COVID-19 Pandemic and Beyond: Considerations and Costs of Telehealth Exercise Programs for Older Adults With Functional Impairments Living at Home-Lessons Learned From a Pilot Case Study.

OBJECTIVE: The purpose of this study was to describe the process and cost of delivering a physical therapist-guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline.
METHODS: Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant.
RESULTS: A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the "value proposition" of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved.
CONCLUSIONS: The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a "blue print" for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. IMPACT: As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.

The current coronavirus disease (COVID-19) pandemic highlights areas in health care where we could be better prepared for disruptive events. In rehabilitation, a clear need for more telehealth-delivered options has emerged. This need has been recognized by the Centers for Medicare and Medicaid Services (CMS). In response to the COVID-19 pandemic, CMS has temporarily loosened restrictions and permitted physical therapists to provide “e-visits” short-term (ie, up to 7 days) to already established patients. Although temporary, this landmark move by CMS highlights the importance of improving access to services during the current pandemic.

To slow the spread of COVID-19, social distancing and quarantine protocols have been enacted. “Social distancing” refers to keeping space (>6 feet) between yourself and others, whereas “quarantine” refers to remaining in your home or current location as much as possible when you have been exposed or might have been exposed to COVID-19. Social distancing and quarantine protocols not only limit access to skilled services but to opportunities for physical activity. Lack of physical activity is detrimental to older adults’ health, functional independence, and quality of life., These detrimental impacts may be compounded in individuals with functional impairments and disability.

The rehabilitation field should be proactive rather than reactive and leverage alternative strategies, such as telehealth, to provide services that diminish the impacts of social distancing and quarantine on physical function. As movement experts, physical therapists are well-positioned to lead efforts to develop programs that provide opportunities for physical activity to individuals at increased risk of decline, such as older adults with functional impairments.

We used information and cost estimates from a pilot study testing the feasibility of a physical therapist–guided synchronous (ie, live and interactive) telehealth exercise program and describe: (1) the process used to develop and deliver the program; and (2) the cost incurred in developing and successfully delivering the telehealth program to an older adult with functional impairments. Our findings will help inform the planning, budgeting, and implementation of telehealth programs designed to improve access to physical activity for older adults with functional impairments.

Methods

We used a descriptive study design to document the steps involved in development and delivery of a physical therapist–guided synchronous telehealth exercise program. We derived process and cost information from the feasibility arm of a parent study, which piloted the program with 1 participant. The steps and considerations were refined postprogram to reflect our actual procedures and serve as a guide informed by our experiences developing and delivering the program. The study complies with the Declaration of Helsinki and was approved by the Medical University of South Carolina’s Institutional Review Board. We obtained informed consent from the participant.

Participant

We recruited the participant through local physical therapists. The telehealth exercise program provider (A.M.) held information sessions about the study at 2 outpatient physical therapy clinics and provided physical therapists who attended a handout detailing study inclusion/exclusion criteria (Tab. 1). The physical therapists were asked to refer patients who met the criteria and expressed interest in participating. The first individual referred met the selection criteria and was enrolled after discharge from physical therapy.

Table 1

Remote Exercise Program Participant Selection Criteria

Inclusion Criteria

Exclusion Criteria to Maintain Safety

Age ≥ 18 years Was discharged from rehabilitative care over prior 14 days Not currently receiving physical therapy or occupational therapy Have a signed medical clearance form from physician Able to walk independently or modified independently (ie, with assistive device) Live in the community Able to follow a 3-step command Own device with video calling capabilities and have internet or cellular service Able and willing to provide informed consent

Serious cardiac conditions (eg, uncontrolled arrythmias, congestive heart failure) Resting hypertension (systolic BP > 200 mmHg or diastolic > 110 mmHg) History of COPD and/or use of supplemental oxygen Uncontrolled diabetes mellitus Preexisting neurologic conditions (eg, Parkinson disease) Severe pain (ie, limits activity) Cognitive impairments that inhibit understanding of information (eg, dementia, receptive aphasia) Visual impairments that inhibit use of video calling

BP = blood pressure; COPD = chronic obstructive pulmonary disease.

