Sorry. Good morning. Welcome. My name is Deborah Vennessy and I'm president of the AAPM&R for one more day and I have the distinct honor of being here as the moderator. I have a few announcements before we start. Welcome. Please turn off your cell phones and... or put them on vibrate please. There are some evaluation forms, so please complete those. It helps us with future planning. There's a session evaluation is located in the mobile app and on the online agenda. All you have to do is search for our session in the mobile app or online agenda and click CME and evaluations to open it. And please make sure that you visit the pavilion. Side note, I was just at a breakfast with a number of them. They are wonderful folks and they welcome you coming there. We couldn't do this academy assembly without them. Wow. What else can I share with you? Make sure you claim your CME. That's an important one. So again, welcome to our session. It's entitled, Improving Mobility and Managing Risk for Fragile Patients via Telemedicine and Patient-Reported Outcome Measures. As I mentioned, I'm Deb Vennessy and I have the... my only job today, I think, is to introduce Todd and Steve. Dr. Todd Rowland has over 25 years... probably a little bit more, right? Yeah. That's an old bio, sorry. ...of experience, which includes roles as a practicing physiatrist and C-suite leader in multiple ventures, including digital health companies. He completed his physical medicine and rehabilitation training at The Ohio State University, with me, and his medical informatics training at Harvard-MIT. As I mentioned to people, this is prior to it. I had no idea what all this stuff was when he was doing it and I'm so excited for him. A couple of years ago I encouraged him to be a chair of our AAPM and our Telehealth Innovation Work Group and he has done a fantastic job over the past couple of years. So thank you. Thank you, Todd. Yay! I'd also like to welcome Dr. Stephen Lewis. He's a clinical assistant professor at the New Jersey Institute for Successful Aging. He serves as medical director for rehabilitation and medical associates, a tech-enabled physiatry practice that combines telehealth and automated health coaching technology with traditional rehabilitation medical care. Dr. Lewis has developed a multi-condition rehabilitation tech platform to improve quality of care within high-risk populations. Steve's been integrating this technology into his physiatry practice for over the past, at least eight years, and he has over 4,000 patient encounters. Dr. Rowland, Dr. Lewis, and myself have been involved with our academy's upcoming white paper on telehealth innovation that will be published soon in the Journal of PM&R. So we're really excited about that. As a little plug, we do that actually in a year and I really give the work group credit. I mean, that was just amazing. So I'm going to turn it over to Todd. Thank you. Great. Alright, everybody. Well, thank you, Deb. I really appreciate that. It's nice to be up here with friends. It's also nice to be in person and now I can finally see people in 3D again. You know, we're just... Everybody's talking about what it's like to be in person. So welcome to folks who are online today and then, you know, we're recording this session. So we really want to cater to that audience as well. So thank you for everybody who's here in person. We're starting at 8 in the morning, so it's a little early, but you know, keep getting caffeinated. You know, it's a pleasure to have somebody like Deb and, you know, she's so nice and smart and then she's taking time and she's kind of busy these days. So I appreciate that we're still on her agenda. So I'm going to kind of do this kind of bigger overview of what's happening in the industry and then Dr. Lewis is really going to get into some really good detail about some of the use cases that he's experienced with his patients. He's gotten a tremendous amount of experience, more than anybody I know, and then our group in North Carolina and we serve multiple healthcare systems, including the Duke system, I've been using his technology. And so I'll talk a little bit about kind of my personal experience with that. So Windows into the Home is a theme for us and the telemedicine telehealth group has been going since 2019 and at first I thought, oh, we'll just kind of do it for one year. It'll be, you know, whatever. And then all this thing called COVID happened and all of a sudden everybody was really, you know, really had no choice, but to do remote care and 2020 was an interesting year for us. I'll give the Academy a lot of credit because we've really figured out how to keep everybody engaged and the volunteers in that group have done far more than I expected them to do. We've got this white paper coming out and one of the things I really want to promote is something we're going to be doing in November is where the Academy has been willing to try something that they've never done before. So they're doing this tech summit and it's called Windows into the Home. And it's really intended