AOTA Position Paper On Telehealth In Occupational Therapy PDF

AOTA Position Paper Telehealth in Occupational Therapy Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1....

AOTA Position Paper Telehealth in Occupational Therapy Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 This paper provides the current position of the American Occupational Therapy Association (AOTA) re- garding the use of telehealth by occupational therapy practitioners.1 This document describes the use of telehealth within occupational therapy practice areas, as discussed in the existing research. In addition, oc- cupational therapy practitioner qualifications, ethics, and regulatory issues related to the use of telehealth as a service delivery model within occupational therapy are outlined. Occupational therapy practitioners are the intended audience for this document, although others involved in supervising, planning, deliver- ing, regulating, and paying for occupational therapy services also may find it helpful. Definitions Telecommunication and information technologies have prompted the development of an emerging model of health care delivery called telehealth, which encompasses health care services, health information, and health education. AOTA defines telehealth as the application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technology (ICT; see Appendix A). Telerehabilitation falls within the larger realm of telehealth and is the application of ICT specifically for the delivery of rehabilitation and habilitation services (Richmond et al., 2017). However, the term telehealth best represents the scope of occupational therapy services (Cason, 2012a) and is the prevailing term used in state and federal policy. For these reasons, telehealth is the recommended term for all occupational therapy services provided through ICT. Use of Telehealth in Occupational Therapy The overarching goal of occupational therapy is to support people in participation in life through en- gagement in occupation for “habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non–disability-related needs” (AOTA, 2014b, p. S1). This goal is achieved through the occupational therapy process: evaluation, intervention, and promotion or maintenance of health and par- ticipation outcomes for individuals, groups, and populations. Occupational therapy services provided by means of telehealth can be synchronous, that is, delivered through interactive technologies in real time, or asynchronous, using store-and-forward technologies. Oc- cupational therapy practitioners can use telehealth as a mechanism to provide services at a location that is physically distant from the client, thereby allowing for services to occur where the client lives, works, learns, and plays, if that is needed or desired. Occupational therapy practitioners use telehealth as a service delivery model to, for example, Help clients develop skills; Incorporate assistive technology (AT) and adaptive techniques; 1When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015b). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2014a). The American Journal of Occupational Therapy 7212410059p1  Modify work, home, or school environments; and Create health-promoting habits and routines. Some benefits of a telehealth service delivery model include increased access to services, especially for cli- ents who live in remote or underserved areas; improved access to specific providers and specialists other­ wise unavailable to clients; prevention of unnecessary delays in receiving care; and sharing of expertise Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 between practitioners through remote consultation (Cason, 2012a, 2012b). Telehealth may ameliorate the impact of personnel shortages, overcome transportation challenges, and be beneficial in situations where service to clients may be best served during nontraditional work hours of some traditional care models. By removing barriers to accessing care, including social stigma, travel, and socioeconomic and language barriers, the use of telehealth as a service delivery model within occupational therapy leads to improved access to care (Gardner, Bundy, & Dew, 2016; Hinton, Sheffield, Sanders, & Sofronoff, 2017; Levy et al., 2018). Occupational therapy outcomes achievable through telehealth include the facilitation of occupational performance, participation in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), health and wellness, role competence, well-being, quality of life, and occupational justice (AOTA, 2014b). Telehealth has potential as a service delivery model in every major practice area within occupa- tional therapy. Given the variability of client factors, activity demands, performance skills, performance patterns, and contexts and environments, the candidacy and appropriateness of a telehealth service deliv- ery model should be determined on a case-by-case basis using clinical judgment. See Appendix B for case examples supporting the use of telehealth within occupational therapy practice areas. Evaluation Using ICT: Tele-Evaluation ICT has broadened the possibilities for conducting evaluations. Studies have described the use of telehealth in areas that are of concern to occupational therapy, such as evaluation and consultative services for cog- nitive screening (Abdolahi et al., 2014; Stillerova, Liddle, Gustafsson, Lamont, & Silburn, 2016), orthopedic (hand) assessment (Worboys, Brassington, Ward, & Cornwell, 2017), lymphedema assessment (Galiano- Castillo et al., 2013), wheelchair prescription (Schein, Schmeler, Holm, Saptono, & Brienza, 2010; Schein et al., 2011), home assessment (Hoffman & Russell, 2008; Nix & Comans, 2017), adaptive equipment pre- scription and home modification (Sanford et al., 2009), and ergonomic assessment (Baker & Jacobs, 2012). Clinical reasoning guides the selection and application of appropriate ICT necessary to evaluate clients’ occupations, client factors, performance skills and patterns, contexts and environments. Occupational ther- apists should consider the reliability and validity of specific assessment tools when administered remotely. Researchers have investigated the reliability of assessments used by occupational therapy practitioners and found the following assessments to be reliable when administered remotely through telehealth: The Montreal Cognitive Assessment (Abdolahi et al., 2014; Stillerova et al., 2016) The Mini-Mental State Exam (Ciemins, Holloway, Coon, McClosky-Armstrong, & Min, 2009; McEachern, Kirk, Morgan, Crossley & Henry, 2014) The Functional Reach Test and European Stroke Scale (Palsbo, Dawson, Savard, Goldstein, & Heuser, 2007) The Kohlman Evaluation of Living Skills and the Canadian Occupational Performance Measure (Dreyer, Dreyer, Shaw, & Wiitman, 2001) The Timed Up and Go Test (Hwang et al., 2016) The FIM, Jamar Dynamometer, Preston Pinch Gauge, Nine-Hole Peg Test, and Unified Parkinson’s Dis- ease Rating Scale (Hoffmann, Russell, Thompson, Vincent, & Nelson, 2008) The Ergonomic Assessment Tool for Arthritis (Backman, Village, & Lacaille, 2008). 