Leveraging Telehealth Technologies in the Service of Rehabilitative Care for Brain Injury
How the clinicians at the Centre for Neuro Skills, a provider of rehabilitative services for patients living with traumatic and acquired brain injury, were able to transition quickly to telehealth-based care
Author - Mark Hagland
May 1st, 2020
Virtually every type of patient care organization in U.S. healthcare has been having to make adjustments in its care delivery, in the wake of the emergence this spring of the COVID-19 pandemic. One area that most members of the public are unlikely to be familiar with, in this context, is that of rehabilitative care for brain injury. Understandably, converting this normally “high-touch” form of care to a virtual format presents special challenges. Yet one organization has successfully made the leap.
Indeed, at the end of March, the Centre for Neuro Skills (CNS), based in Bakersfield, California, and which provides rehabilitation services for patients living with traumatic and acquired brain injury in Bakersfield, San Francisco, Los Angeles, Dallas, Ft. Worth, and Houston, announced that it had converted all patient therapy sessions to remote care, using existing telehealth technology.
“Centre for Neuro Skills has taken steps to maintain the continuity of care for our patients during the COVID-19 pandemic,” said David Harrington, president and COO of Centre for Neuro Skills, on March 30. “Based on guidance from the Centers for Disease Control and local health officials, we are now remotely delivering the same high-quality, individualized treatment to individuals recovering from brain injury. Our highest priority is the safety and health of our patients, staff and the public. Telehealth is one example of how CNS is providing innovative care to its patients.” All of CNS’s patients--day treatment, outpatient and in-patient—are now receiving their therapeutic dosing through telehealth. This includes the full spectrum of CNS’ therapeutic treatments and patient communications, including: counseling, speech therapy, physical therapy, occupational therapy, education therapy, case management, family communication, business partner communication and physician or specialist consultation. Therapy sessions will not be provided in-person at clinics.
The organization’s telehealth program is making use of s the secure and HIPAA-compliant, Zoom-powered platform from the Belmont, California-based Ring Central. That platform supports real-time audio and visual interactions between staff and patients. Founded by Dr. Mark Ashley in 1980, the Centre for Neuro Skills is recognized as an experienced and respected world leader in providing intensive rehabilitation and medical programs for individuals recovering from all types of brain injury. It effectively covers a full spectrum of advanced care from residential and assisted living to outpatient/day treatment, in its locations throughout Texas and California.
Recently, David Harrington spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the organization’s shift to a telehealth platform. Below are excerpts from that interview.
Tell me a bit about your organization, and how it delivers care?
We’re a post-acute neurological treatment center for traumatic brain injury. Most of our patients come from other states. Only 37 percent of our patients in our Bakersfield location are from Kern County. So it’s destination care. We treat approximately 600 patients per year. We have 290 patients currently.
How long has your organization been in existence?
Just over 40 years. In fact, Dr. Mark Ashley, when he founded this, there was no treatment for people with brain injury; they just went home. So in many ways, we were pioneers in neurological rehab. Since then, the neurosciences were able to prove what we do, works.
Who are the main clinicians?
We have both a clinic setting and a residential setting. So our clinic setting is the typical occupational therapy, speech therapy, physical therapy, education, counseling, and behavior analysis, and all of our nurses and physicians are at the clinic. And we have neuro-rehab specialists who will teach the patients how to cook, clean, go grocery shopping. We collect over 350 data sites a day at residential sites alone.
And so your clinician team includes physicians, nurses, and therapists?
Yes, that’s correct.
So, please walk me through the transition to telehealth-based care delivery for your patients?
So we’re a very specialized traumatic brain injury treatment setting; it’s a very hands-on approach. So if we said that the number-one goal is to focus on both staff and patient safety, if we focus on trying to reduce the number of vectors for infection, it forces us to look at a different approach. So as the pandemic began to hit our communities, we had the small chance to implement change as quickly as possible. And we had already been starting a bit into telehealth, especially on the workers’ comp side, where payers had asked us if we could stay in patients’ lives that way. And within two-and-a-half weeks, we’ve fully deployed telehealth both to our residential and clinic settings.
And so let’s walk through the physical mechanics of the process, then?