to be a place where the industry can come together with us with subject matter experts and have a forum and talking about what everybody is doing. And the goal of that, from my perspective, you know, I've been in informatics for over 30 years. I guess I need to update my bio at some point, is all of us have had this experience of electronic medical records and I... You know, whatever expletives you want to use about that, you can in the privacy of your home. Not really been what physicians were looking for. And so I started my career before electronic medical records, lived through that, and now we're kind of in this post-electronic medical record world. Well, we're far from done. And so how can we, as, you know, a specialty, as an organization, really be a good, smart customer, a broker with industry to really be thoughtful about what we want and need from industry. So that's really the intention of that. And I would welcome anybody, you know, in the academy that's interested to kind of come up to Steve or myself and just talk to us about, you know, what that should be because we're going to do it and the academy is committed to doing it, but it still needs to be shaped. So I would look forward to that feedback. So here's kind of my disclosures, my background. As Deb had mentioned, I'm the chairman of this innovation working group and it's been a fantastic group of people. And I'm also involved in informatics and my two companies that I'm involved with are... One's called Vital Flow Health, which is an asthma remote care company. I'm their chief medical officer. And then I joined Steve as a co-founder and chief medical information officer for MyHealthGame.com, which is his company. I have a consulting company called Bridge to Medical and so I do a lot of other things and I'm involved with, you know, health insurance technology, risk analysis, all kinds of interesting little things around the industry. And it continues to give me a perspective that I think is beyond what practicing physicians may experience, right? Now one of the things that I'm very proud of is that I'm part of a practice two days a week where I work in the Duke healthcare system. And, you know, Duke is a really amazing place. We see some really unusual diagnoses. We see some kind of famous people and it's a really vibrant ecosystem to work in in the research triangle. So I really appreciate that. But, you know, there's a lot we have to offer as a specialty to places like Duke. You know, Duke is a great place, but they're pretty underdeveloped as it relates to rehab. And I was kind of having this conversation with, I'll call it my elder statesman last night about that and they were really asking me, you know, what's going on in North Carolina? And I said, well, I think we've got a lot of potential for growth in that state. The other thing that I felt good about last night is I was talking to Randy Bradham and for those of you who know him, he's kind of a character and he did explain to me that I'm middle aged, even though I'm 60. So I feel good about that. So, okay. So that made me feel energetic today. So, you know, so why are we here? Okay. Like what's the purpose of getting up at 8 in the morning and talking to each other about this topic? And so I call that the reason for action. You know, what's motivating us to think about this stuff and incorporate this into our practice? Well, as we just talked about, there was this really crazy period of growth from a minimal use of telehealth to almost universal use of telehealth. You know, admittedly not the smoothest thing, but there's been a persistent, you know, 20 to 25 percent utilization, which is dramatically higher and you never have that happen unless there's a crisis. So obviously COVID has been our crisis. So that reduced the barriers, which we can talk about. It also improved payment. So Medicare said, okay, yeah, we're going to pay for this stuff in a much more universal way, which definitely made it easier. Now as we're getting into this post-COVID world, there's a lot more patients that are having problems, you know, than there were before. And the academy is doing a lot of work on long COVID and it's called PASC is the acronym for that. And estimates of maybe 20 million people or more that are having some lingering problems. So that's another market that's pretty underserved and I'm pretty sure if we just do in-person care, we're not going to get to all those people. So we're going to have to figure out something different. So there's another reason to be thinking about remote care, location-independent care. And you know, the magic, the big question, how long are we going to get paid for this? Well, you know, because the industry is so engaged and there's a lot of lobbying happening, not from us, but from much bigger organizations, I think we're going to find that at least to the end of 2024, there's going to be sustaining payment for video, in-person video services, physicians providing care, at least paid at the same level as in-person care. Okay. So there's a bridge