Los paradigmas de la investigación educativa

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services provided through technology. Using the same lan-guage as these stakeholders may facilitate wider recognition and reimbursement of occupational therapy services pro-vided through telehealth technologies.

In Person vs. Face-to-Face Terminology

Many authors continue to use the term face-to-face to dif-ferentiate an encounter delivered in person from a telehealth encounter. Yet, technically, services using a telehealth model that are provided through interactive videoconferencing technologies can be described as face-to-face because they provide real-time, face-to-face interactions between the client and the practitioner (Mary Ann Liebert, Inc., 2011).

Although the term face-to-face is not widely interpreted to include face-to-face encounters provided through telehealth technologies, a broader interpretation is possible without the need to change regulation. This has significant policy implica-tions. The seemingly insignificant differentiation in terminol-ogy and its interpretation will likely have greater importance as telehealth becomes a more widely used service delivery model within the allied health professions.

BENEFITS OF TELEHEALTH WITHIN OCCUPATIONAL THERAPy Telehealth supports the profession’s Centennial Vision for occupational therapy to be a powerful, widely recognized, science-driven, evidence-based, globally connected profession with a diverse workforce meeting society’s occupational needs (AOTA, 2006). Telehealth enables occupational therapy prac-titioners to meet society’s occupational needs through using technology to (1) overcome access barriers to occupational therapy services, (2) consult with expert practitioners with specialized knowledge and skills, and (3) promote continuing care and engagement in occupation within the contexts and environments in which clients live. The benefits of using a telehealth service delivery model within occupational therapy align with the Patient Protection and Affordable Care Act (2010), which is designed to restructure how health care services are delivered, improve health through prevention and wellness initiatives, and facilitate accessible and coordinated health care services (Cason, 2012).

Overcoming Access Barriers to Occupational Therapy Services The use of a telehealth service delivery model increased access to care for veterans with traumatic brain injury (TBI; Girard, 2007) and multiple traumas (Bendixen et al., 2008). Telehealth technologies demonstrate potential for the delivery of interventions for individuals experiencing posttraumatic stress disorder (PTSD) and other mental health disorders (Germain, Marchand, Bouchard, Drouin, &

Guay, 2009; Gros, Yoder, Tuerk, Lozano, & Acierno, 2011). A telehealth delivery model is also advantageous for conduct-ing ergonomic assessments in situations where a client may be hesitant to disclose a disability and prefers to be assessed

for work modifications discreetly. Baker and Jacobs (2010) developed a systematic two-step program, the Telerehabili-tation Computer Ergonomics System, which allows ergo-nomically trained health professionals to provide explicit client-specific workstation modification recommendations based on remote assessment.

To overcome provider shortages, distance, or other barriers limiting access, occupational therapists may use telehealth technologies to conduct evaluations remotely.

Assessments that have been shown to be valid and reliable when administered through telehealth technologies include the Kohlman Evaluation of Living Skills and the Canadian Occupational Performance Measure (Dreyer, Dreyer, Shaw,

& Wittman, 2001); the Functional Reach Test and European Stroke Scale (Palsbo, Dawson, Savard, Goldstein, & Heuser, 2007); the Functional Independence Measure, the Jamar Dynamometer, the Preston Pinch Gauge, the Nine Hole Peg Test, and Unified Parkinson’s Disease Rating Scale (Hoff-man, Russell, Thompson, Vincent, & Nelson, 2008); and the Functioning Everyday with a Wheelchair—Capacity instru-ment (Schein et al., 2011). Interview- and observation-based assessments appear most amenable for a telehealth service delivery model. The use of a professional or para-professional to complete measurements requiring in-person assistance is an option. Hoffman et al. (2008) used an in-person assessor to read the dial for strength measurements (Jamar Dyna-mometer and Preston Pinch Gauge) and convey the mea-surements to the remote therapist. Similarly, Schein et al.

