Clinical Triaging Considerations for Telehealth

Original Editor - Ashmita Patrao Top Contributors - Ashmita Patrao, Jess Bell, Kim Jackson, Lucinda hampton and Olajumoke Ogunleye

Introduction

Telehealth enables individuals to access rehabilitation services in their home environment. However, because health professionals are unable to assess these patients in person, they must first determine if telehealth is a viable option. This page discusses clinical triaging principles that must be considered in order to determine if a patient is a suitable candidate for telehealth.

The American Telemedicine Association states that physical therapists can see patients via telehealth on a case by case basis. Decisions must be based on clinical judgement, the client's informed choice and professional standards of care.

Clinical Triaging Considerations

There are various factors that must be considered in order to appropriately triage telehealth patients.

Patient’s Clinical Condition or Presentation

You will need to consider if the patient has a formal diagnosis (eg spinal stenosis or COPD), as well as symptom severity (eg pain levels, presence of neurological symptoms, severe shortness of breath). Will these symptoms affect your ability to effectively treat a patient via telehealth? It is also important to consider the chronicity of the condition. More severe and acute cases may need to be triaged sooner.

Presence of Red Flags/Serious Pathology

When assessing any patient, in person or via telehealth, it is essential to consider if there are any potential or actual red flags. Red flags can indicate serious pathology and need to be directly referred to the appropriate medical professional. Red flags are consider in more detail here, but common red flags include:

• Escalation of pain and progressive worsening of symptoms that do not respond to medications or the usual conservative management.
• Fever and weight loss
• Being systemically unwell
• Night pain that disturbs and prevents sleep
• Changes in bladder/bowel habits

Specific Red Flag Conditions:

• Primary and secondary cancers: The common presentations are night pain, escalating pain, systemic illness.
• Insufficiency fracture: Sudden onset pain, most commonly in the thoracolumbar region. This results from low impact trauma.
• Spine related neurological symptoms: relatively new onset weakness that progressively worsens with less than grade 4 in one or more myotome.
• Cervical Myelopathy: The rare occurrence of myelopathy from cervical spondylosis in which the patient presents with pain and diminished coordination ability, balance impairments, and possibly loss f bowel and bladder control.
• Inflammatory arthritis OR rheumatological conditions:
  • Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.
  • Autoimmune disorders of recent onset like Lupus or scleroderma or vasculitis with non-articular manifestations of rashes, Raynauds disease with bluish/ red discoloration of hand or feet, inflammatory arthritis which presents with mouth ulcers or sicca related symptoms (drying of mouth and eyes)
  • Any type of myalgia causes due to viral infection or fibromyalgia but showing worse symptoms proximally, ie shoulder or pelvis, associated with 30 mins of stiffness, and an acute raise response (CRP/ESR). This could be polymyalgia rheumatic or Myalgia that require urgent referral to a Rheumatologist.

• Headache of relatively new onset mainly in the temples which may radiate to the jaw. Also, there will be proximal areas, pelvic and shoulder pain, symptoms of the eye and there will be an acute response with raised ESR and CRP, usually in patients above 50 years. This patient may be a suspect for giant cell arteritis.

Urgency to Access Care

As with face-to-fact consultations, it is essential with telehealth to consider the urgency for the patient to access care. For instance, a patient six weeks post-ACL repair will require more rapid review than a patient who has long standing non specific low back pain with no neurological symptoms. However, each patient needs to be considered on a case by case basis.

Individual Patient Factors

Various patient factors should also be considered when deciding if telehealth is an appropriate method of healthcare delivery.

Age

Age can have a number of impacts on treatment regardless of the mode of healthcare delivery. Young patients tend to recover faster than older patients in most cases. This is likely due to fast healing rates and the presence of comorbidities among older patients. However, with telehealth it is important to consider unique factors related to age. Patients have varying levels of familiarity with the technology required to engage in telehealth and this can often be influenced by age. Similarly, it is important to consider cognitive status when exploring telehealth as an option. Is the patient able to follow instructions and fully consent to the assessment and treatment?

Presence of Comorbidities

While telehealth has been shown to be effective in managing certain long term conditions (eg cardiovascular disease and stroke care), particularly when delivered as part of an overarching MDT programme, face to face triaging may be more effective when managing these patients. However, in the context of COVID-19, many regions/countries are encouraging these vulnerable groups to be triaged via telehealth in order to reduce their risk of contracting this virus.