As of today, all clinicians are doing their treatment via telehealth. And we have staff who are neuro-rehab specialists managing cameras, managing tablets in every apartment, to deliver that telehealth approach. So the therapists may do highly individualized one-on-one sessions. But the counselors also do group counseling. And the platform allows us to pull multiple people in.
So every person in the setting would be setting physically apart?
Yes, and we can even pull in patients in Los Angeles into our Bakersfield sessions. To describe our clinic setting, let’s refer to it as inpatient. It looks like an apartment building. That’s our inpatient program. Our day treatment program involves caring for patients in their homes. And typically, their loved one would bring them into the clinic for four to six hours a day. The inpatient program involves patients staying in our residential settings. They’ll stay with us typically for 100 days or so. And our neuro-rehab specialists will treat the patients, but rather than the patient doing their morning routines and coming into the clinics, the clinicians are remoting into the apartments; and they’re also remoting into the homes of outpatients.
Is there anything physical that cannot be done via telehealth?
It’s about the people; we’re leading a lot of disruptive change, having to navigate the ambiguity. And typically, the clinician is hands-on, so they’re having to innovate their practices in order to deliver this care. Speech therapy will address expressive language, so your ability to talk, or listen and understand. That’s pretty easy to transition to remote care. Where it gets a little bit more challenging is with occupational or physical therapy. So occupational therapists—even for a spouse who’s with their loved one at home, they’ll do a cooking evaluation. And the therapist is evaluating the patient but also interacting with the family member caregiver. So the caregiver really is involved.
And so how is the manipulation of limbs being accomplished?
It’s happening through the hands of a caregiver. It depends on the level of patient. Some patients can be coached through balance exercises, for example. So for the more dependent patients, it involves coaching the spouse, for example, through the modality, teaching them to do the stretching techniques. The clinicians are coaching the family member caregivers.
What have been the biggest learnings so far in this transition?
Integrating not only the spouses but our residential treatment, into the new model. If we improve the clinical acumen of our direct care staff and the spouses, we can improve the care delivery. I’m a hand therapist myself; and you would work carefully with each finger, for example, Here, we’re literally rewiring brains; so you have to put environmental stress on the brain, in order for the neuro system to rewire. So it means making our ecosystem much more robust, and including many more caregivers in the process.
The other learning—we cut our teeth on neuro-rehab, and innovation is in our DNA. So early on, we did a lot of data collection and analysis, and were able to develop clinical protocols in neuro-rehab. So this is not totally unusual for us, to innovate in this way. It’s more about the people and the clinicians to be able to modify that treatment, giving the treatment remotely. All of our patients are now in telecare. And fortunately, we have good relationships with the payers; they’ve been good partners for the most part, in saying, yes, this is the right approach at this time. In the absence of this treatment, these patients would not get better, and in spite of the pandemic, we’re able to make a difference in the lives of these patients.
What would you like to add?
One thing that I’d like to note is that we had to make a massive change occur within a week or two. We had to retool a model that had worked for forty years, to make it work via telehealth. To keep our patients and colleagues safe, we had to retool this, to make a meaningful impact on people’s lives. We’re proud that we’ve been able to keep the continuum functioning. And we see a lot of opportunity to make our continuum more robust, that we could leverage this technology to perhaps reach others, in more remote places. My hope is that at the end of this, more people will get access to brain injury treatment, because of our effectiveness in setting up telehealth.
Did you face any technological challenges in making the transition?
We use RingCentral, and they use Zoom as their platform. So in that sense, it wasn’t difficult. The challenge was to roll out various technologies and contingencies at the residential sites, in a short time. And just as there’s a shortage of toilet paper now, we found out there’s a shortage of cameras. So we had to set things up with one contingency to use the computer and the other to use tablets. So we already had a lot of the technology out there, we just had to thread it all together. So it was a big undertaking, but it was successful.
Will you expand your reach now because of the opportunities made available through the use of the new platform?
We do expect that, yes. There’s a lot of interest from payers in this. And we won’t abandon the philosophy of laying hands on patients. But this gives us the opportunity to stay in people’s lives, when they go back home, discharged from our facilities. The other approach will be to open access for patients who couldn’t otherwise receive this care.