Considerations for Virtual Care

BACKGROUND 

Emily is an occupational therapist practising in the community and has received a referral for falls prevention with an older adult.  She reviews the referral information and learns the client, Hilda, is 75 years old, has recently been diagnosed with COPD, arthritis, and lives alone in an apartment. Due to COVID-19 restrictions, Hilda has drastically reduced her mobility within the community.  Over the past eight months Hilda has experienced several falls, swelling in her legs and knee pain which also impacts her ability to complete daily tasks. Hilda has a daughter that provides ongoing support to her mother. Hilda is agreeable to having her daughter be present during the in-person or virtual appointments.

Due to concerns about COVID-19 transmission, it has been recommended that Emily provide occupational therapy services virtually. Emily is considering her options about the best way to deliver her services to Hilda.


CONSIDERATIONS

As models of care are evolving, Emily references the Information Privacy Commissioner’s Fact Sheet on Privacy and Working from Home and the Virtual Services document. 

Some of Emily’s questions and considerations include clinical, technical, and organizational factors such as;

  • Can Hilda manage a virtual appointment (what are the physical, cognitive, emotional, behavioural, sensory, or environmental factors to consider)?

  • Based on Hilda’s unique risk factors and clinical needs, what is the urgency of Hilda’s appointment? Does the urgency of the appointment help inform the decision of in-person vs virtual appointment? 

  • Can a virtual assessment provide the information necessary for making an informed and valid assessment? For example, does remotely observing transfers and the physical environment impact Emily’s ability to form a reliable professional opinion?

  • What are risks vs benefits of in-person vs virtual care and which one outweighs in Hilda’s circumstance? Is a blended approach possible? 

  • Does Emily’s employer have guidance or policies that can help inform her decision on in-person versus virtual sessions that should be considered or followed?

  • What are Emily’s organization’s technical policies and procedures regarding virtual practice? This includes the security and privacy features, proper training and workspace set up and any guidelines available for clients about virtual appointments. 

  • If she proceeds with a virtual appointment, Emily considers what additional points need to be included in the informed consent dialogue regarding assessments at this time, for example, privacy risks, and any service limitations related to in person or virtual appointments at this time.

OUTCOME

After considering the above, Emily decides she will proceed with an initial virtual appointment with Hilda’s daughter present. Having Hilda’s daughter there will help Emily conduct a more comprehensive safety and functional assessment.

  • To prevent further falls Emily would like to book the appointment as soon as possible and a virtual appointment can be available immediately. Based on the information from this initial assessment, Emily will determine if a follow up in-person appointment is needed or if virtual education and recommendations regarding fall prevention are sufficient.

  • Emily knows she will need to select the types of assessments appropriate for addressing falls prevention. She decides to consult with her colleagues/clinical lead on how she can best adapt the initial assessment to be done remotely. Emily also considers the information she learned from recently attending a workshop on virtual care offered by the professional association.  

  • Initially she confirms Hilda’s identity using personal health information and reviewing identification using the computer camera. For consistency and reference purposes, Emily starts the virtual appointment with explaining her scope of practice, and any benefits, risks, and alternatives to participating in virtual healthcare services. Emily shares a form of instructions for clients to troubleshoot common technical challenges of virtual care and some tips on what to expect.  

  • As part of adapting the assessment, Emily asks Hilda specific questions about her falls, including frequency, the activity she was doing at the time of the fall, the surfaces she transfers to and from in her home, stairs and railings, any use of a gait aid, and specific questions about her footwear.  Hilda’s daughter uses the computer camera to provide a virtual tour of the environment and of Hilda performing transfers.

  • During the virtual assessment Emily observes that Hilda is unsteady as she rises from the chair and uses the wall for support. The daughter is nearby to offer help if needed. Emily provides immediate education on sit-to-stand fall prevention strategies, as well as some environmental modification recommendations. 

  • Emily will document her virtual appointment in the client record and include any collateral information obtained from the daughter. Emily will include a rationale for her decision to start with virtual services. Emily also reviews the Standards for Record Keeping and Standards for Consent to ensure she is meeting the College standards for practice.

  • Based on her assessment and the potential safety risk to Hilda, Emily concludes that an in-person follow up appointment is warranted to further assess Hilda’s safety and potential need for a mobility device and hands-on education and training.

DISCUSSION

Emily is aware that she should consider each client on a case-by-case basis. If the risks outweigh the benefits of conducting a virtual occupational therapy appointment, Emily will investigate alternative supports and treatment options. Any occupational therapy services which can be safely and effectively provided remotely (online, by telephone, or other virtual means) is encouraged to continue at this time. Occupational therapists are asked to also review their policies as information is changing rapidly in the current environment.  

When determining what services are appropriate for remote delivery, occupational therapists need to implement a risk assessment and use their professional judgment to ensure clients receive safe, ethical, and quality services regardless of virtual or in-person delivery. Occupational therapists are encouraged to contact the Practice Resource Service for any additional input or resources regarding their navigation of COVID-19 assessment and treatment challenges.  

REFERENCES 

  1. Virtual Services
  2. Standards for Consent
  3. Standards for Record Keeping
  4. Standards for Assessments
  5. Information on COVID-19

CONTACT

If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org.

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