Program Content

The telehealth exercise program consisted of 36 sessions, each of which were 45 minutes in duration, delivered approximately 3 times per week. The duration (36 sessions) and content of the program was founded on high-quality evidence from stroke literature, as the parent study focused on a telehealth exercise program for survivors of stroke. All exercise sessions were delivered via a telehealth platform on a tablet computer. The exercises performed in each session were individualized to the participant’s impairments and progressed with the goal of maintaining a rating of perceived exertion (RPE) between 12 and 16 on the 6-to-20 RPE scale. The participant was provided an RPE handout that used color-coding and pictures to increase understanding of the scale. We asked the participant to report the RPE after each exercise set (eg, 12 repetitions) and adjusted the next set accordingly. The primary focus was strength and balance, and we included both seated and standing exercises. In Table 2, we show example exercises from the program and their progression.

Table 2

Example Activities and Progression

Activity Category	Example Activities	Progression
Upper Extremity Strengthening	Shoulder flexion
	Shoulder abduction
	Elbow flexion/extension
Trunk Strengthening	Row	Against gravity → Against gravity with TheraBand → More resistive TheraBand → Exercise in standing (if movement can be performed in standing)
	Modified seated abdominal crunch
Lower Extremity Strengthening	Hip flexion/extension
	Hip abduction
	Knee flexion/extension
	Ankle plantar flexion/dorsiflexion	Exercises in sitting → Exercises in standing with upper extremity support → No upper extremity support
Balance & Functional Mobility	Weight shifting
	Reaching
	Turning
	Marching
	Sit-to-stand from chair	Activities in sitting → Activities in standing with upper extremity support → No upper extremity support → Increased duration or speed

Functional Assessments

To inform session activities and determine the effects of the program on the participant’s functional status, we performed preprogram and postprogram evaluations. The evaluations included the following measures: 5 Times Sit-to-Stand Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Stroke Impact Scale, 5-Meter Walk Test (self-selected and maximal speeds), and steps per day. Steps per day were collected via 7 days of activity monitoring using an ActiGraph GT3X+ accelerometer (Actigraph Corporation, Pensacola, Florida, USA) worn on the ankle of the nonhemiparetic leg. We selected these measures because they provide a fairly global view of functional status (mobility, strength, and balance).

Personnel

A physical therapist (A.M.) led all exercise sessions. The physical therapist had more than 5 years of clinical experience but no prior experience delivering care via telehealth. To establish comfort with the technology, she received 1 hour of training on the telehealth platform from the health system’s manager of telehealth technologies. To better understand how to deliver care remotely, she consulted with physical therapists who had experience with telerehabilitation. The therapist trained an assistant to help with documentation.

Costs

All costs incurred during development and delivery were tracked. Personnel costs were calculated using the salaries of both the physical therapist conducting the program and the trained assistant. For both, a modification of the Time-Driven Activity-Based Costing (TDABC) approach was used, focusing on the cost perspective of the program provider. A loaded salary was calculated by multiplying the individual’s annual salary (physical therapist, $107,000; assistant, $42,000) by their employer’s fringe benefit rate (1.378). Total annual hours (2080) were then multiplied by a usable time factor (physical therapist, 0.76; assistant, 0.8) to generate total annual clinical hours (physical therapist, 1580.8; assistant, 1664). Each individual’s “loaded” salary was then divided by annual clinical hours to generate their “loaded” hourly rate (physical therapist, $93.27; assistant, $34.78).

We separated the fixed equipment costs required to initiate the program, the variable costs associated with personnel time and travel, and the variable supply cost required per participant. For the base cost estimate, time was included for a physical therapist and an assistant, and the cost estimates were based on 33 participants. That number was selected because the participant required 48 contact hours (environmental setup, technology training, preprogram and postprogram evaluations, and exercise sessions) to complete the program. Our estimate assumed the physical therapist had 1580.8 clinical hours available annually, which would allow the physical therapist to work with a maximum of 33 participants in a work year, if the therapist was present during all sessions. In the base program, we used both a physical therapist and a research assistant, so the costs may be expected to be on the high side. Thus, the costing assumption does not account for the possibility of utilizing a trained assistant to replace some physical therapist hours, or having no assistant present to help the physical therapist. To examine value, 2 potential measures of the “value proposition” of this type of intervention were calculated: the value-for-money equation, and comparison of cost per session to Current Procedural Terminology (CPT) codes commonly billed in physical therapy.