(2011) used an on-site generalist occupational therapist to facilitate a wheeled mobility and seating (WMS) assessment with a remote expert occupational therapist. Schein et al.

concluded that telerehabilitation “could improve the quality of WMS and other rehabilitation services, as well as develop the skills and confidence of generalist practitioners in remote rehabilitation clinics” (p. 123).

Consult With Practitioners With Specialized Knowledge and Skills Expert consultation through telehealth technologies dem-onstrates promise for linking practitioners with specialized knowledge to generalist practitioners. Remote consultation may lead to increased access to quality health care services, prevent secondary complications, promote health and quality of life, and build capacity among local practitioners who may have less experience with specific conditions (Hagglund &

Clay, 1997; Harper, 2006).

A telehealth model is especially beneficial for providing expertise not otherwise available on an interdisciplinary team. In this case, recommendations and services may be carried out by team members who are available to work with the client and/or caregivers within their natural environ-ments under the guidance of the remote expert(s). Harper (2006) highlighted the benefits of this model for conducting team-to-team interdisciplinary telemedicine evaluations for

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children with special needs. Benefits included comprehen-sive parent and professional dialogue and real-time discus-sion of evaluation results, treatment recommendations, and coordination of care between remote evaluators and local practitioners who would be working directly with the child (Harper, 2006).

Telehealth technologies enable individuals with upper-extremity prosthetic devices to receive expert consultation and remote device adjustment from the device manufac-turer’s prosthetists and occupational therapists. These practitioners share expertise and knowledge with local practitioners in order to enhance the therapeutic outcomes for individuals with newly acquired upper-extremity devices (Whelan & Wagner, 2011). Similarly, individuals with com-plex spinal cord injuries may experience barriers to accessing practitioners with specialized knowledge when discharged from inpatient rehabilitation facilities. In this case, telehealth technologies afford opportunities for tele-consultation with a practitioner with expertise in the area of spinal cord injuries (Hagglund & Clay, 1997). Through remote consultation with expert practitioners, local practitioners gain new knowledge and skills that may enhance their future practice.

Surprisingly, even interventions that are generally thought to be “hands on” in nature may be implemented through a telehealth model. Forducey et al. (2003) used telehealth technologies (videophone) to mentor on-site practitioners in delivering neurodevelopmental treatment (NDT) with a patient post-TBI residing in a long-term-care facility. The participating practitioners were competent therapists who had little or no experience with the NDT approach. The nurs-ing home clinicians indicated that through tele-mentornurs-ing, the patient made functional gains beyond what they thought was clinically possible. The practitioners also reported having acquired new treatment skills that would benefit their cur-rent and future practice (Forducey et al., 2003). Recognizing that not all occupational therapy services should be delivered through telehealth technologies, further research is needed to determine which occupational therapy assessments and interventions are conducive to a telehealth service delivery model.

Promote Engagement in Occupations Within Context

Engagement in occupation is an important aspect of health and quality of life. Occupational therapy practitioners evalu-ate the complex interplay between client factors, activity demands, performance skills, performance patterns, and con-text and environments influencing occupational performance (AOTA, 2008). Telehealth technologies afford the opportu-nity to promote engagement in occupations within context and in the environments where clients’ occupations naturally occur (e.g., home, work, school, community). Though not exhaustive, the following cited literature provides an

over-view of how a telehealth service delivery model can be used to promote engagement in occupations within context.

Home and Community Environment

Cason (2009) and Kelso, Fiechtl, Olsen, and Rule (2009) described the use of videoconferencing technologies to con-nect a remote occupational therapist with caregivers and children with special health-care needs participating in early intervention services as mandated by Part C of the Individu-als with Disabilities Education Improvement Act of 2004.