7212410059p2 November/December 2018, Volume 72(Supplement 2) In some cases, an in-person assistant, such as a caregiver or other health professional, may be used to relay assessment tool measurements or other measures (e.g., environmental, wheelchair and seating) to the re- mote therapist during the evaluation process. When using a telehealth model for conducting an evaluation, occupational therapists must consider the client’s health care needs, client’s preference, access to technology, and ability to measure outcomes. Prac- Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 titioners should adhere to all copyright laws and requirements when administering assessments (AOTA, 2015a). If assessment materials or the administration protocol requires modification when used via tele- health, this should be documented and factored into the scoring and interpretation of the assessment. While AOTA supports state regulation of the profession and supports the role of state regulatory boards (SRBs) in regulating the practice of occupational therapy, certain requirements imposed by individual state regulations such as that a practitioner be physically located in the same state as the client to use telehealth technologies denies access to services and specialists unavailable to the client. Similarly, a requirement that a client must first be seen in person by the practitioner before receiving services via telehealth is not ap- propriate and should be determined by the practitioner based on clinical reasoning and ethical judgment (Cason, 2014). This requirement denies access to services and specialists unavailable to the client and negates the benefits of a telehealth service delivery model. When telehealth is used on the basis of sound clinical reasoning and ethical judgment, evidence demon- strates that clients can be effectively treated without the need to first be seen in person by the remote prac- titioner (Baker & Jacobs, 2012; Hwang et al., 2016; Worboys et al., 2017). The occupational therapist may determine that an in-person evaluation or a hybrid evaluation approach (i.e., some aspects of the evalua- tion are administered through telehealth and other aspects in person) is required for some clients. Because of the evolving knowledge and technology related to telehealth, occupational therapists should review the latest research to remain current on the appropriate use of ICT for conducting evaluations. Intervention Using ICT: Teleintervention A telehealth model of service delivery may be used for providing interventions that are preventative, ha- bilitative, or rehabilitative in nature. Factors to consider when planning and providing interventions de- livered with ICT include Technology availability and options for the occupational therapy practitioner and the client; The safety, effectiveness, and quality of interventions provided exclusively through telehealth or a hy- brid model; The client’s choice about receiving interventions by means of telehealth; The client’s desired outcomes, including their perception of services provided; Reimbursement; and Compliance with federal and state laws, regulation, and policy, including licensure requirements (AOTA, 2017a; Richmond et al., 2017). Consultation Using ICT: Teleconsultation Teleconsultation is a virtual consultation that includes the Remote provider and client, with caregiver as appropriate; Remote provider and local provider (e.g., therapist, durable medical equipment vendor, prosthetist, physician) with the client and caregiver, as appropriate; or Remote provider and local provider without the client present. The American Journal of Occupational Therapy 7212410059p3 Teleconsultation uses ICT to obtain health and medical information or advice. Teleconsultation has been used to overcome the shortage of various rehabilitation professionals across the United States. For exam- ple, an occupational therapist can remotely evaluate and recommend adjustments to a client’s prosthetic device using computer software with videoconferencing capability and remote access to a local clinician’s computer screen despite the physical distance between the expert clinician and client (Whelan & Wagner, 2011). Similarly, Schein, Schmeler, Brienza, Saptono, and Parmanto (2008) demonstrated positive outcomes Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 associated with teleconsultation between a remote seating specialist and a local therapist for evaluating wheelchair prescriptions. In addition, teleconsultation may be used to conduct home safety and home modification evaluations (Romero, Lee, Simic, Levy, & Sanford, 2017), prevention and wellness services (Parmanto, Pramana, Yu, Fairman, & Dicianno, 2015), ergonomic consultation (Baker & Jacobs, 2012), preadmission consultation for patients undergoing total hip and total knee replacement (Hoffman & Russell, 2008), and to facilitate sup- port groups for people with chronic conditions (Lauckner & Hutchinson, 2016). In the area of pediatrics, teleconsultation has been used to treat children with complex pediatric feeding disorders (Clawson et al., 2008), facilitate coordination and motor control in children with cerebral palsy (Reifenberg et al., 2017), support school-based services for children with complex medical needs (Cormack et al., 2016), and provide occupation-based coaching for caregivers of young children with autism (Little, Pope, Wallisch, & Dunn, 2018). Monitoring Using ICT: Telemonitoring Telemonitoring, or remote patient monitoring (RPM), is commonly used in the medical model for chronic disease management and involves the transmission of a client’s vital signs (e.g., blood pressure, heart rate, oxygen levels) and other health data (e.g., blood sugar levels, weight, ADL performance, fall events) for review by a clinician to assure more timely monitoring. This type of monitoring can prevent health crises, emergency department use, and hospitalization and can promote health and wellness. Occupational therapy practitioners may work on interprofessional teams using telemonitoring for chronic disease management, for instance. Practitioners may use ICT to monitor a client’s Adherence to an intervention program (Paneroni et al., 2014), ADLs (Gokalp & Clarke, 2013), Cognitive changes (Stillerova et al., 2016), and Fall risk (Horton, 2008; Naditz, 2009). Wearable and home-based sensor monitoring systems are being examined for efficacy with older adults to aid recovery of the ability to effectively and safely perform ADLs following hip fracture (Pol et al., 2017). Telemonitoring can be a tool to enable occupational therapy practitioners to assist clients in achieving desired outcomes. Further, telemonitoring can give occupational therapy practitioners insights and infor- mation about issues and concerns with performance in clients’ natural environments. Considerations for Occupational Therapy in Telehealth Practitioner Qualifications and Ethical Considerations It is the professional and ethical responsibility of occupational therapy practitioners to provide services only within each practitioner’s level of competence and scope of practice. The Occupational Therapy Code of Ethics (AOTA, 2015a) establishes principles that guide safe and competent occupational therapy practice and that must be applied when providing occupational therapy services through a telehealth service deliv- ery model. Practitioners should refer to the relevant principles from the Code and comply with state and federal regulatory requirements. 