Role of the Funding Source

The funders played no role in the design, conduct, or reporting of this study.

Results

The participant was a 67-year-old white man with a history of stroke (19 months prior), hypertension (controlled), and diabetes mellitus (controlled). He lived with his wife in a single-story house and ambulated with a quad cane and bilateral ankle-foot orthoses. The participant completed all 36 exercise sessions over 14 weeks. He maintained an average RPE in the target range (12–16) for 35/36 sessions. His functional mobility, balance, and Stroke Impact Scale perceived recovery scores improved from preprogram to postprogram. However, little change was observed in his walking speed, steps per day, or overall Stroke Impact Scale score (Tab. 3).

Table 3

Participant Performance on Functional Measures

Functional Measure	Pre-Program	Post-Program
5 Times Sit-to-Stand Test (s)	24.8	12.0
Stroke Impact Scale total score (range = 0–100)	61	62
Stroke Impact Scale Domain Scores (range = 0–100)
Strength	60	65
Memory	77	77
Emotion	67	67
Communication	80	80
ADL/IADL	62	54
Mobility	53	67
Hand Function	28	36
Participation	50	48
Stroke Impact Scale – percent perceived recovery (score range: 0–100%)	40	70
Activities-specific Balance Confidence Scale (score range = 0–100)	56.9	71.9
Berg Balance Scale score (score range = 0–56)	30	39
Average steps per day (steps)b	1280	1335
Self-selected walking speed (m/s)	0.48	0.45
Maximal walking speed (m/s)	0.59	0.55

ADL = activities of daily living; IADL = instrumental activities of daily living.

Steps per day collected via 7 days of activity monitoring (ActiGraph GT3X+ accelerometer worn on the ankle of the nonhemiparetic leg).

Process

The steps involved in developing and delivering the telehealth exercise program are presented in Table 4, along with important considerations for each step.

Table 4

Steps and Considerations for Developing and Delivering Telehealth Exercise Programs

