​During the pandemic, it hasn’t been unusual to see residents in their rooms or apartments lifting books, dancing, standing up from a chair and sitting down repeatedly, or talking on their tablet or laptop. While concerns about containing the COVID-19 virus and protecting everyone are paramount, residents are still getting the rehabilitation services they need—often in creative and unique but always safe ways.

When COVID-19 hit, therapists, physicians, nurses, and other team members wasted no time, partnering to ensure that needed therapy services continue, goals are set and reached, and residents and families are involved in decision making and discussions every step of the way.

“We’ve had to be creative about alternative modalities, for instance, to address pain. We’re working with physical therapists and other team meetings to devise out-of-the-box ideas that work,” says Bader Almoshelli, MD, a physiatrist at Community Physicians in Illinois.

“Communication and education have been key. The pandemic is on the news every night, but people need to know what we are doing, how, and why to keep people safe and as functional, mobile, and pain-free as possible.”

The Good, The Bad, and The Hopeful

Members of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) were invited to participate in a survey out of Brown University to gain different perspectives about the challenges, opportunities, and best practices of therapy delivery during the pandemic.

The responses, which included input from administrators, nursing and other practitioners, and rehabilitation clinicians, will help shape research moving forward. Among key concerns and challenges respondents identified:

• Residents’ confinement to their rooms limits access to equipment and modes of delivery such as group and concurrent therapy.
• Residents are often less motivated due to the depression, anxiety, or sadness caused or exacerbated by quarantines, isolation, and social distancing. They also miss having their loved ones with them to help with therapies or just cheer them on.

Daniel Ciolek, associate vice president of therapy advocacy at AHCA/NCAL, stresses the value of getting different perspectives on this issue.

“There is no one-size-fits-all answer on how to deliver therapy during a pandemic,” he says. “However, we can give people a heads-up about what people are doing and thinking. Having our members represented in this study gives us insights that we wouldn’t get otherwise, and this is resonating with people.”

From Hopeless to Hopeful

Keely Kent, DPT, RAC-CT, senior vice president at Encore Rehabilitation, agrees with the survey responses that therapists and rehab clinicians are seeing depression, hopelessness, and loneliness among residents.

“We’re going in and seeing that the motivation and engagement aren’t always there. Residents don’t get to have loved ones or others clap or cheer them on as they take their first steps in the gym,” she says. “We’re also seeing cognitive decline.”

At the same time, Kent says that it’s more challenging to recognize cognitive or other issues, as “you’re not able to observe people in the dining hall, in activities, or moving around the facility.”

Vanessa Tejeda, director of business development at Ability Rehab in Des Plaines, Ill., notes, “It was challenging at first. Our patients still needed rehab, but they weren’t as motivated to get up and participate.”

Almoshelli agrees. “We’ve been able to watch for visual cues during our telehealth visits, but we also count on staff on the ground to be our eyes and ears,” he says. “Communicating back to the patient and family members was crucial. The fear of the unknown during this trying time is significant. Keeping everyone in the loop has helped to relieve stress and anxiety.”

Sharing a slightly different experience, Kelly Cooney, president of the National Association of Rehabilitation

Providers and Agencies in San Diego, says, “I’ve found that people actually like spending some quality time with another person. They don’t want to be ‘deserted,’ and want us to find ways to continue—safely—to work with them.”

From Challenges to Opportunities

Of course, with challenges come opportunities. Survey respondents observed that telehealth and telemedicine waivers have enabled new ways to connect with patients and a seamless continuum of care, although they worry about what will happen after the pandemic regarding reimbursement.  

Still, there is optimism. As Clare Coleman, president and chief operating officer at Encore, says, “There are still many opportunities to use this platform for things like measuring range of motion. PDPM [Patient-Driven Payment Model] put an emphasis on function in therapy, and telehealth enables us to pursue this.

Moving forward, this technology will enable us to help residents gain the skills they need for everyday activities.”

Depending on what the Centers for Medicare & Medicaid Services (CMS) decides moving forward, telehealth is likely to play a key role in therapy, with more practitioners and facilities employing hybrid models using both in-person and remote care.

Kathleen Weissberg, MS, OTD, OTR/L, CMDCP, CDP, national director of education at Select Rehabilitation in Delaware, observes, “Once CMS opened the door to allow for telehealth, we quickly utilized this opportunity to roll out a national telehealth program to our clients affected by the pandemic.”