to that period. Many people I talk to have experienced a lot of really positive things about remote video care, particularly in the mental health space. And we're all going through that as families, right? And I think there's kind of no going back. I think the genie is out of the bottle for that stuff. So consumers want it. And then the good thing is Medicare is adding more payment codes all the time and that's something that, you know, Steve has become a particular expert on and we're working on partnerships, you know, that we really are enhancing this multidisciplinary collaboration where physicians can be at top of license and then really kind of take it to the next level and leveraging this fee-for-service payment model. So another why. Well, this is more of my touchy-feely side, but these are my in-laws and, you know, I got the Michigan logo there for Deb because she's at the Ohio State. And if anybody's been to those games, those are interesting. But these are my in-laws and they're just wonderful people and, you know, our job was to protect them from COVID, keep them at home. You know, to my wife's credit we've been able to do that. But boy, it would have been really great to have more remote services that were easier to use for them because, you know, bringing them in and out of clinics, you know, we felt risk every time we did that. Okay. So what happened in 2020? This is kind of old news, you know, if you've been looking at this space, you know, what you're seeing here is this really dramatic, you know, this crazy growth and then kind of this trailing off. And that's pretty much been the pattern. So we're getting kind of to this steady state of sustained use. And what many people in the industry think is that we kind of had a 10-year's growth in 12 to 18 months. Okay. And we had what I call cultural compression because usually it was kind of a two-sided problem because, you know, physicians weren't doing it, but consumers weren't ready for it and how are we going to get this going, but all of a sudden they got pushed together. So we had this compression of customers and service providers that said, yeah, we'll do it because there's no other way to do it. So we all learned how to do it. Okay. So it's not esoteric. It's not always perfect though. Right. Now, kind of fast-forwarding a little bit, you know, what is the industry saying? You know, companies like McKinsey who do this pretty intense, you know, research and they're saying, you know, what's... they're saying, well, it's stabilized and it's 38 times higher than the pandemic. What service grows 38 times? You know, it's just... this is historic time for us. And, you know, right now when I talk... I've talked to a lot of providers and, you know, I was walking through the exhibition hall yesterday and just talking to all these folks about, you know, how is telemedicine working for you? And to my pleasant surprise people were pretty positive about it and one of the ladies I worked with back at VCU, she's a PEDS doc at Ohio State and she's just... you would just love to hear what she's talking about with telehealth. I mean, the things she's doing for families are just invaluable, right? You know, regardless of you getting paid for it, there's just some invaluable things that parents of these kids need and so there's... she has an ability to do some things that she simply could not do before and so providers are net positive on this whole thing. Obviously, we've got a lot to do and for sure psychiatry, mental health has been the leader in this whole thing. Okay. So the talking part is working pretty well. Okay. So to replay a little bit about what we were talking about earlier is, you know, we formed pre-COVID, weren't exactly sure what we were going to do, but fast forward to today, you know, we're producing this white paper which will come out in the Purple Journal and it's very comprehensive. We got at least 15 authors and we covered really every patient population that we could think of and our goal with that was to say, what's the level of evidence that telehealth is a safe, effective, you know, method? Okay. And what's the research show? You know, some of the areas there's not a lot of research on it, as you'd expect. In other areas, in the area that Steve and I work with in the post-acute world, there's fantastic evidence. So this is not... You know, this has been shown to be effective. Okay. So we've kind of got this level... We think this is a foundation for all PM&R docs to look at and then for us to kind of continue to evolve and say, you know, how are we going to do this? You know, what can I use this for? How can I blend this with in-person care? Because we don't think that, you know, telemedicine, telehealth solves every problem, but it's a tool. It's something to use. And I've been really satisfied with the partnership with the AMA that we've forged. I mean, I think the Academy has always been able to do that and there's a lot of behind-the-scenes that docs don't realize. You know, all these organizations seem to be in Chicago