Phase	Step	Provider-Related Considerations	Participant-Related Considerations
	1. Select telehealth platform	Costs of license and any additional equipment Ease of use – Complexity of initial installation and connecting with participants – Provision of technical support Devices that are compatible with the platform (ie, smart phone, tablet, computer) Quality of visual and auditory output Privacy and security of transmissions Obtainment of HIPAA Business Associate Agreement	Costs of use, including data streaming Internet/cellular and bandwidth requirements and availability Ease of use – Complexity of initial installation and connecting with provider for sessions – Availability of support – Accessibility of features (eg, size of font and buttons) Devices that are compatible with the platform (ie, smart phone, tablet, computer) Quality of visual and auditory output Data security and encryption
Development	2. Develop documentation system	Costs The components of the session that need to be documented Timing of documentation (real time vs post-session) Ease of data input and extraction Integration with electronic health record	Outcomes: – Selection of self-report versus performance outcomes – Opportunity for verbal versus text/typed/interactive response – Balance of synchronous versus asynchronous reporting (within or between sessions)
	3. Identify and obtain necessary resources (personnel and supplies)	Personnel – Qualifications of individual who will run program and/or deliver sessions Supplies – Exercise equipment needed to deliver content – Additional supplies needed to enhance delivery of program (e.g., adjustable stands for communication devices) – Develop procedures for infection control, if equipment will be transferred to subsequent participants	Availability of family or caregivers for setup or participation Environmental setup in participants’ homes (eg, moveable and safe chairs, counters/rails for support) Technology available in participants’ homes (e.g., tablet, laptop) Exercise equipment available in participants’ homes Safety of participants using equipment
	4. Identify recruitment sources and develop recruitment strategies	Define target population Identify individuals who interact regularly with target population (e.g., physical therapists, physicians) Develop resources for recruitment (e.g., flyers)	Characteristics of individuals who may benefit from a home telehealth exercise program Characteristics of individuals who would not be appropriate for a home telehealth exercise program
	1. Evaluate the participant’s functional status prior to and following the program	• Determine location and delivery of assessments: home or clinic? In-person or remote? • Use functional performance measures that will guide delivery (preprogram) and will demonstrate whether/how participant benefitted from program (postprogram)	• Burden with travel to assessments • Impairments that the program will target
Delivery	2. Conduct preprogram training and environmental setup with participant	• Determine location and delivery of training: home or clinic? In-person or remote? • May be helpful to include caregiver/partner in training on use of telehealth technologies • Some participants may benefit from a technology trial run prior to the 1st session • Location in home should be level floor space free of loose objects next to a stable surface (e.g., counter top, back of chair) that can be used for support if needed	• Burden with travel to training • Cognitive status and comfort with technology • Availability of a caregiver/partner • Home setup and flexibility in the setup
	3. Connect with participant via telehealth technology at scheduled session times	• Depending on telehealth platform, updated links may need to be sent for each session • Provider may need to be easily accessible via phone around session start time to troubleshoot connection-related issues on participant’s end • Confirm patient and provider identification prior to starting session • Ensure participant understanding of right to refuse telehealth session • Ensure participant understanding of emergency procedures, in case of fall or other emergent events	• Comfort and ability with technology • Access to reliable internet or cellular services • Ability to keep the battery on device they will use for sessions charged
		4. Start each session by ensuring environment safe and video frame adequate	• Ensure participant within reach of a stable support surface • Ensure participant has exercise equipment (e.g., resistance bands) in reach • Ensure participants’ device is positioned so the provider can see the participant well • Ensure the participant can hear the provider well and adjust volume as needed	• Ability to modify the environment if needed • Safety when retrieving exercise equipment during sessions (e.g., reaching for something on floor) • Availability of a caregiver/partner to assist with session setup
		5. Monitor intensity of selected exercises and progress participant as appropriate	• Monitor intensity consistently throughout session • Progress activities as appropriate to ensure adequate intensity to achieve training effect	• Current medications and health conditions (eg, beta blockers) • Ability to communicate exertion (e.g., may benefit from an RPE scale handout with color-coding and/or pictures to increase understanding of the scale)
		6. Document exercise session content, technological issues, and safety concerns	• Capture information needed to guide future sessions and inform billing (if applicable)	• n/a

Development Step 1. Select telehealth platform

We selected the telehealth platform, Vidyo (Vidyo Inc, Hackensack, NJ, USA). An important consideration was our need for a secure platform that allowed us to conduct synchronous sessions. We also wanted a platform that was easy to use and, once we secured a license, freely accessible to the participant. Another consideration was the flexibility of devices that could connect with the platform. Vidyo is compatible with smartphones, tablet computers, and personal computers. As we are learning in the current pandemic, we do not always have the luxury of going to individuals’ homes to set up equipment. Under such circumstances, we need to select platforms that are compatible with commonly used technology (eg, smartphones and tablets) and avoid platforms that require in-home setup of additional equipment by program personnel.

Development Step 2. Develop documentation system

We developed a documentation system in REDCap (REDcap Consortium, https://www.project-redcap.org/software). Our system was developed to collect data for the research component of the telehealth program; new systems may not be needed if current systems can be used or modified to meet documentation needs. A consideration when developing or modifying a documentation system for a telehealth program is whether participants will enter information on their end, or whether all information will be collected and entered by the provider. During development, the provider should determine whether a system that captures audio, video, and/or text data from participants is needed, and, if so, whether these data need to be captured during sessions (synchronously), between sessions (asynchronously), or both.

Development Step 3. Identify and obtain necessary resources (personnel and supplies)

Our first resource consideration was personnel. There are multiple approaches for setting up “who” delivers telehealth exercise programs. However, knowledge and experience are important considerations. Individuals who know how to safely prescribe and modify exercises for older adults with functional impairments should deliver programs designed for this population or, at a minimum, should supervise and train other staff involved in delivery. We decided to have a physical therapist and trained assistant deliver all sessions. This personnel mix allowed 1 person to closely supervise the participant while the other person documented the session. Detailed documentation was required for the research component of the program.