She admits that adopting this technology was not without its challenges, including patient safety and privacy considerations, addressing hearing and vision deficits and staff proficiency with the process.

Nonetheless, she says, telehealth has enabled her teams to meet the needs of a vulnerable population that needs therapy services, even when many of these individuals have been confined to their rooms and at high risk for COVID-19.

Equipping Creatively

With gyms and equipment unavailable, creativity abounds. For instance, Kent says, “I’ve seen people make a basketball hoop out of a tissue box and use rolled up tissues as balls. Lack of access to the resources we usually have hasn’t stopped us.”

Tejeda agrees. “We brought equipment into the rooms as possible,” she says. “Of course, we were limited about what was practical, and we had to follow protocols and sanitize everything properly.” At the same time, some improvisation was necessary. “We couldn’t bring parallel bars to help people walk. Instead, we’d use things like portable standing tables,” she says.

Not surprisingly, fears abound about cross-contamination. Arif Hussain, DO, of Community Physicians, says,

“One thing we have done is to coordinate and have assigned therapists work exclusively with COVID patients to ensure there is no cross-contamination.”

Mobile equipment, such as bike pedals and free weights, are becoming the norm, he says. “These aren’t a permanent replacement, but they are a good temporary solution.”

No Substitute for Family

In many locations, families still can’t visit with their loved ones, and where visits are permitted, social distancing and other safety measures are in place. Yet, families have always been a key part of therapy and rehab, providing encouragement and support as well as learning techniques to employ when their relative comes home.

“I was working with one patient whose daughter was very involved,” Tejeda says. “We got an iPad and had an assistant hold it up so her daughter could see her walk. The patient did great, partly because her daughter was cheering her on. It was beautiful—the energy from the patient and her connection with her daughter.”

Dawn Andresen, MA/CCC-SLP, LNHA, RAC-CT, senior director of therapy and rehab, the Evangelical Lutheran Good Samaritan Society, Sioux Falls, S.D., adds, “Things like tablets enable families to have a presence during therapy and be part of the process, even if they can’t be there in person.”

Clearly, family involvement is key. But more than ever, therapists and other team players have a role in engaging and supporting residents, especially when they can’t see their families and friends. “We’ve encouraged our therapists to get more personal and establish and maintain a connection with residents.

This goes a long way to help motivate people,” says Andresen.

“We need to engage residents and listen to them. We need to be mindful about what is causing their lack of interest and motivation and address this accordingly in a coordinated care plan,” she observes. “This needs to incorporate activities and interests that are important to each resident and focus on the outcome.”

While it is essential to spotlight both short- and long-term goals, therapists and other team members must be supportive and validate patients’ and families’ fears and concerns about the pandemic, she says.

Communication was essential from the start, says Linda Riccio, vice president of therapy services at Transitional Care Management in Chicago. “We had to make sure that our assessment forms captured all the information and ensured follow-up with potential admissions.  

“Communication isn’t a one-size-fits-all proposition,” she notes. The capability for emails, phone calls, videoconferencing, texting, and other efforts such as webinars and YouTube videos is key, and families and team members should have the opportunity to identify how they prefer to be contacted.

These interactions are the lifeline of crisis management. As Riccio says, “We were able to quickly identify which residents needed what types of therapy and what equipment or resources facilities needed. By working together and communicating regularly, we were able to identify and address needs early on.”

Pain Problem-Solving

During pandemic-related quarantines, pain presents new challenges. Residents aren’t as active or mobile; elective surgeries such as hip or knee replacements are being delayed; and people don’t have the distraction of activities, events, and socialization. As a result, some residents may experience new or worsened pain.

“We have trained therapists to be alert to this and understand it. We partnered quickly with a modality provider for virtual training on pain management,” says Riccio. “We have been watching quality measures relating to pain, and we haven’t seen any outliers.”

Almoshelli says, “We’ve had to be creative about alternative modalities to address pain. Our physicians have employed mobile ultrasound, as well as nerve blocks as appropriate.” Hussain adds, “We focus on a team approach to pain management and focus on nonpharmacologic modalities such as electrical stimulation. While we sometimes employ pharmacologic interventions, these are non-opioid-centric.”

Often, the therapy teams went “back to basics” with the use of hot and cold applications, music therapy, meditation, and breathing exercises. While there are times when opioids are appropriate on a short-term basis, Almoshelli says, “we’ve addressed this on a case-by-case basis.”