7212410059p4 November/December 2018, Volume 72(Supplement 2) Principle 1A of the Code states that “occupational therapy personnel shall provide appropriate evaluation and a plan of intervention for recipients of occupational therapy services specific to their needs” (AOTA, 2015a, p. 2). This requirement reinforces the importance of careful consideration about whether evaluation or intervention through a telehealth service delivery model will best meet the client’s needs and is the most appropriate method of providing services given the client’s situation. Clinical and ethical reasoning guides the selection and application of appropriate telehealth technology Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 necessary to evaluate and meet client needs. Occupational therapy practitioners should consider whether the use of technology and service provision through telehealth will ensure the safe, effective, and appro- priate delivery of services. Due to the intimate nature of some occupational therapy services (e.g., inter- ventions related to dressing, bathing, toileting), special consideration should be made to avoid exposure of the client on camera in an undressed or otherwise compromised state. Targeting client factors and perfor- mance skills in a different context, viewing the client engaged in the occupation while wearing tight-fitting clothing or a bathing suit, and relying on caregiver report may be viable options to address the area of concern while upholding ethical principles and standards of conduct (AOTA, 2015a, 2017a). In addition, the American Telemedicine Association’s “Principles in Delivering Telerehabilitation Services” outlines important administrative, clinical, technical, and ethical principles associated with the use of tele- health (Richmond et al., 2017). Occupational therapy practitioners may use various educational approaches to gain competency in using ICT to deliver occupational therapy services. They may gain experience with telehealth and ICT as a part of entry-level education (Standard B.4.15; Accreditation Council for Occupa- tional Therapy Education, 2018) or may participate in continuing education opportunities as clinicians to acquire knowledge of this service delivery model. Examples of ethical considerations related to telehealth are outlined in Appendix C. Practitioners should have a working knowledge of the hardware, software, and other elements of the tech- nology they are using and have technical support personnel available should problems arise (Richmond et al., 2017). They should use evidence, mentoring, and continuing education to maintain and enhance their competency related to the use of telehealth within occupational therapy. Supervision Using Telehealth Technologies State licensure laws, institution-specific guidelines regarding supervision of occupational therapy students and personnel, the Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services (AOTA, 2014a), and the Occupational Therapy Code of Ethics (AOTA, 2015a) must be fol- lowed, regardless of the method of supervision. Telehealth may be used while adhering to those guidelines to support students and practitioners working in isolated or rural areas (Bernard & Goodman, 2013; Miller, Miller, Burton, Sprang, & Adams, 2003; Nicholson, Bassham, Chapman, & Fricker, 2014; Rousmaniere & Renfro-Michel, 2016). Factors that may affect the model of supervision and frequency of supervision in- clude the complexity of client needs, number and diversity of clients, skills of the occupational therapist and the occupational therapy assistant, type of practice setting, requirements of the practice setting, and other regulatory requirements (AOTA, 2014a). Legal and Regulatory Considerations Occupational therapy practitioners are to abide by state licensure laws and related occupational therapy regulations regarding the use of a telehealth service delivery model within occupational therapy (AOTA, 2015a, 2017a). AOTA supports state regulation of the profession and supports the role of SRBs in regulating the practice of occupational therapy. Given the inconsistent adoption and non-uniformity of language regarding the use of telehealth within occupational therapy (AOTA, 2017b), it is incumbent upon the practitioner to check a state’s statutes, reg- ulations, and policies before beginning to practice using a telehealth service delivery model (Cason, 2014). Typically, information may be found on SRBs’ websites, which often include links to relevant statutes, regulations, and policy statements. SRBs should be contacted directly in the absence of written guidance to The American Journal of Occupational Therapy 7212410059p5 determine the appropriateness of using telehealth for the delivery of occupational therapy services within their jurisdictions. In addition, the policies and guidelines of payers should be consulted. Practitioners engaging in interstate practice should consult the occupational therapy licensure board in their state as well as in the state where the client is located for further clarification on policies related to tele- health before rendering services. While a formal license portability mechanism (i.e., licensure compact) is not yet in place, some states have exemptions in licensure laws for temporary practice and for consultation. Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 There is a mechanism for licensure portability through a federal rule (U,S. Department of Veterans Affairs, 2018) for practitioners providing services to veterans. Occupational therapy practitioners are to abide by Health Insurance Portability and Accountability Act (HIPAA, 1996; Pub. L. 104–191) regulations to maintain security, privacy, and confidentiality of all records and interactions. Additional safeguards inherent in the use of technology to deliver occupational therapy services must be considered to ensure privacy and security of confidential information (Peterson & Watzlaf, 2015; Watzlaf, Zhou, Dealmeida, & Hartman, 2017). Occupational therapy practitioners are to con- sult with their practice setting’s or facility’s privacy officer or legal counsel or to consult with independent legal counsel if they are in independent practice or other employment or contracting situation to ensure that the services they provide through telehealth are consistent with protocol and HIPAA regulations. Funding and Reimbursement It is the position of AOTA that occupational therapy services provided through telehealth should be val- ued, recognized, and reimbursed the same as occupational therapy services provided in person. At this writing, Medicare does not list occupational therapy practitioners as eligible providers of services deliv- ered through telehealth (Centers for Medicare and Medicaid Services, 2016). However, AOTA supports the inclusion of occupational therapy practitioners on Medicare’s approved list of telehealth providers. The U.S. Department of Defense and Veteran’s Health Administration uses telehealth to provide occupational therapy services as well as other telehealth programming (U.S. Department of Veterans Affairs, n.d.). Opportunities for reimbursement exist through some state Medicaid programs; insurance companies; school districts; and private pay with individuals, agencies, and organizations. It is recommended that occupational therapy practitioners contact their state Medicaid agency or other third-party payers to de- termine the guidelines for reimbursement of services provided through telehealth. When billing occupational therapy services provided by means of telehealth, practitioners may be required to distinguish the service delivery model, sometimes designated with a modifier (Cason & Brannon, 2011; Richmond et al., 2017). However, regardless of whether the services are reimbursed or the practitioner is responsible for completing documentation related to billing, the nature of the service delivery as being performed through telehealth should be documented. Summary Telehealth is a service delivery model that uses information and communication technology to deliver health-related services when the client is at a distance from the practitioner. AOTA asserts that occupation- al therapy practitioners may use synchronous and asynchronous ICT to provide evaluative, consultative, preventative, and therapeutic services to clients who are physically distant from the practitioner. Occupa- tional therapy practitioners using telehealth as a service delivery model must adhere to all standards and requirements for practice, including the Occupational Therapy Code of Ethics (AOTA, 2015a), maintain the Standards of Practice for Occupational Therapy (AOTA, 2015b), and comply with federal and state regulations to ensure their competencies as practitioners and the well-being of their clients. Occupational therapy practitioners must give careful consideration as to whether evaluation or intervention via telehealth will best meet the client’s needs and provide the most appropriate method of providing ser- vices given the client’s situation and the capacity and competence of the practitioner. Clinical and ethical rea- soning guides the selection and application of appropriate use of telehealth to evaluate and meet client needs. 