We also considered the supplies needed to deliver the program. Because the participant would be performing the sessions in their home and might not have access to exercise equipment, we provided the participant with resistance bands (7 levels). Due to concerns about camera angles and being able to adequately see relevant parts of the participant during sessions (eg, lower extremities), we also supplied the participant with an adjustable stand for their tablet. Provision of supplies may need to be modified during periods of social distancing and quarantine. Dropping off supplies while maintaining social distancing (eg, leave on porch) may be appropriate, or the equipment used during the program may need to be creatively constructed out of what the individual already has on hand. Creative construction will likely require guidance by the physical therapist either through video calls or emails with simple step-by-step guides.

Development Step 4. Identify recruitment sources and develop recruitment strategies

An important consideration when developing a telehealth exercise program is determining how to identify individuals who are appropriate for the program. We believed that physical therapists represented one avenue for identifying these individuals. However, other health care sources (eg, primary care providers) and community sources (eg, senior centers) should also be considered. Recruitment strategies will have to be modified during periods of social distancing and quarantine. Planning will need to focus on remote meetings with recruitment sources and development of electronic recruitment materials.

Delivery Step 1. Evaluate the participant’s functional status prior to and following the program

Location (home vs clinic) and delivery (in-person vs remote) of assessments are considerations in telehealth programs. We decided to travel to the participant’s home to conduct the assessments in-person. However, in-person assessments may not be an option during periods of social distancing and quarantine. Remote assessments may be required, and safety and feasibility will need to be considered when selecting outcome measures. Measures such as the Timed “Up and Go” Test and Functional Reach Test demonstrate the potential to be accurate and reliable when delivered via telehealth; however, these measures may not be appropriate for individuals with cognitive impairments or other safety concerns. Clinicians will need to determine the best measures to use for each participant. Considerations include what information is needed to guide care, what tests the participant can perform safely with remote supervision, and what resources are available (eg, equipment, space).

Delivery Step 2. Conduct preprogram training and environmental setup with participant

While in the participant’s home for the preprogram evaluation, we identified a safe place for the participant to perform the exercise sessions and trained the participant on the telehealth technology. Our approach worked well under normal circumstances; however, in-person environmental setup and technology training are not an option during periods of social distancing and quarantine. Under such circumstances, we will have to guide program participants through training and environmental setup remotely. Program providers may want to consider developing instructional videos or simple step-by-step written guides. Audio or video calls with participants will also likely be needed to problem solve issues and ensure that the technology is working correctly and the environment is set up for safely engaging in exercise sessions.

Delivery Step 3. Connect with participant via telehealth technology at scheduled session times

We accessed our “room” in the Vidyo telehealth platform 5 minutes prior to scheduled sessions. We also made sure we were near an open phone line so that we could be available to the participant if there was any trouble connecting.

Delivery Step 4. Start each session by ensuring environment safe and video frame adequate

We scanned the environment around the participant at the start of each session to ensure that it was safe. We also started all sessions by asking the participant if there had been any changes in their health and/or function since the previous session and if they had experienced any adverse events (eg, falls). During this “check-in,” we made sure the audio and video was working well on both ends. We corrected any issues noted with the environment or audio/video before beginning the session.

Delivery Step 5. Monitor intensity of selected exercises and progress participant as appropriate

We selected exercises that were individualized to the participant’s impairments, safe for him to perform with remote supervision, and dosed in the target intensity range. We used RPE to monitor intensity; however, heart rate may be a more valid metric if the logistics of monitoring it remotely can be resolved and the participant is not on a medication that impacts heart rate response to exercise.