While pain management remains a focus, there is a slightly different demographic requiring these services. For instance, with elective procedures being put on hold in recent months, “elective procedures are at about 25 percent of the usual therapy level, and surgical groups have provided statistics about how much their business has dropped off,” says AHCA/NCAL’s Ciolek.

At the same time, post-acute and skilled nursing facilities are seeing fewer short-stay post-surgical patients with the kinds of pain management and rehab services these individuals generally need. While these patients will start coming to facilities for post-operative care as the pandemic is controlled, “For the time being, census has been dramatically impacted—dropping about 10 percent—and it hasn’t yet recovered,” Ciolek says.

Looking Ahead

“We anticipate an increased need for therapy services post-pandemic,” says Andresen. “Facilities and practitioners should prepare now to identify some of the gaps that exist in the current care delivery model and create partnerships with health systems and providers to begin those services now.”

Preparation should include education for nurses and others to help them identify individuals who have cognitive or mental health issues due to months of isolation, as well as those at risk for falls due to immobility. “We need to consider now what residents’ therapy and rehab needs will be post-pandemic and be proactive on planning to fulfill these,” she says.

According to the Institutes on Aging, a person can lose 1 percent of lean muscle mass with each day spent in bed. With that in mind, physical and occupational therapy will play a critical role in addressing COVID-related deficits such as weakness, gait dysfunction, and issues in performing basic activities of daily living.

“Facilities need to plan now to address isolation, quarantine, and limited mobility,” Weissberg says. “What activities can be provided in these cases? How can we keep people socially connected? How can nursing help? How can therapy assist in developing individualized therapeutic plans?”

This is the time, Weissberg says, for interdisciplinary teams to “come together and brainstorm how we can keep our residents active and engaged in isolation so as to prevent decline and depression. We need to build up our toolbox of purposeful and meaningful activities each individual can engage in, based on interests, roles, values, and history.”

Recovery and Maintenance

There is a need to assess and monitor those residents who have recovered from COVID and address complications such as breathing difficulties, cognitive impairments, or neurological issues. However, at the same time, it will be essential to attend to the ongoing needs of residents with chronic conditions. “We also need an increased level of communication and an awareness of how all our residents are feeling, responding, and recovering,” Andresen says.

“One of the areas we’re focusing on is residual cardiopulmonary issues,” Cooney says. “Those are more obvious, but even in milder cases of COVID we are seeing some substantial damage. A lot of older COVID survivors also are showing up with neurological conditions such as ‘brain fog.’ As therapists, we need to be able to do the diagnostics, determine what is related to COVID, and determine how to treat it.”

According to Hussain, “Moving forward we will learn more and more about post-recovery complications related to COVID. For instance, some patients will be hard to get off oxygen, and others will have cognitive issues.”

He says that therapists are seeing some increased risk for strokes in younger patients. “And we know that some COVID survivors may be susceptible to thromboembolisms. We just don’t know yet what to expect.”
Nonetheless, Hussain suggests preparing with measures such as a good prophylaxis for blood clots and nutritional programs to address muscle loss. “We need to plan a stepwise approach and be mindful of potential post-COVID complications,” he says.

There is no question that preparing for the future, however uncertain it may be, makes a difference. It has helped some facilities and practitioners get ahead of the curve during the COVID pandemic.

“Early on, we put tablets in all of our facilities with video conferencing capabilities that has enabled residents to communicate with their families and practitioners,” Riccio says. “We were early adopters of these high-tech strategies.” By Easter, she says, “all of our residents were video chatting with families for the holiday.”

Inspiration, Courage, and Business as ‘Usual’

Organizational leaders and clinicians are currently functioning with a COVID mindset, and this clearly has affected how everyone functions. Nonetheless, therapy and rehab services continue unabated, albeit in different, unique, and inventive ways.

“COVID really hasn’t changed what we do. Our techniques used to get people functional haven’t changed. It’s just a matter of how we use these techniques,” says Coleman. “We know in health care what we’re getting into, and even during the pandemic, we haven’t seen people running for the door.”

Nonetheless, everyone needs to stay on high alert to some degree. For instance, Coleman stresses, “I think we’ll find our biggest concern post-COVID will be related to mental health issues such as cognitive decline and depression stemming from the extended period of isolation and quarantine.”

Tejeda says, “We always need to be prepared for crises. We need to be ready for the next change. We’ve learned much from the pandemic about how to be creative and adaptable.”

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.