7212410059p6 November/December 2018, Volume 72(Supplement 2) References Abdolahi, A., Bull, M. T., Darwin, K. C., Venkataraman, V., Grana, M. 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Disability and Rehabilitation: Assistive Technology, 12, 417–423. https://doi.org/10.1080/17483107.2016.1176259 The American Journal of Occupational Therapy 7212410059p9 Palsbo, S. E., Dawson, S. J., Savard, L., Goldstein, M., & Heuser, A. (2007). Televideo assessment using Functional Reach Test and European Stroke Scale. Journal of Rehabilitation Research and Development, 44, 659–664. https://doi.org/10.1682/JRRD.2006.11.0144 Paneroni, M., Colombo, F., Papalia, A., Colitta, A., Borghi, G., Saleri, M., … Vitacca, M. (2014). Is telerehabil- itation a safe and viable option for patients with COPD? A feasibility study. COPD, 12, 217–225. https:// doi.org/10.3109/15412555.2014.933794 Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 Parmanto, B., Pramana, G., Yu, D. X., Fairman, A. D., & Dicianno, B. E. (2015). Development of mHealth system for supporting self-management and remote consultation of skincare. BMC Medical Informatics and Decision Making, 15, 114. https://doi.org/10.1186/s12911-015-0237-4 Peterson, C., & Watzlaf, V. (2015). Telerehabilitation store and forward applications: A review of applica- tions and privacy considerations in physical and occupational therapy practice. International Journal of Telerehabilitation, 6, 75–84. https://doi.org/10.5195/IJT.2014.6161 Pol, M. C., Ter Riet, G., van Hartingsveldt, M., Kröse, B., de Rooij, S. E., & Buurman, B. M. (2017). Effective- ness of sensor monitoring in an occupational therapy rehabilitation program for older individuals after hip fracture, the SO–HIP trial: Study protocol of a three-arm stepped wedge cluster randomized trial. BMC Health Services Research, 17, 1–13. https://doi.org/10.1186/s12913-016-1934-0 Reifenberg, G., Gabrosek, G., Tanner, K., Harpster, K., Proffitt, R., & Persch, A. (2017). Feasibility of pedi- atric game-based neurorehabilitation using telehealth technologies: A case report. American Journal of Occupational Therapy, 71, 7103190040. https://doi.org/10.5014/ajot.2017.024976 Richmond, T., Peterson, C., Cason, J., Billings, M., Terrell, E. A. Lee, … Brennan, D. (2017). Principles for delivering telerehabilitation services. Retrieved from https://www.americantelemed.org/main/ membership/ata-members/ata-sigs/telerehabilitation-sig Romero, S., Lee, M. J., Simic, I., Levy, C., & Sanford, J. (2017). Development and validation of a remote home safety protocol. Disability and Rehabilitation: Assistive Technology, 13, 166–172. https://doi.org/10. 1080/17483107.2017.1300345 Rousmaniere, T., & Renfro-Michel, E. (Eds.). (2016). Using technology to enhance clinical supervision. Alexan- dria, VA: American Counseling Association. https://doi.org/10.1002/9781119268499 Sanford, J., Hoenig, H., Griffiths, P., Butterfield, T., Richardson, P., & Hargraves, K. (2009). A comparison of televideo and traditional in-home rehabilitation in mobility impaired older adults. Physical and Occupa- tional Therapy in Geriatrics, 25, 1–18. https://doi.org/10.1080/J148v25n03_01 Schein, R. M., Schmeler, M. R., Brienza, D., Saptono, A., & Parmanto, B. (2008). Development of a service delivery protocol used for remote wheelchair consultation via telerehabilitation. Telemedicine Journal and e-Health, 14, 932–938. https://doi.org/10.1089/tmj.2008.0010 Schein, R. M., Schmeler, M. R., Holm, M. B., Pramuka, M., Saptono, A., & Brienza, D. M. (2011). Tele­ rehabilitation assessment using the Functioning Everyday with a Wheelchair-Capacity instrument. Jour- nal of Rehabilitation Research and Development, 48, 115–124. https://doi.org/10.1682/JRRD.2010.03.0039 Schein, R. M., Schmeler, M. R., Holm, M. B., Saptono, A., & Brienza, D. M. (2010). Telerehabilitation wheeled mobility and seating assessments compared with in person. Archives of Physical Medicine and Rehabilita- tion, 91, 874–878. https://doi.org/10.1016/j.apmr.2010.01.017 Stillerova, T., Liddle, J., Gustafsson, L., Lamont, R., & Silburn, P. (2016). Could everyday technology im- prove access to assessments? A pilot study on the feasibility of screening cognition in people with Par- kinson’s disease using the Montreal Cognitive Assessment via Internet videoconferencing. Australian Occupational Therapy Journal, 63, 373-380. https://doi.org/10.1111/1440-1630.12288 7212410059p10 November/December 2018, Volume 72(Supplement 2) Sugita, N., Kojima, Y., Yoshizawa, M., Tanaka, A., Abe, M., Homma, N. … Handa N. (2012). Development of a virtual reality system to evaluate skills needed to drive a cycling wheel-chair. Engineering in Medicine and Biology Society, 2012 Annual International Conference of the IEEE, 6019–6022. https://doi.org/10.1109/ EMBC.2012.6347366 U.S. Department of Veterans Affairs. (2018, May 11). VA expands telehealth by allowing health care provid- ers to treat patients across state lines. Retrieved from https://www.va.gov/opa/pressrel/pressrelease. Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 cfm?id=4054 U.S. Department of Veterans Affairs. (n.d.). VA telehealth services. Retrieved from https://www.va.gov/ COMMUNITYCARE/docs/news/VA_Telehealth_Services.pdf Vanbellingen, T., Filius, S. J., Nyffeler, T., & van Wegen, E. E. H. (2017). Usability of videogame-based dex- terity training in the early rehabilitation phase of stroke patients: A pilot study. Frontiers in Neurology, 8, 654. https://doi.org/10.3389/fneur.2017.00654 Watzlaf, V. J. M., Zhou, L., Dealmeida, D. R., & Hartman, L. M. (2017). A systematic review of research studies examining telehealth privacy and security practices used by healthcare providers. International Journal of Telerehabilitation, 9, 39–58. https://doi.org/10.5195/IJT.2017.6231 Whelan, L. R., & Wagner, N. (2011). Technology that touches lives: Teleconsultation to benefit persons with upper limb loss. International Journal of Telerehabilitation, 3, 19–22. https://doi.org/10.5195/IJT.2011.6080 Worboys, T., Brassington, M., Ward, E. C., & Cornwell, P. L. (2017). Delivering occupational therapy hand assessment and treatment sessions via telehealth. Journal of Telemedicine and Telecare, 24(3), 185–192. https://doi.org/10.1177/1357633X17691861 Wright, W. G., McDevitt, J., Tierney, R., Haran, F. J., Appiah-Kubi, K. O., & Dumont, A. (2016). Assessing subacute mild traumatic brain injury with a portable virtual reality balance device. Disability and Rehabil- itation, 39, 1564–1572. https://doi.org/10.1080/09638288.2016.1226432 Yeh, S. C., Lee, S. H., Chan, R. C., Wu, Y., Zheng, L. R., & Flynn, S. (2017). The efficacy of a haptic-enhanced virtual reality system for precision grasp acquisition in stroke rehabilitation. Journal of Healthcare Engi- neering, 2017, 9840273. https://doi.org/10.1155/2017/9840273 Authors Jana Cason, DHS, OTR/L, FAOTA Kim Hartmann, PhD, OTR/L, FAOTA Karen Jacobs, EdD, CPE, OTR/L, FAOTA Tammy Richmond, MS, OTR/L, FAOTA for The Commission on Practice: Julie Dorsey, OTD, OTR/L, CEAS, Chairperson Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly, 2018 Note. This revision replaces the 2012 document Telehealth, previously published and copyrighted in 2013 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 67, S69–S90. https:// doi.org/10.5014/ajot.2013.67S69 Copyright © 2018 by the American Occupational Therapy Association. Citation. American Occupational Therapy Association. (2018). Telehealth in occupational therapy. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410059. https://doi.org/10.5014/ajot.2018.72S219 The American Journal of Occupational Therapy 7212410059p11 Appendix A. Overview of Telehealth Technologies Synchronous Technologies: Videoconferencing Synchronous technologies enable the exchange of health information in real time (i.e., live) by interactive audio and video between the patient or client and a health care provider located at a distant site. Several options for HIPAA-compliant videoconferencing software are available. Software features commonly used with telehealth include screen sharing, onscreen annotation, and text chat. Additional features may include remote control of the client’s camera to allow the occupational therapy practitioner to change the camera Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 angle or to “zoom in” as needed (see Table A.1 for an overview of ICT used in telehealth). Advantages of synchronous ICT include service provision within the context where occupations naturally occur (e.g., home, work, community), minimal infrastructure requirements, and lower costs for equipment and connectivity (e.g., residential service plan, data plan). Disadvantages may include privacy, security, and confidentiality risks; lack of infrastructure (e.g., limited access to high-speed Internet/broadband; inadequate bandwidth for connectivity); recurring expense (e.g., residential service plan, data plan); di- minished sound or image quality; and technological challenges associated with end-user experience and expertise with videoconferencing technology (Cason, 2011; see Table A.1). Asynchronous Technologies Telehealth applications that are asynchronous, commonly referred to as store-and-forward data transmission, may include video clips, digital images, virtual technologies, and other forms of electronic communica- tions. With asynchronous technologies, the provider and client are not connected at the same time. Potential applications within occupational therapy include home assessments and recommendations for home modifications that are based on recorded data of the home environment; recommendations for inclusion of ergonomic principles and workstation modifications that are based on recorded data of the work environ- ment; and secure viewing of video and digital images for evaluation and intervention purposes. Technologies That May Be Synchronous or Asynchronous Telemonitoring Technologies Occupational therapy practitioners providing services through telehealth technologies can take advantage of digital or mhealth (mobile health) devices. These include wearable devices (e.g., Apple Watch, Fitbit) and home devices (e.g., AMC Healthcare Console) that enable occupational therapy practitioners to monitor and subsequently provide services within varied environments. These technologies provide information that allows offsite occupational therapy practitioners to assess performance and modify services and the environment. Telemonitoring technologies also enable occupational therapy practitioners to understand the real-life oc- cupations and performance challenges of the client and to plan appropriate interventions. As a result, practitioners can tailor environmental accommodations for clients with physical limitations or can develop individualized technology-based cueing systems for clients with cognitive disabilities so that they can live more independently. Sensor Technologies Sensor technologies detect and respond to input or stimuli from an individual or the physical environment. Sensor technologies include some digital or mhealth devices (e.g., wearable devices), gaming systems, vir- tual reality (VR), augmented reality, the Internet of things, and sensor driven environmental and personal assistant technologies (e.g., Alexa through Amazon’s Echo and Echo Dot, Google’s Home and Home Mini). Although typical use of sensor technologies does not constitute a telehealth service delivery model, live data (synchronous) streamed to a remote occupational therapy practitioner or recorded data (asynchronous) used 7212410059p12 November/December 2018, Volume 72(Supplement 2) by an occupational therapy practitioner to monitor and adjust a client’s course of treatment would constitute the use of sensor technologies within a telehealth service delivery model. Practitioners can use sensor technol- ogies within a telehealth service delivery model when providing interventions, home exercise programs, or consulting in setting up a “smart home” to increase independence and performance within various contexts. VR typically refers to the use of interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real-world objects and events. Occupational therapy practitioners can use a telehealth service delivery model with VR technologies when conducting evaluations and providing interventions. Telehealth combined with VR has been used in stroke rehabilitation (Corbetta, Imeri, & Gatti, 2015; DeLuca et al., 2017; Laver et al., Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 2017; Vanbellingen, Filius, Nyffeler, & Van Wegen, 2017), assessment for client’s with traumatic brain injury using virtual environments (Lamargue-Hamel et al., 2015; Wright et al., 2016), training of users of power wheelchairs (Nunnerley, Gupta, Snell, & King, 2017; Sugita et al., 2012), and for rehabilitation for clients with Parkinson’s disease (Albiol-Pérez et al., 2018) and hand injuries (Huang, Naghdy, Naghdy, Du, & Todd, 2018; Yeh et al., 2017). Low-cost video capture gaming systems (e.g., Nintendo Switch, Sony PlayStation MOVE and PlayStation Virtual Reality Platform) were not developed specifically for rehabilitation, but they offer an easy-to-set- up, fun, and less-expensive alternative to the expensive VR systems. Although typical use of gaming sys- tems does not constitute telehealth, live data (synchronous) streamed to a remote occupational therapy practitioner or recorded data (asynchronous) used by a practitioner to monitor and adjust a client’s course of treatment would constitute a telehealth application of the devices. Table A.1. Telehealth Technologies Technology Type Examples Considerations Synchronous Videoconferencing software for health care (e.g., Vsee, Confidentiality (security, privacy) Zoom, Doxy.Me) Integrity (information protected from changes Consumer high-definition television videoconferencing by unauthorized users) Telephone/POTS Availability (information, services) Telehealth network with commercial videoconferencing Cost–benefit ratio system Socioeconomic considerations Sensor technologies (with live-streaming data to remote Leveraging existing infrastructure (equipment practitioner) and personnel) Technology connection requirements (e.g., broadband, T1 line) Sound and image quality Equipment accessibility Asynchronous Mobile messaging