Delivery Step 6. Document exercise session content, technological issues, and safety concerns

For each exercise set performed, we documented position (seated or standing), side and body part (eg, right upper extremity), amount of resistance, number of repetitions (or time for timed activities), support (eg, left hand on rail), and RPE. We also had an open “Notes” field for other observations, such as losses of balance or verbal cueing. At the end of each session, we recorded safety and technological issues encountered. Our documentation was very thorough because the program was part of a research study. In clinical practice, it may not be necessary to record as much detail. As with in-person care, the goal of documentation in telehealth programs should be to capture the information needed to guide future sessions and inform billing, if applicable.

The total fixed costs to initiate the program was $4,119.50. This included $2,200 for the telehealth platform, $1,299 for an iPad for delivering sessions, and $620.50 for 7 rolls of 25-foot Theraband at different resistance levels. Variable participant costs included a stand for the participant’s tablet ($18.52), mileage for initial visits and final evaluation ($285), and personnel time costs ($5,250). When the fixed start-up cost were allocated based on a capacity of 33 participants per full-time equivalent (FTE) physical therapist per year, the mean total cost per participant for the program was approximately $5,680, or $158 per session. The question then becomes, is this “good value” for the money spent? To answer this question, we must examine the value-for-money equation. This (N-of-1) participant improved from a Stroke Impact Scale perceived recovery score of 40 at the program’s start to 70 postprogram (Tab. 3). That is a cost of $1,893 per 10% perceived recovery. This sounds like “good value,” but the issue is that we do not know how much he would have improved without the program.

Another measure of value is a comparison of cost per session to CPT codes 97110 or 97530 (therapeutic exercise or activities, direct one-on-one) to improve functional performance. The mean allowable charge to Medicare based on 2017 data from a 5% sample of all Medicare beneficiaries is $49.09, mean payment is $38.17, and beneficiaries’ mean coinsurance is $9.72 per 15-minute increment. Thus, if reimbursed, this service would be charged at $196.36 per hour, paid for at $152.68 by Medicare with a $38.88 copay, for a total of $191.56 (in 2017 dollars). On average, personal trainers charge $40 to $70 per hour session. Thus, the copayment appears to be “good value” from the perspective of the participant. Our per-session cost of $158 appears to be a feasible business case, especially if the physical therapist–to–trained assistant personnel mix could be improved.

There is no accepted benchmark for the value of perceived recovery. However, to place the program cost in perspective, we can compare it to reported cost for follow-up care for populations such as stroke and frailty. We found in a previous study that a 1-point difference in modified Rankin score at 90 days (score of 1 vs 2) is associated with savings of $7,420 to $8,253 (in 2012 dollars) in the 12 months poststroke. This is about a $10,031 cost to Medicare in 2020 dollars. Furthermore, patient frailty is strongly associated with higher cost. Improved functional independence may offset substantial costs, as better recovery is associated with reduced risk of hospital admission, and the mean cost of 1 day in the hospital in 2020 is $3,949. Thus, the $5,680 cost of the program is equal to 1.4 days avoided in the hospital. However, these examples underscore the fact that we need good economic studies of the benefits of care focused on functional improvement. Without such studies, it is difficult to judge when we get “good value” for our money.

Discussion

We provide a description of the process and cost of developing and delivering a synchronous telehealth exercise program for older adults with functional impairments. During development, it is important to consider participant and provider needs related to the telehealth platform and documentation system. It also is important to identify necessary resources. During delivery, it is important to consider participant and provider needs related to assessments, telehealth technology training, environmental setup, and program content. Our cost findings support the value of telehealth exercise programs for older adults with functional impairments. The demand for programs that improve access to opportunities for physical activity to this at-risk population may grow as regions across the United States and countries around the globe respond to the current pandemic and enforce social distancing and quarantine protocols.