and they're really working together. And I think the AMA has done a masterful job at putting together a lot of education materials. And so we are not recreating those, because we don't need to. And to their credit, they've partnered with us and we'll be doing a series of webinars with them going forward, where we have PM&R docs on panels with the AMA and we get a much bigger audience. So I think it's going to be really helpful for our specialty and I'm really interested in recruiting folks beyond the working group as well, who are using telehealth, telemedicine and their practices. And it's really... It gives us a great opportunity to kind of be ambassadors for our specialty. So, you know, really nice audience. And Steve has been great at helping me think outside the box with other organizations and one example is the American College of Lifestyle Medicine and guess what? Our PM&R doc is the president right now, Beth Fradies. Okay. And we had this call with her and boy, she was loving what we were doing. And so, you know, can we... Should we do some kind of partnership with them? Like what is telemedicine, remote care for like, remote care for lifestyle medicine, right? Because we feel like we are doing lifestyle medicine and you'll hear Steve talk about that. So it's, you know, PM&R is bigger than the academy hopefully, right? And so we really want to promote the docs that are in leadership and really support them and we need to really kind of grow the influence of our field. And then we talked about that leadership summit that we'll be doing later this year, later next year. Obviously there's a lot going on here, you know, 3.8, 3.9 million dollars. That's just one deal. So, you know, clearly Amazon and others, they think the home is a really big deal and they're investing a ton of money. And this one medical thing, part of the asset that they got in there was a pretty formed telemedicine function, but they've got this kind of in-person, you know, telemedicine care and we definitely need to be thinking about that, you know, in our practices and making sure that we're not left on the outside of that trend. So how can we, you know, keep working together? And then I'm going to introduce Steve here really soon and he's going to have plenty of time to talk and you're going to really benefit from him. But I personally want to make sure that the academy and the AMA really just continue to collaborate in telehealth and really leverage that relationship and we get as much value for you guys out of that as we can. And then I think it's really important as always to educate other specialties in the industry about what is the value of human RDocs, because we know anybody who's been in the field for very long, we know, you know, people don't even know what we are as a specialty. Like I was getting a... seeing my GI doc recently and I talked to his nurse and she was in her 60's and had never heard of our specialty. I was like, oh my goodness. Wow, we've got a lot of work to do. Okay. So we really need to... and we can provide leadership because we are great natural leaders. We're natural collaborators and we can really make these service models work at scale. And this is a little bit of a teaser for what Steve is going to talk about. So let's kind of... We'll get in... We'll hold our Q&A to the end of the meeting and at this point I'm just really excited to have Steve talk to us and just really share his experience and go into some detail about what he's been doing with his patients. So at this point I'm going to hand over to him. Also I want to mention to the folks that are online, go ahead and put in your Q&A through the app and then we're going to be looking at that. I believe also the folks in the live audience can use your app to do kind of a questions for us and then at the end of the session I'll be moderating those. We'll be working through all those. Okay. Alright. Okay. Well, thank you very much and thanks to Dr. Vennessy for a nice introduction and thank you, Todd. Um, so to help frame this discussion let's first identify a few major gaps in traditional care management for fragile high-risk patients and then we'll highlight how telehealth can potentially help to fill in these gaps. This is from a 2013 consensus statement from global leaders in geriatric medicine including from the American Geriatric Society. They issued a report called, quote, Frailty Consensus, A Call to Action. This was based on a World Health Organization white paper recognizing the need to better stratify older patients based on overall risk for poor outcomes. The goal was to improve the ability of older persons to age in place. And in the report they highlighted the care gap in assessing and managing frailty as an important measure of reduced functional capacity and overall poor health. Stating, quote, with the aging of our population we cannot wait. We must implement the screening and management of frailty in a clinical practice worldwide. And this is a related scientific statement from the American Heart Association highlighting