Data from wearables or remote patient-monitoring devices Digital images, videos, or files Sensor technologies (with store-and-forward data to remote practitioner) Synchronous (interactive) Telemonitoring technologies or asynchronous – Home monitoring systems/devices (store-and-forward data) – Sensor/wearable technologies Sensor technologies – Remote use of gaming and VR systems/devices Source. From “Telerehabilitation: An Adjunct Service Delivery Model for Early Intervention Services,” by J. Cason, 2011, International Journal of Telerehabilitation, 3(1), p. 24. https://doi.org/10.5195/ijt.2011.6071 Copyright © 2011 by Jana Cason. Adapted with permission. Note. POTS = plain old telephone service; VR = virtual reality. The American Journal of Occupational Therapy 7212410059p13 Appendix B. Telehealth Case Examples While not explicitly stated in each case example, occupational therapy practitioners should complete the following steps prior to implementing telehealth: Examine state telehealth laws and regulations that may affect the delivery of services using ICT Explore the state occupational therapy practice act and state occupational therapy board’s website for additional guidance on the use of telehealth to deliver occupational therapy services within the state Inquire from the payer source about telehealth reimbursement and coding requirements Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 Confirm with malpractice insurance carrier that malpractice policy provides same coverage for services provided through ICT. In addition, practitioners engaging in interstate practice should examine state laws and regulations related to telehealth in the state where the client is located. Practitioners should also consult the occupational ther- apy licensure board in their state as well as in the state where the client is located for further clarification on policies related to telehealth before rendering services. Application of Telehealth in the Case Description Occupational Therapy Process Intervention and Outcome Mathew is an OT employed by a home First, Mathew examines the practice act in the state Use of ICT enables the OTAs to carry out health company. He provides services in where he is licensed to determine if there are the plan of care; Mathew will provide multiple counties within a rural portion any regulations or policies that may affect his effective supervision and clinical of the state where he lives. The company ability to use telehealth to supervise OTAs. On support to 2 OTAs serving a large recently employed 2 OTAs to provide investigation, Mathew learns that he is permitted geographical area within the state. In services in the same counties and has to provide a portion of the required supervision adherence with his state’s occupa- asked Mathew to provide the requisite hours using ICT/telehealth. Mathew also works tional therapy practice act, including supervision. Due to the large geograph- with administrators within the home health com- supervision requirements, the use ical area and limited days spent in each pany to identify reimbursement requirements of of telehealth enables Mathew and county, Mathew would like to incorporate the third-party payers. the OTAs to provide client-centered telehealth as a means for supervision. Next, Mathew identifies ICT, including HIPAA- occupational therapy services in a compliant videoconferencing software, to be home health setting. used for remote supervision. A protocol for supervision using ICT and documentation (including process for countersignatures) is established in adherence with supervision requirements set forth in the state’s practice act. Lisa, age 70 years, has difficulty perform- Lisa meets with her OT in a clinic for the initial Lisa makes functional gains in using her ing her daily occupations because of a evaluation. During the evaluation, Lisa learns right hand for everyday occupations. stroke resulting in right-sided weakness. additional strategies for incorporating her right She reports that she is able to rely Although she had learned compensatory hand to perform her farm work. She is fitted for less on compensatory strategies techniques for completing ADLs, IADLs, a functional electrical stimulation orthosis that and use her right hand more easily, and work, she wants to increase the she can use at home once it is programmed in especially while completing ADLs. function of her right hand, particularly the clinic. Twice each week, Lisa meets with Lisa achieved these outcomes with for tasks related to managing her farm. her OT by computer, using a Web camera and only 2 trips to the clinic and without Lisa learned of a program in a nearby online video software. As Lisa continues to make therapist travel. community using new technology that progress, the OT instructs her in how to more might be beneficial for people with hemi- effectively use her right hand for completion of paresis; however, the clinic is 2 hours ADLs and IADLs, including farm chores. from her home. (Continued) 7212410059p14 November/December 2018, Volume 72(Supplement 2)  Application of Telehealth in the Case Description Occupational Therapy Process Intervention and Outcome José, age 35 years, is administrative José scheduled an appointment with an OT who had Explicit workstation modification assistant working at an urban university. expertise in ergonomic workstation evaluation. recommendations were provided He has been employed in this position for During his initial contact with the OT, he requested by the OT by means of a videocon- 5 years. Recently, he began experiencing that because of his busy schedule, he would ference consultation with José. The discomfort in his neck, shoulder, and prefer to have his evaluation conducted through recommendations included raising back areas. He reported this discomfort, telehealth. the notebook computer so that his which he associated with computer work, The OT asked José to have photographs taken of head was not positioned in flexion or Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 to his immediate supervisor. him while working at his office computer work- extension and that the monitor was station. The OT requested that the photographs about arm’s length away (closed fist) be from multiple angles and then emailed to a and using a keyboard and mouse secure platform, where the OT would be able to as input devices. An adjustable review them. In addition, José was asked to keep keyboard tray was recommended a time log for a week into which he would input for the keyboard and mouse. On the information on his activities along with when he basis of data from the time log, the experienced discomfort. OT encouraged José to change his A consultation via videoconference was arranged, work behaviors by taking regular during which the OT reviewed findings from stretch breaks every 20 minutes. the photographs along with the time log. José A second videoconference consultation reported on the time log that he sat at his occurred within 2 weeks. José computer workstation 100% of the time during reported that his supervisor ordered the work day. During this time, he multitasked by the external notebook computer using a hand-held telephone while keying. It was accessories and that this new work- observed from the photographs that José was station arrangement had reduced his using a notebook computer, which placed him in discomfort. an awkward posture for computing. Angela, age 10 years, has a complicated Angela has trouble traveling and sitting for long After interviewing Angela and her mother medical history that includes spina bifida. distances. She