Individuals who are currently receiving physical therapy will need to continue to receive skilled care during the pandemic. To address this need, many providers are exploring telerehabilitation options. We believe that it is important to continue to provide this skilled rehabilitative care, and we are not suggesting to replace it with an exercise program; however, exercise programs may be an appropriate strategy for preventing decline among at-risk populations. Rather than waiting and addressing declines in health and function after they occur, physical therapists can be proactive and keep at-risk individuals active. There is a growing focus on prevention in health care, which has extended to the rehabilitative field. An example of this trend is a study by Bean et al testing a 12-month “prehabilitation” program for older adults. The program included remote monitoring of participants’ exercise adherence by physical therapists through a web-based app. Participants in the program demonstrated better physical function and less emergency department utilization than a matched comparison group at 12 months. Findings from the Bean et al study support the role of telehealth in helping individuals stay active to prevent decline. We need to build on this emerging evidence and continue to push the rehabilitative field forward through provision of prehabilitation and preventive services. Such services demonstrate the potential to be beneficial under usual circumstances and may be a critical resource during events that disrupt the health care system and normal day-to-day activities, such as the current COVID-19 pandemic. Physical therapists have the opportunity to deliver innovative programs that prevent decline, rather than trying to help individuals recover their independence after decline occurs.

Cost is an important consideration when developing a new program or transitioning an existing program to a new delivery format, such as telehealth. Prior studies examining costs have focused on home exercise programs that were not delivered via telehealth. The largest expense we encountered in the development phase was the license for the telehealth platform. Telehealth platform selection may be an easy target for reducing costs when designing new programs. There are more affordable options available; however, it is important to consider features such as ease of use, compatibility with other devices, trialability, and security of transmissions. In our program, the largest cost during the delivery phase was personnel. A physical therapist and trained assistant delivered all sessions. Costs in future programs could be reduced by altering who delivers sessions or how other resources are integrated (eg, community-based programs and virtual assistants). However, if the target population is older adults with functional impairments, it may be important to have a physical therapist supervising the program and delivering intermittent sessions on a planned or as needed basis to ensure safety and appropriate progression of activities.

Broader Implications

During pandemics and other disruptive events, the short-term focus is timely solutions to address pressing needs. As already discussed, one short-term focus in rehabilitation is how to prevent declines due to inactivity in our at-risk populations. We also need to consider the longer-term impacts and prepare for gaps that may appear moving forward. Early reports suggest that older individuals and those with comorbidities experience more severe effects of COVID-19. Because these individuals will likely need rehabilitative care, we may encounter a surge in older adult patients recovering from the virus. If the surge occurs while the health system is still strained and social distancing and/or quarantine protocols remain in place, we will need strategies for delivering remote care to these individuals. Telehealth exercise programs and/or telerehabilitation programs will be critical for filling this gap. While our program focused on exercise, the content was strength and balance, which also falls under the umbrella of “rehabilitation.” Our findings, therefore, may help inform development of telerehabilitation programs for older adults with functional impairments, as well.

Limitations

Our findings are purely descriptive and should be interpreted and generalized with caution. However, we provide timely information that can serve as a foundation for future studies and potentially inform nonresearch telehealth exercise program development. We used information from a pilot feasibility study, which included only 1 participant in the exercise program part of the study. Due to the nature of recruitment (volunteer) and lack of randomization, there is potential for participant bias. The sample size did not impact our ability to address our objectives with this ancillary project focused on process and costs. The parent study focused on individuals poststroke. Although we believe the information shared in this article may be useful for other populations of older adults with functional impairments, further research and evaluation is needed to confirm its broader applicability.

Limitations related to the program should also be considered. Remote delivery increases fall risk, as providers cannot guard participants or assist during losses of balance. Remote delivery also requires access to internet services, which may be a limitation in resource-poor areas.

Conclusions

The current COVID-19 pandemic should serve as an impetus for progress in the rehabilitative field. It is urgent that we to develop innovative strategies for preventing functional decline among at-risk individuals during periods of social distancing and quarantine. However, the value of such programs is not limited to crisis periods. Many of our rural residents need these types of services even under normal circumstances. Telehealth exercise programs are one avenue for improving access to physical activity. Our findings provide insight into the process and cost of developing telehealth exercise programs for older adults with functional impairments. Research is needed to examine implementation and scalability during periods of social distancing and quarantine while maintaining effectiveness and safety. Consumer demand and provider preferences should also be explored. Importantly, we need to continue to work with payers and legislators to ensure regulatory and reimbursement barriers are removed to expand reach to those isolated by circumstances or geography.