Kelso et al. (2009) evaluated the usability and feasibility of virtual home visits as measured by parent and intervention-ist satisfaction with services. Based on the pilot study of four families from a remote area of a large Western state, the authors concluded that virtual home visits are both “feasible and beneficial” (p. 339). Cason (2009) also reported a high level of satisfaction among families participating in a pilot telerehabilitation program. Although the telerehabilitation program described by Cason (2009) used a state-designated telehealth network site, newer and more mobile technologies create opportunities to promote participation within context by implementing telehealth programming where childhood occupations naturally occur (Cason, 2011). Heimerl and Rasch (2009) also designed a telehealth program to deliver evaluation follow-up, therapeutic interventions, and consul-tation with local practitioners to support therapy outcomes for children receiving early intervention services. In reporting the impact of 224 telerehabilitation encounters that occurred from 2004 to 2006, the authors indicated a high level of satis-faction among parents and providers. The authors concluded that services delivered through telehealth are a viable alter-native when in-person services are not available (Heimerl &

Rasch, 2009).

The home setting is also a natural context to promote engagement in occupations for adults with disabilities.

Hermann et al. (2010) evaluated the efficacy of a telehealth service delivery model to implement a functional electri-cal stimulation (FES) program with an individual >3 years poststroke. The client’s occupation-based, task-specific prac-tice of activities of daily living using a neuroprosthesis was managed through telehealth technologies (computer-based camera and free videoconferencing software). The authors reported that the participant was able to engage in occu-pations in his own environment as a result of a telehealth service delivery model, thus leading to increased carryover of skills (Hermann et al., 2010). Similarly, Clark, Dawson, Scheideman-Miller, and Post (2002) reported on a case study for an individual poststroke who received rehabilitation ser-vices in the home environment through telehealth technolo-gies. Outcomes included a cost-savings analysis indicating caregiver travel savings ($8,217) and caregiver productiv-ity savings ($11,256) over the 17-month tele-intervention period. The authors concluded that using telehealth

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ogies to deliver rehabilitation services in the home environ-ment is a viable option and resulted in improved functional abilities, minimized physical and language impairments, and supported the primary caregiver (Clark et al., 2002).

A telehealth model for veterans with polytrauma (Ben-dixen et al., 2008) and TBI (Girard, 2007) in the home envi-ronment has also proven beneficial. Diamond et al. (2003) used learning modules delivered through an Internet-based, interactive tool (e.g., Virtual Rehabilitation Center [VRC]) to deliver education, rehabilitation, and social support services to individuals with TBI. Despite having cognitive impairment, all of the participants learned how to effectively use all of the modules on the VRC (as measured by performance scores).

Although the interventions were provided in the home envi-ronment, the authors reported on a single case study within the larger study in which the skills learned in the home environment generalized to a community-based activity (Dia-mond et al., 2003).

There is also emerging evidence supporting the use of telehealth to provide therapeutic services and recommen-dations in the home environment for adults with multiple sclerosis (Finlayson, 2005; Finlayson & Holberg, 2007) and for adults with chronic illness (Bendixen, Horn, & Levy, 2007) and mobility impairments (Hoenig et al., 2006; Sanford et al., 2007).

School Environment

For children ages 3 to 21 years, a primary occupation is that of student. Verburg, Borthwick, Bennett, and Rumney (2003) described the use of telehealth technologies to support rein-tegrating students with brain injury into the classroom. In one case study reported by the authors, telehealth technolo-gies enabled a student with a dual diagnosis of mild TBI and paraplegia to overcome his fear of returning to school by using interactive videoconferencing technologies to connect and communicate with his classmates remotely prior to rein-tegrating into school. Gallagher (2004) reported significant improvement in parent satisfaction in the areas of timeliness, accessibility, availability of school-based evaluations, and ease in accessing the evaluation process when comparing the use of telehealth technologies with an established diagnostic clinic for the purpose of diagnosing attention deficit hyperac-tivity disorder. Additionally, parent and teacher satisfaction with occupational therapy and/or physical therapy using tele-health technologies were uniformly positive and statistically significant (Gallagher, 2004).

