Value-Based Care. Neurorehabilitation Technology Could Help.

If you are an OT or PT you most likely have heard about the recent surge over the last few years in neurorehabilitation technology. You may be asking yourself: why now? One reason may be that over the last few years a number of studies have suggested that increased time and intensity in motor learning programs improved therapy outcomes [1] [3]. Animal models suggest that hundreds of daily repetitions are necessary for maximal gains [1] [4]. However, implementing this level of intensity can be a real problem for therapists in the hospital setting. In a time where traditional motor learning ideas are challenged and a shift towards value-based care is taking place, rehabilitation technology is here to help. 

Common Problems in the Rehabilitation Realm

Typically following stroke, a patient will first be taken into an acute care hospital to stabilize for a short period of time before being transferred another location for continued rehabilitation. It is also common for patients to transfer between multiple sites and therapy teams. Changes in staff and healthcare organizations as well as rigid requirements for Medicare and payers restricting therapy time often make it difficult to carryover intensive, high-repetition upper-limb treatment protocols that may be seen in research studies.

For many clinicians, a full 60 minutes of daily task-specific motor repetition may be difficult to obtain due to factors such as physical strain on the therapist, the need for a second person for patient transfers, and transportation time. A metanalysis by Serrada et al., in 2016 analyzed pooled results from 94 studies in the acute care setting that examined adult patients within four-weeks post-stroke. The study found that 21.4% of a 36.7 min session was concentrated in upper limb rehabilitation practice [2]. Similarly, a study by Catherine Lang in 2009 found that the average number of motor repetitions in an OT session concentrating on upper limb rehabilitation was 32 [1]. It has become clear that stroke recovery research may in some cases directly compete with healthcare business practices [5], structure of therapy, resources, and even billing structure in some settings.  

Transitioning to the Value-Based Care Model

Occupational therapists have achieved a huge landmark in the past year with the passing of the Bipartisan Budget Act of 2018. This act repealed the Medicare Part B outpatient therapy cap and made other major changes to Medicare reimbursement policy. The therapy cap, which was enacted in 1997, put a hard limit on the amount of occupational therapy beneficiaries with Medicare Part B coverage could have [6] [7]. Its repeal had been a major goal and lobbying effort set by AOTA for years and marks the beginning of a series of significant changes in billing policy. Hopefully this major reform will spark other future changes in the structure of therapy services to provide more time for direct, intensive treatment in the inpatient setting and the best possible patient-centered care.

Medicare and other health systems are moving to value vs. volume-based patient care. What this means is that payments will be associated with patient progress and performance, providing a greater push for outcome measures and data [8].

The Value of Technology is Efficiency.

Can various rehabilitation technologies help solve these common problems in rehabilitation and keep up with the value-based care model?  It is the shared goal of many rehabilitation technology companies to provide a dynamic platform for clinicians. The goal(s) of these high-tech rehabilitation platforms may include increasing therapy intensity, reducing burden on the treating therapist, improving outcome tracking, or providing an innovative platform for patient engagement. Rehabilitation technology platforms could provide a way to navigate some of the traditional hurtles in inpatient and outpatient rehabilitation.

Technology has already dramatically changed the healthcare setting over the past ten years. Changes include the introduction to the electronic medical chart, EHR (Electronic Health Records), telemedicine, and the use of mobile health applications [9]. These changes have greatly affected overall efficiency, and the way we provide and access healthcare.

What can rehabilitation robots bring to the table?

Rehabilitation robots offer a unique platform for patient engagement. Often combining high-tech features such as interactive gaming, haptic (or tactile) vibration feedback, robotic guidance and gravity elimination. They can also offer unique real-time visual and kinematic feedback of a patient’s active movement within the gaming platforms and data measures [9]. These technologies offer cutting-edge innovations to the physical rehabilitation environment. Robotic therapy platforms can provide an additional hand to maximize motor learning practice and repetition complimenting an existing inpatient program. They may be beneficial in tracking patient progress through the use of upper extremity assessment and patient data tracking measures to support the value-based care model. In fact, one thing robotic devices certainly excel at is precision, consistency and efficiency; all useful factors in occupational and physical therapy treatments. Upper extremity robots may be helpful assets to clinicians who wish to find another creative platform to maximize intensity and monitor patient progress in their neurorehabilitation program.

Article by Holly Mitchell, MOT, OTR/L

References

Lang, C. E., Macdonald, J. R., Reisman, D. S., Boyd, L., Jacobson Kimberley, T., Schindler-Ivens, S. M., … Scheets, P. L. (2009). Observation of amounts of movement practice provided during stroke rehabilitation. Archives of physical medicine and rehabilitation, 90(10), 1692–1698. doi:10.1016/j.apmr.2009.04.005

Serrada, I., Mcdonnell, M. N., & Hillier, S. L. (2016). What is current practice for upper limb rehabilitation in the acute hospital setting following stroke? A systematic review. NeuroRehabilitation,39(3), 431-438. doi:10.3233/nre-161374

Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting Neurorehabilitation Right - What Can We Learn From Animal Models? Neurorehabilitation and Neural Repair,26(8), 923-931. doi:10.1177/1545968312440745

Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996;272:1791–1794

Cramer, S. C., Wolf, S. L., Adams, H. P., Jr, Chen, D., Dromerick, A. W., Dunning, K., … Broderick, J. P. (2017). Stroke Recovery and Rehabilitation Research: Issues, Opportunities, and the National Institutes of Health StrokeNet. Stroke, 48(3), 813–819. doi:10.1161/STROKEAHA.116.015501

Victory in Sight: Permanent Repeal of Therapy Cap in House Budget Bill Being Voted on Today. (n.d.). Retrieved from https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-Issues-Update/2018/Victory-in-Sight-Permanent-Repeal-Therapy-Cap-House-Budget-Bill-Vote.aspx

Therapy Cap Repealed After 20 Years: A Message From the AOTA President. (n.d). Retrieved from https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-Issues-Update/2018/therapy-cap-repealed-signed-into-law-aota-president-message.aspx

Payment for Value-Based OT: Implications for Quality and Practice (n.d). Retrieved from https://www.aota.org/Practice/Manage/value.aspx

The Impact of Technology on Healthcare (April, 2018). Retrieved from https://www.aimseducation.edu/blog/the-impact-of-technology-on-healthcare/

Kai Zhang, Xiaofeng Chen, Fei Liu, Haili Tang, Jing Wang, and Weina Wen (2018). System Framework of Robotics in Upper Limb Rehabilitation on Poststroke Motor Recovery. Behavioural Neurology, vol. 2018, Article ID 6737056, 14 pages, 2018. https://doi.org/10.1155/2018/6737056.