and her mother meet with an and observing Angela navigate in She is significantly limited in her ability OT in person at a nearby clinic. Concurrently, her current chair, the remote OT to be mobile in the home and commu- an OT who has expertise in wheeled mobility at recommends the appropriate power nity. Although she uses a basic power another location participates in the occupational wheelchair and seating features. wheelchair to drive around town and therapy session remotely using HIPAA-compliant On approval from the insurance attend her family activities, it is in poor videoconferencing software. The remote OT company, the remote OT uses the condition and too small for her. Angela provides consultation to the local OT, Angela, and HIPAA-compliant videoconferencing cannot adequately reposition herself or her mother about seating system frames, bases, software to monitor the delivery, properly perform a weight shift because and accessories; policy implications and funding evaluate the fitting, and provide of decreased UE strength and ROM. mechanisms; and wheeled mobility and seating feedback and advice to Angela about options. use of the wheelchair within the community and home. Angela benefited from services without the need to travel a long distance. The local OT gained additional knowledge about wheeled mobility and seating options. (Continued) The American Journal of Occupational Therapy 7212410059p15  Application of Telehealth in the Case Description Occupational Therapy Process Intervention and Outcome Ethan, age 55 years, is a self-employed Ethan completed a telehealth participation screen- Ethan is able to manage his physical entrepreneur who has severe depression, ing and initial occupational therapy evaluation and mental health needs and is able anxiety, and isolation after head and neck during his hospital stay. It was determined that to leave his house to purchase gro- cancer resection surgery. The surgery he would continue with occupational therapy ceries and complete other errands in left one side of his face disfigured. He 2X/week via telehealth using secure videocon- his community. His pain is tolerable, plans to have reconstructive surgery in ferencing software and a web camera within his and breathing and stamina have the future. home environment. During the biweekly occupa- improved to allow 20–30 minutes Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 Ethan has difficulties with eating, fatigue, tional therapy sessions delivered via telehealth, of physical activity after 6 weeks facial–body image, depression, and pain. focus is on establishing a therapeutic wellness of occupational therapy delivered He lives alone and over 50 minutes away plan and implementing compensatory eating through telehealth. from the hospital/outpatient therapy techniques, pain management and relaxation Ethan continues his daily journaling. clinic. techniques, stress management, and engage- The OT will follow up with Ethan via Ethan was seen by an OT in the hospital and ment in progressive physical activities. telehealth weekly until reconstruc- prescribed outpatient occupational ther- Ethan completes a home program and a daily jour- tion surgery and again after surgery apy for his physical and mental health nal sent to him by his OT through ICT. to make sure Ethan continues his needs. Due to travel distance to the wellness plan. outpatient therapy clinic and anxiety as- sociated with being seen in public, Ethan is interested in the option to continue his therapy at home through ICT. Alex, age 7 years, is an elementary school To provide seamless delivery of school-based The use of a telehealth service delivery student with a diagnosis of spastic diple- occupational therapy services, which Alex is model enables Alex to continue to gic cerebral palsy. Alex currently receives entitled to under the IEP, the educational team receive direct school-based occu- 45 minutes per week of direct school- proposes that Alex receive occupational therapy pational therapy services via ICT based occupational therapy as a related services via telehealth during the 7–8 weeks while on homebound services. The service on an IEP to support academic he is at home. The school-based OT is familiar OT sees Alex at the same day and performance. with the use of telehealth, and the school district time as he was previously scheduled Alex typically attends classes in a general has previously explored software and hardware while in attendance in the school education classroom in a brick-and- capabilities, as well as privacy, security, ethical, building, preventing any disruption mortar school but currently is receiving and other logistical considerations regarding to schedules. Parent satisfaction is short-term homebound academic the use of telehealth. The occupational therapy high, and Alex’s parent is actively services due to a recent surgery. While intervention, delivered via telehealth, consists of involved in therapeutic sessions and recovering from the surgical procedure, weekly direct services and ongoing collaborative facilitates the use of therapeutic Alex will be out of the classroom for 7–8 consultation among parent, student, and OT. strategies throughout the week. weeks and will receive academic tutoring Each weekly virtual session lasts for 45 minutes. Alex continues to demonstrate function- services during this time. The student’s parent is present throughout the al improvements in performance in live therapy sessions. The OT ensures that each the areas of tool usage (e.g., scis- telehealth session involves at least a 5-minute sors, glue stick, pencil), handwriting, period of collaborative consultation, including a literacy, and school-related self-care discussion of student progress and instructions (e.g., donning/doffing coat) while for the implementation of a home program on home services. He re-enters the between sessions. brick-and-mortar school after 8 weeks with no regression in skills. (Continued) 7212410059p16 November/December 2018, Volume 72(Supplement 2)  Application of Telehealth in the Case Description Occupational Therapy Process Intervention and Outcome Jane, age 22 years, is an undergraduate Jane worked with her OT using videoconferencing Occupational therapy services through student with a history of depression and technology to identify and implement strategies telehealth enabled Jane to identify anxiety. She has been unable to attend to improve her occupational performance and and implement effective therapeutic classes because her medications are participation in ADLs and IADLs. The OT requested strategies. As a result, she was able making her drowsy, and she has become that Jane complete a 1-week activity time log. to complete the semester’s courses socially isolated from classmates. She is Jane and the OT reviewed the log virtually where with passing grades. unable to get to classes on time or com- areas of challenges with attending classes, Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 plete assignments in a timely manner. completing assignments and going to medical As a result of Jane’s difficulty keeping appointments were identified. They discussed medical appointments due to fatigue and strategies for reaching out the school’s Disability anxiety, telehealth was selected as the Services to apply for reasonable accommoda- preferred delivery method for occupa- tions such as a self-paced academic workload tional therapy services. and flexible due dates for assignments. The OT suggested energy conservation strategies such as simplifying activities and setting realistic goals; spacing out activities