another major gap in care management for the number one chronic disease that places aging patients at risk for frailty, namely cardiovascular disease. They issued a report called, quote, Importance of Assessing Cardiorespiratory Fitness in Clinical Practice, a Case for Fitness as a Clinical Vital Sign. And the authors pointed out that cardiorespiratory fitness is the only major risk factor not routinely assessed within clinical practice. It quantifies the functional capacity of an individual. And with a nod to frailty-related disability the American Heart Association released another scientific statement entitled, Prioritizing Functional Capacity as a Principal Endpoint for Therapies Oriented to Older Adults with Cardiovascular Disease. And in the report the authors noted that numerous studies have documented the importance of functional capacity as a predictor of outcomes across the spectrum of age including the very old. They went on to state that current standards of disease management have glaring deficiencies in prioritization of interventions to enhance and maintain exercise capacity. And with regard to skilled nursing facilities they pointed out that although 70% of older patients who use SNFs are eligible for some type of cardiac rehab, there typically are no standard cardiac assessments and no cardiac education. Novel programs using mobile technology or telehealth have been demonstrated to be as effective as traditional center-based programs. And here they're talking about tech-enabled cardiac rehab programs delivered wherever is most convenient for the patient. So with these gaps in mind, gaps in centering care around what matters most to patients' functional capacity and independence, gaps in the measurement, monitoring, and treatment of frailty for related reduced cardiorespiratory fitness, I'll discuss the use of telehealth and related technologies as a tool to help rehabilitate frail or vulnerable patients wherever they reside. And so to do this we'll start out by defining frailty. Then I'll discuss how utilizing a rules-based or phenotypic approach to assessing frailty can be achieved without an extensive physical exam, potentially making this amenable to effective telehealth delivery. Then we'll discuss some common underlying determinants for frailty and illustrate how the experience of being hospitalized can worsen these determinants. Then I'll discuss the use of telehealth technology to deliver modified versions of cardiac and pulmonary rehabilitation as potential models for treating frailty before, during, and after a hospitalization. And we'll pause there to contemplate the new and emerging hospital-at-home models of care where we as physiatrists might fit in. So first I'm going to present a real patient to help frame our discussion in the telehealth use case. So we'll call him Randy. Randy is a 68-year-old male who is living at home with his wife, fully independent ambulatory with a cane for ambulation. Randy loved going on walks with his wife and attending church on Sundays. He also loved taking his grandkids to professional sporting events. These were the things that mattered most to Randy. Randy reports that over time as he got older, particularly in his mid-50s, he started putting on some weight and was eventually diagnosed with type 2 diabetes, high blood pressure, and hyperlipidemia. He was started on metformin, a statin, and a beta blocker by his family doctor. He went on to require two additional oral hypoglycemics as his diabetes progressed at age 65. He began getting numbness and tingling in his feet and was told by his family doctor that in addition to peripheral neuropathy, he also developed renal insufficiency and that this was probably due to the progression of his diabetes and high blood pressure. He was started on gabapentin for dysestesias in his feet, Lexapro for mild depression, and melatonin for reports of sleep disturbance. He went on to require Lasix for fluid retention and he reported his system began to slow up from exhaustion and weakness that seemed to be related to the progression of the diabetes and to getting older. And as a result of fatigue and weakness, he became much more sedentary at home. He was taking approximately nine medications at that time and Randy reported eventually needing a cane to help him steady his balance and was worried that he might have a fall. After church on one Sunday, Randy became short of breath and reported chills, a sore throat, ear pain, and a productive cough. His wife became concerned and brought him to the local emergency room. In the ER, his oxygen saturation had dropped down to 70% and his white count was elevated to 18.9. CT of the chest was done, which showed atelectasis and patchy infiltrates. COVID-19 testing was done and was positive. He was admitted to the hospital and treated by infectious disease, but within 24 hours went into respiratory arrest and he required intubation in the ICU. He was eventually extubated after seven days and was transferred to the floor, but remained mostly in bed for another five days. He