Remote Physical Therapy Solutions — Mobility Is Essential For Delivering Value

By Robert Haywood, Senior Marketing Manager, Breg

New entrants in remote physical therapy use game consoles to deliver in-home rehabilitation. While there are benefits from game-based therapy, these tethered solutions fall short.

Game console therapy solutions were originally designed for use in skilled nursing and facility settings. Recently, their use has expanded to include pre-and post-operative therapy at home. Game console therapy involves performing exercises in front of a TV using an Xbox or camera enabled laptop/tablet tracking the patient’s movement using Microsoft Kinect camera technology. Results are delivered back to the therapist via a web portal with video communication enabled to discuss the patient’s therapy.

The goal is to keep patients compliant in the home setting in order to hit triple aim objectives: lower the cost of care, improve outcomes and create a superior patient experience. Patients also have the option to begin during “pre-hab” and extend into their post-acute therapy setting.

There is little argument as to the intended value of game console based therapy: get patients moving at home, keep them on the path to an optimal outcome in the intended timeframe, and reduce the cost of the post-acute therapy portion of the orthopedic episode. However, there are several red flags that point to a sub-optimal experience with game console based therapy.

• The patient is “tethered” to a television/device in the home setting. With a growing number of total joint patients using smartphones and tablets, offering a mobile platform is essential. Many patients want the ability to do their exercises when and where they have the time. Likewise, clinicians need the ability to monitor/communicate from whenever and wherever as well. Time is of the essence; in our increasingly mobile society data must be available when needed.
   
• The solution can be complicated to learn/use for patients. Introducing a new technology (game console) vs. using a known platform (smartphone, tablet, etc.) is inefficient. By using a familiar platform the patient knows and is comfortable with, there will be less apprehension and likelihood they will abandon the technology. Recent studies show 70 percent of the baby boomer population owns two smart devices or more and more than 50 percent owns a smartphone. While smartphone and tablet ownership has grown 10 times since 2010, only 15 percent of baby boomers own a gaming console and gaming console ownership is flat since 2010. Therefore, providers will need to figure out how to rent consoles, or otherwise solve for the fact a large percentage of their patient base will not have these units.
   
• Camera technology limitations. Offering a simple, yet accurate, method to gather range-of-motion is critical to the first 8 to 12 weeks of a total joint patient’s rehab. Camera technology has proven challenging when used to provide accurate measurements for flexion and extension. Without trust in accuracy the clinician may not prescribe or fully use the solution, neutralizing the efficiency gains.
   
• EMR connectivity limitations. With the growing interoperability between clinical data systems, sharing data with a clinic’s EMR will be mandatory and critical. Currently, game console-based solutions are limited when it comes to EMR connectivity. Without the ability to seamlessly connect with the patient’s care record, health systems will dismiss console-based systems. Connectivity is no longer a “nice to have,” it is now “a must” to play in the space. Data and results, including patient-reported-outcomes (PROs) and progress notes, are essential to keeping a care team aligned on a patient’s progress. With the growing size of organizations and care teams, creating a silo effect will ultimately cause extra time and effort spent tracking down patient information. As patient and procedure volume grows, stand-alone systems will be completely phased out due to inefficiencies.

While there is benefit in game based remote therapy, the solution falls short by creating value gaps because of the limitations of tethered, console-based systems. These gaps are a significant barrier in “crossing the chasm” to delivering true value to the market with remote therapy monitoring. Untethered mobility, familiarity, flexibility, simplicity, and interoperability will be the absolute drivers of adoption and adherence. To drive critical mass in the remote therapy space, both patients and clinicians need to have trust in the solution(s).

The challenge to the industry is to drive for a better solution. To improve patient compliance and help achieve the triple aim, remote therapy monitoring must use a patient-friendly, ubiquitous platform, have true portability with anytime, anywhere connectivity, and interoperability with the provider’s EHR/EMR for a seamless integration of data. Providers, patients, and organizations cannot settle for anything less.

The Importance Of Remote Therapy Monitoring In Value-Based Care

The rise of value-based care started with elective options through Accountable Care Organizations (ACO), Bundled Payments for Care Improvement (BPCI), and select commercial bundled payment plans. The first mandated program came from Medicare with comprehensive joint replacement (CJR) rolled out in 2016. The program targets 67 metro areas and is a 5-year initiative focused on total joint procedures (TKA/THA DRG groups).

In addition, the program covers in-patient episodes through 90 days post-acute. It is a retrospective look at cost per episode moving to a true bundled payment program. Each facility has a target price which is a blend of regional and historical episode spending with a discount factor (up to 3 percent) and a two-sided reconciliation, downside if costs are higher than target price, and bonus eligible if costs are lower.

Some experts anticipate 50 percent of total joint procedures for the main commercial payers will be covered under a value based plan. This is in addition to the Medicare CJR mandate already in place. Early returns show the technology enables organizations to hit the triple aim objectives.

Along with that focus comes a gap in objective data in the post-acute setting leading to cost volatility directly correlated with therapy type (skilled nursing, inpatient therapy, home therapy, and outpatient therapy). This creates challenges in the post-acute setting where clinicians try to determine the baseline for an optimal outcome. In addition, they cannot see clearly when a challenge arises, creating a delay (or avoidance) of action. With patient outcomes and satisfaction becoming paramount, remote therapy monitoring possibly offers a pathway to effectively achieve the triple aim objectives.

Current data shows post-acute therapy costs consist of up to 40 percent of the episode costs.

This is a direct correlation to post-acute discharge therapy setting and higher costs. Patients going to inpatient rehabilitation facility (INF) and/or skilled nursing facility (SNF), mixed with assisted home therapy create an immediate cost overrun for the organization and subject them to penalties from payers.

Fear of readmission has driven many facilities to over-utilize the higher cost therapy options. Without an effective way to drive care paths based on objective data, the SNF pathway seemed the best way to diffuse the risk. Takeaway: to effectively manage total joint arthroscopy patients moving forward, organizations will need objective, real-time data to track and manage patients throughout the episode, including (and perhaps most importantly) data gleaned from at-home patient monitoring.