throughout the day; and stress management strategies to address Jane’s anxiety. For time management, the OT recommended CST and specific apps that Jane agreed to use. Jane and the OT agreed to meet weekly using a virtual platform. Rick, age 56 years, is a real estate agent Rick was evaluated initially at the clinic to establish Rick completed all scheduled online who enjoys biking on the weekends in a short- and long-term goals. During the initial occupational therapy sessions and bike club. He recently fell off his bike and visit, Rick completed a telehealth screening his home exercise and stretching fractured his collarbone on his right side. tool that demonstrated that he had adequate program. He continued to work Treatment consisted of immobilization for hardware and bandwidth at his home and work, full-time while receiving therapy and 2 weeks with an UE sling. technology skills, and appropriate impairment returned to biking after 8 weeks of Rick received a referral for occupational to receive occupational therapy services via therapy. therapy services. His physician has telehealth. The OT had Rick sign a telehealth All materials related to patient educa- cleared Rick to remove the sling and informed consent and establish an account to tion, home program, and home and return to full-time work with modifications access the company’s HIPAA-compliant video- work modification recommendations and begin UE AAROM/ROM and progres- conferencing software. were archived in Rick’s account sive strengthening over the next 4 weeks. Rick logs into the company’s web portal 2 times on the company’s web portal. Rick Rick prefers to receive occupational ther- per week for 4 weeks for occupational therapy downloaded and printed materi- apy services via telehealth because of his services. The OT provides progressive ROM, als provided by his OT after each work schedule and difficulty traveling for stretching, and therapeutic exercises; functional session. appointments. activities to improve use of his right UE, including the shoulder, neck, and upper back; and home and work modification recommendations to reduce unnecessary stress on the fracture site. Note. AAROM = active assisted range of motion; ADLs = activities of daily living; CST = cognitive support technology; HIPAA = Health Insurance Portability and Accountability Act; IADLs = instrumental activities of daily living; ICT = information and communication technology; IEP = individu- alized education program; OT = occupational therapist; OTA = occupational therapy assistant; ROM = range of motion; UE = upper extremity The American Journal of Occupational Therapy 7212410059p17 Appendix C. Ethical Considerations and Strategies for Practice Using Telehealth Ethical Considerations Strategies for Ethical Practice Fully inform the client regarding Occupational therapy personnel shall... the implications of a telehealth “Fully disclose the benefits, risks, and potential outcomes of any intervention; the personnel who will be service delivery model vs. an providing the intervention and any reasonable alternative to the proposed intervention” (Principle 3B) in-person service delivery “Establish a collaborative relationship with recipients of service and relevant stakeholders to promote model. shared decision making” (Principle 3D) “Obtain consent after disclosing appropriate information and answering any questions posed by the recipi- Downloaded from http://research.aota.org/ajot/article-pdf/72/Supplement_2/7212410059p1/47518/7212410059p1.pdf by Lenoir-Rhyne University, Lesly James on 19 September 2024 ent of service or research participant to ensure voluntariness” (Principle 3C) Abide by laws and scope of prac- Occupational therapy personnel shall... tice related to licensure and “Maintain awareness of current laws and AOTA policies and Official Documents that apply to the profes- provision of occupational therapy sion of occupational therapy” (Principle 4E) services using telehealth. Adhere to professional standards. Occupational therapy personnel shall... “Provide occupational therapy services, including education and training, that are within each practi- tioner’s level of competence and scope of practice” (Principle 1E) “Take steps (e.g., continuing education, research, supervision, training) to ensure proficiency, use careful judgment, and weigh potential for harm when generally recognized standards do not exist in emerging technology or areas of practice” (Principle 1F) “Maintain competency by ongoing participation in education relevant to one’s practice area” (Principle 1G) “Maintain awareness of current laws and AOTA policies and Official Documents that apply to the profes- sion of occupational therapy” (Principle 4E) Understand and abide by Occupational therapy personnel shall... approaches that ensure that “Maintain the confidentiality of all verbal, written, electronic, augmentative, and non-verbal communica- privacy, security, and confidenti- tions, in compliance with applicable laws, including all aspects of privacy laws and exceptions thereto ality are not compromised as a (e.g. Health Insurance Portability and Accountability Act [Pub. L. 104-191], Family Educational Rights and result of using telehealth. Privacy Act [Pub. L. 93-380])” (Principle 3H) Understand and adhere to Occupational therapy personnel shall... procedures if there is any “Maintain the confidentiality of all verbal, written, electronic, augmentative, and nonverbal communica- compromise of security related tions, in compliance with applicable laws, including all aspects of privacy laws and exceptions thereto to health information. (e.g., Health Insurance Portability and Accountability Act [Pub. L. 104–191], Family Educational Rights and Privacy Act [Pub. L. 93–380]).” (Principle 3H) “Maintain awareness of current laws and AOTA policies and Official Documents that apply to the profes- sion of occupational therapy.” (Principle 4E) Assess the effectiveness of Occupational therapy personnel shall... interventions provided through “Refer to other providers when indicated by the needs of the client” (Principle 1I) telehealth by consulting current “Reevaluate and reassess recipients of service in a timely manner to determine if goals are being research and conducting achieved and whether intervention plans should be revised.” (Principle 1B) ongoing monitoring of client “Use, to the extent possible, evaluation, planning, intervention techniques, assessments, and therapeutic response. equipment that are evidence-based, current, and within the recognized scope of occupational therapy practice” (Principle 1C) Recognize the need to be culturally Occupational therapy personnel shall... competent in the provision of “Facilitate comprehension and address barriers to communication (e.g. aphasia; differences in language, services via telehealth, includ- literacy, culture) with the recipient of service (or responsible party), student, or research participant” ing language, ethnicity, and (Principle 3J) socioeconomic and educational “Assist those in need of occupational therapy services in securing access through available means” background that could affect (Principle 4B) the quality and outcomes of “Address barriers in access to occupational therapy services by offering or referring clients to financial aid, services provided. charity care, or pro bono services within the parameters of organizational policies” (Principle 4C) Note. AOTA = American Occupational Therapy Association. Ethical principles are from AOTA’s (2015a) Occupational Therapy Code of Ethics (2015). 7212410059p18 November/December 2018, Volume 72(Supplement 2)