was noted to be weak, unable to ambulate without assistance, and when he was deemed stable, he was transferred to a subacute rehab facility on five liters of O2 nasal cannula and he was noted to ambulate 10 feet requiring moderate assist. He was followed by physiatry, primary care, and the therapy team. After three weeks in the SNF, he was finally ready to be discharged home and was independent in ADLs, IADLs, and was ambulating 75 feet with a rolling walker distance supervision, but he remained on three liters of oxygen. Just prior to discharge, Randy and his wife met with their physiatrist who introduced them to a telehealth facilitator. The telehealth facilitator helped both Randy and his wife download a telehealth app on their smartphones and then educated them on all aspects of home-based telehealth. The telehealth facilitator demonstrated the use of Bluetooth connected pulse oximeter, a pedometer, and then used the app to assist Randy in completing patient-reported outcome measures that reflected Randy's own assessment of his current degree of dyspnea, his ability to walk, to perform bathing and dressing, to perform usual activities, degree of current pain, discomfort, or anxiety, depression. His health-related social needs at home, like whether he had stable housing that was in good condition, food scarcity, transportation challenges, or had trouble paying his heating and gas bills. Also, whether he felt safe at home. The facilitator also educated Randy on the board ratings of perceived exertion scale, how to keep track of daily steps at home, how to use the pulse oximeter to monitor O2 sats and heart rate. The telehealth facilitator also showed Randy how to send private messages using the app and scheduled a telehealth visit for 10 a.m. on the second day after discharge with the physiatrist. At 10 a.m. on that day, Randy received an email and text message inviting him to the video visit. Randy selected the connect button to begin the video call. The physiatrist had the EMR in front of her and reviewed Randy's case, including two days of Randy's home pulse ox readings and his daily step counts. And during the visit, the physiatrist found out that the home care agency never showed up to Randy's house and that Randy's family doctor was not able to see him for three weeks. Randy was eating okay, but reported feeling anxious since he had never been hospitalized before, never been on oxygen. Per the pedometer readings, Randy was walking around 300 to 400 steps per day and his pulse ox readings were 97% consistent even after walking. He understood that he should keep his rating of perceived exertion to low to moderate or 3 out of 10. He took frequent rest breaks, ate the recommended six small meals a day instead of three larger meals and was performing diaphragmatic breathing to reduce atelectasis. After the telehealth visit, the physiatrist called the social worker at the SNF facility to ensure that the home care had been ordered, gave Randy the phone number of the pulmonologist that he had seen in the hospital so that he could get additional pulmonary support sooner and the physiatrist recommended lowering of the oxygen from three liters to two liters and increasing daily step count targets to 500 to 1,000 per day. Telehealth follow-up was scheduled for the following week at the same time and in between the telehealth visits, step counts and O2 sat data was submitted by Randy at home each day. The physiatrist knew that she would receive an alert on her smartphone if the O2 sat dropped too low or if Randy sent her a message. At the next week's telehealth appointment, the physiatrist was happy to find that the O2 sat had remained at 97% each day, that step counts had increased to 1,200 per day, that the home care team had come out and instituted physical therapy and that Randy was to see the pulmonologist the next day. The home monitoring and weekly telehealth continued for another three weeks until Randy was weaned off of oxygen and his step counts had increased to 4,000 per day. Once this occurred, telehealth frequency was reduced to bimonthly visits for another four weeks until the physiatrist felt that Randy was stable and safe. The physiatrist made sure that there was follow-up with primary care and wanted to make sure that the patient was ready and able to play an active role in increasing step counts to 7,500 per day over the next several months. Prior to the last telehealth visit, the telehealth facilitator helped Randy repeat the initial patient-reported outcome measures to assess Randy's current dyspnea, functional capacity, and mood. Since things seemed stable, the physiatrist told Randy that she would follow him only on an as-needed basis. So as a case study of how to help reduce systemic risk within fragile populations utilizing telehealth to improve quality, let's discuss Randy's journey of risk. From fit and functional to frail and disabled. And let's break it down into three periods of acquired risk so that we can identify some of the risk factors that we can target using