAYNE

The past months of changes as a result of the coronavirus have affected the way business and services operate, but maybe none more than medical and therapeutic services. Most all of these services have explored and embraced the use of telehealth to continue to provide support and empowerment, especially for those with disabilities.

Audrey, a mother to a young daughter with Downs syndrome in Tennessee says, "Telehealth has meant for us that our daughter could keep a bit of normalcy in a time that has been anything but normal. She gets to see her 'friends' (therapists) and regularly 'play' with them over the computer. It has allowed her to continue care and get moving while we feel stuck in our apartment most of each day. This has also kept her safe when we knew very little about how the virus would spread. Audrey says that telehealth has allowed her family to continue her occupational development and mental health, while keeping her physically healthy as well.

The Department of Health and Human Services defines telehealth as electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration. Telehealth technologies may include video conferencing, shared images and videos over the internet, or simple phone calls.

Telehealth, especially for a therapeutic purpose with individuals with intellectual and developmental disabilities, is about empowering a person to provide appropriate support and education so the person can safely and successfully make choices in their life. For many, the provision of these services is a vital part of successfully living as a part of their community. Because of increased levels of stress and anxiety for many individuals, psychiatric management must continue to prevent decompensation and avoid consequences like suicide attempts, emergency department visits, and psychiatric hospitalizations (especially for those individuals with dual diagnosis). Psychotherapy, in particular, provided via telemental health has demonstrated efficacy in reducing pain, disability, depression, and anxiety comparable to traditional face-to-face encounters and without significant risks or adverse effects.

For many, telehealth provides a more accessible mode of support. Studies this year show that a person is eight times more likely to utilize psychotherapy if the service is provided over telehealth platforms than if provided only through in-person platforms. It can allow physicians and patients to communicate 24/7, using oftenaccessible smartphones or webcam-enabled computers. Even before coronavirus, more than 50 large, U.S. health systems already had such programs, including large companies such as Jefferson Health, Mount Sinai, Kaiser Permanente, Cleveland Clinic, and Providence. However, according to a J.D. Power survey before the pandemic, only 1 in 10 U.S. patients used telemedicine services. In fact, a white paper from 2017 entitled "Closing the Telehealth Gap", noted that in the U.S., 82 percent of consumers do not use such services. In some cases, this is because of lack of improper infrastructure to telehealth, such as webcams or camera-equipped devices with internet connectivity. In other cases, it is because of lack of awareness of services or the effects of cultural considerations related to discomfort with technology.

The effects of coronavirus set into play a number of changes which have altered the landscape of telehealth provision and access. Both the CDC and WHO are now advocating for telemedicine to monitor patients and reduce risks of them spreading the virus by traveling to hospitals. After they began advocating for more access, the Academy of Family Physicians and the American Medical Association (AMA) released related guidelines. The U.S. Government also took significant steps in order to expand telemedicine services.

There has been broad bipartisan support to increase access to telehealth at the federal level. The House of Representatives voted to allow the easing of telehealth restrictions for Medicare patients on March 5, and the Senate passed a similar bill 96-1. On March 6th, the Coronavirus Preparedness and Response Supplemental Appropriations Act 2020 was signed by the President. The FCC provided money to nonprofit medical groups to pay for telehealth with the COVID-19 Telehealth Program. This provided $200 million in funding, appropriated by Congress as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, to help healthcare providers provide connected care services to patients at their homes.

Early on, a major concern was to uphold HIPPA compliance over Telehealth platforms, for which many companies and insurance groups still felt uncomfortable. The United States Office for Civil Rights issued guidance to empower health care providers to serve patients through telehealth during the national public health emergency. HIPAA-covered health care providers may, in good faith, provide telehealth services to patients using remote communication technologies, such as commonly used apps.

These apps include FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype – for telehealth services, even if the application does not fully comply with HIPAA rules. Apps and platforms must be non-public, facing remote communication products. Such products include commonly used texting applications such as Signal, Jabber, Facebook Messenger, Google Hangouts, Whatsapp, or iMessage. Typically, these platforms employ end-to-end encryption, which allows only an individual and the person with whom the individual is communicating to see what is transmitted. Since January appointments made on telehealth apps like PlushCare are up by 70%. Amwell, another service, had its app use increase by 158%. The Centers for Medicaid and Medicare Services have also worked to temporarily change how telehealth can be provided. Accommodations include allowance for care outside of designated areas, the ability to practice remote care across state lines, delivery of care to both established and new patients through telehealth, and the ability to bill for telehealth services (both video and audioonly) as if they were provided in person.

At Orange Grove Center, in Chattanooga Tennessee, I coordinate our mental health programs for individuals with dually diagnosed intellectual and developmental disabilities and mental health disabilities like bi-polar disorder or schizophrenia. As part of our Intensive Outpatient Program (IOP), we host cohort-based sessions with small groups of individuals, meeting in person a few times a week. We work to establish understanding of emotions and decision-making for the individuals in the cohort as well as their sup porters and staff. Coaching and connecting with our participants and our staff is a vital part of the process.

When coronavirus precautions started, all of our sessions moved to telehealth. First, we started with phone calls, and eventually we made our way to access video-conferencing capabilities for all our participants. For us, telehealth especially over the video conferencing platform Zoom, has provided increased receptivity to information and attention during program sessions.

A few strategies that have been helpful for us while utilizing the video conferencing platform to conduct our telehealth sessions are related to motivation and attention. We work to conduct our video sessions physically in the classroom space which participants will later occupy for in-person IOP sessions. We do this in order to build visual comfort with the space, minimizing lost transition time when later restarting in-person sessions. We also work to include high-frequency rewards in sessions, such as an award system in which an Orange Grove Skills Master Award is received after three sessions of positive attitude as displayed through modeled vocal tone and facial expressions.

Everything we do through our telehealth program adaptations works to empower our participants to make safe and fulfilling choices in their everyday life. To foster engagement, experts note the importance of providing choices when educating students with disabilities. People who have disabilities are just like everyone else—they want to make choices and be in control of their own lives as much as possible.

Disasters and pandemics pose unique challenges to healthcare delivery to individuals with disabilities. Though telehealth will certainly not solve them all, it is well suited for scenarios in which infrastructure remains intact and individuals can be seen by clinicians. Payment and regulatory structures, state licensing, credentialing, and program implementation all take time to transition, but health systems that have invested in telemedicine are well positioned to ensure that patients with Covid-19 receive the care they need. In this instance, it may be a virtually perfect solution.•

ABOUT THE AUTHOR:

Johnny Payne is the Mental Health Coordinator at the Orange Grove Center in Chattanooga TN.