Mental Health

Psychological factors affect the functioning of an individual and may have an impact on whether or not they can be safely triaged by telehealth.

Mobility of the Patient and Other Impairments

Subjects who are frail and immobile are considered a high priority when triaging patients as they are at a higher risk of developing complications. However, it is essential to consider their safety when determining if telehealth is an apporpiate option. Consider if you need to be present or perhaps if a carer/support person can assist when balance or mobility impairments are present. Similarly, visual or hearing impairments can have a significant impact on a patient's ability to engage in telehealth consultations.

Other Considerations

You may determine that a patient is a suitable candidate for telehealth, but you must also consider at which point in their care you use it. Can you complete the initial assessment via telehealth or will you just use it for reviews? Perhaps a hybrid model is best. This decision will be based on the client's condition and individual patient factors.

Language Barriers

When language is a barrier, assessment meets a roadblock. Thus telerehabilitation must involve the use of translation softwares

Patient’s Physical Location

• ·        In case the patient residing close to a community facility, or the General Practitioners clinic then it would only make sense to schedule appointments with these facilities to unload the system.
• ·        If there is someone else with the patient, these individuals could assist in the special tests and aid 
• ·        If the geographical location of the residence of a client has architectural barriers that don’t suit his travel needs then telerehabilitation becomes the obvious choice for him.
• ·        Influence of internet connection barriers when present puts these clients on a list of cases to be seen in person.  

Who Is Present During the Consult

Specific staff need to be established for this purpose or role

The recently retired staff who are at a higher risk of contacting Covid 19

Staff who are self-isolating but can support telerehabilitation clinics

Technology support teams and administrative teams to ensure the maintenance of appointments, notifications, and provide technical assistance.

Advantage: assistance with tests, or supervision. 

Disadvantage: privacy and confidentiality.  

Privacy of the Patient If You Need to Visualize Areas of the Patient’s Body

• The environment should have only the therapist and the client use a private space
• The communication channel needs to be a safe medium to prevent hacking. Thus an end to end encrypted platform is more apt.
• Data information needs to retain in the documentation form and not telephonic or video graphic data
• Also consider individual factors (Some cultures are conservative and are not comfortable exposing certain body parts, especially when being recorded)
• Clinical consultation of pelvic area pain conditions may be awkward for the client.
• The workforce team (each member must maintain the privacy and security of the client)
• The site that is being used as a platform needs to be continually checked for its policies on communication and information technology  

Therapist Skill to Translate It to Telehealth 

An assessment of telerehabilitation shoulder relies mostly on subjective assessment, posture examination, movement examination. When overpressure is necessary it can be given by the patients in case possible. Special tests performed actively can be carried out. Muscle length examination should be included in If required a visit from the local healthcare provider (Village healthcare provider may help to aid the assessment process.

Scope of Practice and Registration Within Your State or Country

The telehealth governing rules vary from place to place

• AS stated by the APTA Physical therapists are not yet recognized under the scope of telehealth of medicare, thus an e-visit paid to a therapist cannot be reimbursed under Medicare and most insurance companies. However, Tricare offers coverage in case all the criteria are met  Medicare however is providing coverage for a 7-day consultation which involves clinical decision making.

• The Health Professions Council of South Africa has permitted the practice of telerehabilitation given the COVID 19 situation and applicable to this situation doesn’t resolve. However, this facility is restricted to already established patient-therapistt relationships. New patient consultations are discouraged. Also, Therapists must professionally conduct themselves over these consultations.

• The Australian Physiotherapy Association has permitted the practice of telerehabilitation and the Australian Heath Funds will provide benefits to individuals availing telerehabilitation consultation.

Clinical Triaging process in a nutshell

Review the charts of all the patients on waiting lists

Identify the high-risk patients and provide a direct referral, if not able to meet the demand to identify those patients whose treatment can be delayed, without the risk of any further progression or complication

However, this increases the patients on waiting lists and isn’t advised given the Covid-19 situation

Offer remote consultation services

Arrange a face to face consultations in case remote consultations aren’t possible

Thus as therapists, it is our responsibility to provide the necessary essential musculoskeletal care before there is worsening of symptoms. So let us act early and aid the healthcare system and patients in every way possible.

References

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