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For patients with spinal cord injuries, traumatic brain injuries or other neurological problems, being discharged from a rehabilitation hospital is just a step in their recovery. Many require follow-up sessions with a variety of therapists. Before 2020, Shirley Ryan AbilityLab patients routinely traveled to the hospital’s downtown campus or satellite sites in the suburbs for such visits.
But with the COVID-19 pandemic, that care model went out the window. Shirley Ryan AbilityLab outpatients, many of whom had underlying health conditions that made them more vulnerable to the virus, began canceling their appointments and staying home. The hospital’s therapists quickly became concerned about what the disruption would mean for their clients and they started brainstorming. If other people could use conferencing software like Zoom or Microsoft Teams to conduct virtual meetings, why couldn’t clinicians see their patients the same way?
At the leadership level, Shirley Ryan AbilityLab’s top executives were thinking the same thing and reaching out to public policymakers and insurers to see how they could make it happen. On March 19, 2020, Illinois Gov. J.B. Pritzker declared a public health emergency, announcing that insurance providers in Illinois would be required to cover telemedicine services for rehabilitation services. The next day, Shirley Ryan AbilityLab shut down its outpatient clinics for public safety reasons and shifted its outpatients to remote care. “When I look back at that time, I’m very humble and proud,” says Nancy Paridy, President and Chief Administrative Officer of Shirley Ryan AbilityLab. “Always guided by our mission, we embraced innovation and creativity for the benefit of our patients.”
Many medical experts agree: the rapid expansion of remote healthcare services known as telehealth was an unexpected upside of the COVID-19 pandemic. Instead of traveling to a clinic, patients were able to see their clinicians over computer screens or by phone and get what they needed, whether it was a prescription or a speech therapy session. “It was a remarkable time for the telehealth community,” says Kyle Zebley, Senior Vice President of Public Policy at the American Telemedicine Association (ATA) in Washington D.C. "Within a year, we had an astounding level of growth that significantly accelerated anticipated telehealth utilization, which otherwise would have taken at least a decade."
At the peak of the pandemic, telehealth visits made up 13% of total outpatient encounters around the country, up from near zero before the COVID health emergency began in 2020, according to the ATA. Use of telehealth services by patients with Medicare, the government’s insurance plan for senior citizens, showed a massive 63-fold increase.
By late March 2020, Shirley Ryan AbilityLab had pivoted to a completely new telehealth model that affected the roughly 800 patients who were using the DayRehab Centers at the hospital’s downtown location and suburban sites. Those clients required intensive wrap-around therapy, which could include physical therapy, speech therapy and psychological support, but they no longer needed to be hospitalized. Virtual care was also rolled out to the hospital’s six outpatient clinics, which provide services to more than 13,000 patients a year in orthopedics, adult neurology and pediatrics. Telehealth was also used by the hospital’s Pain Management Center, which helps people deal with chronic pain, and its Vocational Rehabilitation department, which helps people with disabilities find employment or return to work.
To get things up and running, therapists reached out to their clients to assess their technology options and find out if they had good internet connections. The majority of them did. Then the clinicians scheduled video calls just as they would a regular appointment. Clients were emailed a meeting link and a calendar invitation. “Many of the kinks were worked out quickly,” says Kimberly Brennan, Director of Day Rehabilitation at the Shirley Ryan AbilityLab. “The staff worked collaboratively to get it off the ground fast. It turned out to be a great experience for our patients, the staff and our operations leaders. The patients were grateful they still had a connection to us.” Adds Steven Jackson, PhD, Administrative Director of Outpatient Therapy Services at Shirley Ryan AbilityLab: “We had to figure out new workflows. We didn’t limit it to any particular discipline because we wanted continuity of care.”
Shirley Ryan AbilityLab staff soon discovered there were pluses and minuses to telehealth for different disciplines. For example, therapists found that speech therapy via video conference was very effective for certain conditions and resulted in similar outcomes as if the patient had been in the same room. Many psychologists also found the transition to virtual care relatively smooth.
But providing physical and occupational therapy remotely was more challenging, Brennan and Jackson say. Watching someone walk or do exercises over a computer screen wasn’t quite as good as being there in person. And there were safety issues for people who were struggling with their balance. “In some cases, the patient needed a caregiver to help them,” Brennan says. “Luckily, we had access to a lot of families and caregivers because many people were working from home during the pandemic. That made our jobs easier.”
Therapists became very adept at instructing their clients on where to place their computers so they could focus on the specific areas they needed to see. Despite the drawbacks of remote physical therapy, there also were unexpected benefits to virtual care. Therapists were able to see the home environments of their patients rather than just hearing about them. And there was a psychological shift as well, according to Jackson.
“Some patients come in with the idea that the therapist is going to do something for them to make them better,” he explains. “We want to empower the patient and let them know it’s not a passive treatment that will make them better but their active participation under the guidance of a therapist. The fact that they couldn’t come into the clinic forced that point home. That was a silver lining.” Having a virtual option available also allowed therapists to continue to care for patients as they moved to new locations or began traveling again, he adds.
The DayRehab Centers and outpatient clinics were fully closed for only about six weeks, but the COVID-19 pandemic continued to rage as new variants emerged and swept the country. Many patients opted to continue remote care but many more started coming back for in-person treatment. “Once we opened the doors again in June 2020, we saw a gradual decline in telehealth and a gradual increase in in-person care,” says Jackson. “After a while, telehealth stabilized at around 2% of visits. That’s been totally driven by patients.” Despite the low level of current usage, telehealth remains an option for Shirley Ryan AbilityLab patients who prefer it. Therapists also expect to see a rise during the winter months when weather often creates transportation problems, Jackson says.
Both the national Public Health Emergency and the Illinois version expired in May 2023. As part of an omnibus government funding bill signed by President Joe Biden on Dec. 29, 2022, Medicare will continue to cover telehealth services around the country until the end of 2024. The situation for Medicaid recipients and those covered by private insurance is more complicated, but “Every state program is covering some degree of telehealth,” says ATA’s Zebley. “And every commercial payor is covering it to some degree.”
ATA Action, the ATA’s advocacy group, is hopeful that the funding will eventually become permanent across all types of payors. “If you think how telehealth can play in our system, the need is endless. We have too few medical professionals and an aging patient population,” Zebley says. “We believe that healthcare delivery must include both in-person and virtual care, to best serve the needs of our patients and healthcare providers. Telehealth has come a long way in the past three years, but we still have much work to do to make virtual care a permanent care option.”
Shirley Ryan AbilityLab’s Paridy says the entire experience was an unprecedented test of the hospital’s resiliency and creativity but one that improved it. “We emerged stronger and smarter,” she says. “Our team members never took their focus off patients in their quest to advance ability. As a result, we’re an even better organization.”