Work Environment

There are few studies in which telehealth technologies have been used to promote engagement in the context of work.

Bruce and Sanford (2006) described the use of telehealth technologies to conduct remote assessments in the work environment. Schmeler, Schein, McCue, and Bretz (2009)

also described using telehealth technologies for vocational applications. Baker and Jacobs (2010) developed a sys-tematic program to evaluate ergonomic and workstation modifications remotely in order to provide individualized recommendations. Telehealth technologies present oppor-tunities for occupational therapy practitioners to remotely analyze work environments and provide customized recom-mendations and modifications, education, and training to promote health and eliminate risk factors for injury in the workplace.

Summary of the Existing Literature

In evaluating the potential benefits of using telehealth technologies for delivering rehabilitation services, the World Health Organization and the World Bank (2011) concluded in their World Report on Disability that “growing evidence on the efficacy and effectiveness of telerehabilitation shows that telerehabilitation leads to similar or better clinical outcomes when compared to conventional interventions” (p. 119).

Steel, Cox, and Garry (2011) came to the same conclusion after conducting a systematic review of the literature exam-ining the use of videoconferencing to provide therapeutic interventions for people with chronic conditions. Evidence indicated a high level of patient satisfaction with the delivery method, lower levels of satisfaction among clinical staff than patients, and confirmation that a therapeutic relationship is possible with this service delivery model. While acknowledg-ing a gap in the literature in the area of telerehabilitation for physical conditions, Steel, Cox, and Garry (2011) concluded:

Good- and moderate-quality evidence indicated that the clinical outcomes of therapy delivered by videoconferenc-ing (or similar) are equivalent to those delivered in-person. Evidence was found to demonstrate that patient satisfaction with this means of treatment delivery was high, with some people even preferring videoconferencing to in-person contact. (p. 115)

Though emerging evidence suggests that some services provided through telehealth technologies are comparable in quality to services delivered in-person (Harper, 2006; Hoff-man et al., 2008; Steel et al., 2011), a telehealth service deliv-ery model is not meant to replace in-person occupational therapy services when in-person services are available and preferred by the client, or therapeutically indicated based on clinical reasoning. A telehealth service delivery model is ideal for improving access to underserved populations; individuals living in remote, rural communities; or areas with personnel shortages (Cason, 2009; Forducey et al., 2003; Heimerl &

Rasch, 2009; Hoffman & Cantoni, 2008; Steel et al., 2011).

TELEHEALTH TECHNOLOGIES

The advancement and proliferation of communication and information technologies and ubiquitous devices creates

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multiple technology choices for remote service delivery.

Telehealth technologies may be classified as synchronous or asynchronous. Synchronous technologies provide real-time, live interaction between the health care provider and the patient/client located at a distant site. Videoconferencing technologies, real-time monitoring devices, and interactive virtual reality are examples of synchronous technologies. In contrast, asynchronous technologies (sometimes referred to as “store-and-forward” technologies) involve recorded data (e.g., video, digital photographs, data from asynchro-nous monitoring and virtual technology devices, electronic communication).

Many technologies for delivering occupational therapy services remotely are commonly used by practitioners in their personal lives. For example, interactive videoconfer-encing capabilities are becoming increasingly common on mobile devices (e.g., smart phones, electronic tablets). The increased proliferation of technologies in practitioners’ per-sonal lives may result in increased comfort in their use as an extension of practice. However, practitioners must be equally cognizant of the implications of using “off-the-shelf” devices and software for delivering health-related services—namely, the potential compromise of security, privacy, and confiden-tiality of protected health information. Practitioners must evaluate the risks and benefits of using various technologies prior to considering their use for delivering occupational therapy services remotely. Watzlaf, Moeini, and Firouzan (2010) and Watzlaf, Moeini, Matusow, and Firouzan (2011) provided excellent information and a useful checklist to assist practitioners in conducting a risk analysis in the areas of privacy, security, and HIPAA compliance for Voice over Internet Protocol (VoIP) videoconferencing software (e.g., Skype, Facetime). If practitioners and health care organiza-tions determine that the risk associated with free or low-cost VoIP software is too great, there is VoIP software built specifically for telehealth purposes that may provide a higher level of security and privacy. Regardless of the technology used, it is incumbent on the practitioner to understand the ethical and legal implications associated with using a tele-health service delivery model.

In addition to concerns with privacy, security, and confi-dentiality of protected health information, barriers include the limited interoperability of devices, inadequate technology infrastructure, inaccessibility of some technology for persons with disabilities, and end-user (practitioner and client) inex-perience and discomfort with technology.

ETHICAL AND LEGAL CONSIDERATIONS

Practitioners using telehealth as a service delivery model within occupational therapy must ensure that the services rendered remotely are of the same professional, legal, and ethical standards as services provided in person. Clinical reasoning guided by existing evidence should be used to

determine if and when a telehealth service delivery model is indicated. Practitioners should seek out resources including AOTA’s Telerehabilitation Position Paper (2010c) and the American Telemedicine Association’s ATA Standards and Guidelines: A Blueprint for Telerehabilitation Guidelines (Brennan et al., 2011), which outline important administra-tive, clinical, technical, and ethical principles associated with telehealth. AOTA’s Standards of Practice for Occupational Therapy (AOTA, 2010b) and Occupational Therapy Code of Ethics and Ethics Standards (2010) (AOTA, 2010a), are also pertinent documents to review prior to engaging in prac-tice using a telehealth service delivery model. Practitioners must also explore licensure issues, such as whether addi-tional licenses are required (if services are rendered to cli-ents located in a different state than where the practitioner is located) or whether telehealth is expressly disallowed by a state licensure board. Cason and Brannon (2011) provided information on legal and regulatory considerations associated with a telehealth service delivery model addressing licensure, using modifiers when documenting for reimbursement, mal-practice insurance, and HIPAA compliance.

REIMBURSEMENT CONSIDERATIONS

Currently, reimbursement for occupational therapy services delivered through telehealth technologies is limited. Some insurance companies reimburse for select services that are provided through telehealth technologies as a result of cost-benefit analyses that determined the use of a telehealth model results in improved health outcomes and preven-tion of secondary complicapreven-tions (U.S. Department of Health and Human Services [HHS], n.d.). In some states, insurance companies are mandated to reimburse for services provided through telehealth technologies if those same services are covered when provided in person (American Telemedicine Association, 2011). Some occupational therapy practitioners are receiving reimbursement for services provided through a telehealth model by individuals who pay privately, or through contracts with independent schools, school districts, agencies, or organizations. The Department of Defense and the Veterans Administration provide funding for specific telehealth programming for active military personnel and vet-erans (Girard, 2007; Stout & Martinez, 2011). Medicaid

Currently, reimbursement for occupational therapy services delivered through telehealth technologies is limited. Some insurance companies reimburse for select services that are provided through telehealth technologies as a result of cost-benefit analyses that determined the use of a telehealth model results in improved health outcomes and preven-tion of secondary complicapreven-tions (U.S. Department of Health and Human Services [HHS], n.d.). In some states, insurance companies are mandated to reimburse for services provided through telehealth technologies if those same services are covered when provided in person (American Telemedicine Association, 2011). Some occupational therapy practitioners are receiving reimbursement for services provided through a telehealth model by individuals who pay privately, or through contracts with independent schools, school districts, agencies, or organizations. The Department of Defense and the Veterans Administration provide funding for specific telehealth programming for active military personnel and vet-erans (Girard, 2007; Stout & Martinez, 2011). Medicaid

In document LOS FACTORES DE PROTECCIÓN, DE RIESGO Y LA PREVENCIÓN DE RECAÍDAS EN POBLACIÓN (página 181-187)