telehealth. Randy's three periods of acquired risk included pre-hospital, hospital, and post-hospital. Prior to the hospitalization, Randy had developed potentially preventable comorbid health conditions including weight gain that resulted in a cascade of medication prescription for elevated blood sugar, blood pressure, and blood lipids. He also began slowing up from participating in the activities that he enjoyed, began developing end-organ system damage reflected in renal insufficiency, and he became sedentary. We could surmise that Randy was heading towards a period of increased risk or relative frailty compared to his earlier years when he was fit, energetic, and living with no comorbidities. So I'm sure that many of you have seen patients similar to Randy and as we all know in the United States the health of older patients has become a matter of great clinical interest, particularly since it is estimated that the 54 million adults aged 65 and older is expected to double in size by 2050 and the Medicare Hospital Trust Fund is projected to run out of money by 2028. And as we work to prevent disability and recurrent hospitalization as major outcome measures for population health quality improvement initiatives, there's now a growing evidence base supporting a personalized approach for the care of older patients. This approach takes into account the understanding that older patients can age differently and those who are fit respond differently than older patients who are frail when it comes to physical, cognitive, and emotional responses to stressors like a hospitalization or to Parley Pharmacy or to blood pressure that is too low or blood sugar that is too low. Frail patients are more vulnerable to falls, to recurrent hospitalization, and to all-cause mortality. So frailty has been defined as, quote, a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing dependency and or death. It is associated with reduced functional capacity and reflects the overall vulnerability of an individual relative to others in that same age group. Risk for frailty is increased as a result of aging and from the accumulation of often preventable and lifestyle-related comorbidities like diabetes. From the accumulation of medications or polypharmacy, from loneliness and social isolation, and from overall lack of physical activity. Frailty is associated with the dysregulation of normal homeostatic systems of the body like the immune and energy regulatory systems and it is believed that this can pave the way to adverse health outcomes like those seen with Randy after being exposed to COVID-19. So to better identify frailty in clinical settings, Linda Freed and colleagues... Let me just go back here. In 2001, published in the Journal of Gerontology, a rules-based standardized definition of frailty linked to outcomes assessments in 5317 men and women aged 65 and older followed for seven years and this was based on their previous work and Freed and colleagues diagnosed frailty if three or more of the following criteria were present within an individual. Unintentional weight loss as reflected by 10 pounds in the past year. Self-reported exhaustion. Weakness as reflected by reduced grip strength. Slow walking speed and low physical activity. And during the study period they looked at rates of hospitalization, falls, disability, and mortality within patients who met the criteria of frail. And this frailty phenotype was found to be independently predictive of worsening falls, mobility, ADL performance, hospitalization, and death. Okay, and there's the five components to the phenotype. It was also predictive of cognitive decline and related onset of dementia. Intermediate frailty status or what can be termed pre-frailty as indicated by the precedence of one or two of these criteria showed intermediate risk of these outcomes as well as increased risk of becoming frail over three to four years of follow-up. Therefore, this study offered a potential and standardized definition for frailty and pointed to an intermediate stage that potentially could be a target for preventive rehabilitation delivered using telehealth. Both frailty and possibly related dementia, sometimes referred to as cognitive frailty, have been linked to altered energy metabolism like insulin resistance and to alterations in musculoskeletal function or sarcopenia. They also share some common related risk factors that include aging, genetics, and often preventable metabolic conditions like hypertension, hyperlipidemia, and diabetes. The stress response system is also abnormal in frail patients and similar to many other chronic conditions, inflammation is a hallmark with findings of elevated levels of inflammatory mediators like C-reactive protein, interleukin-6, and white blood cells including macrophages and neutrophils among others. Frailty is also associated with autonomic nervous system dysregulation and with demonstrated reduced second-to-second heart rate variability and compromised orthostatic responses. Frailty is also associated with dysregulation of the hypothalamic pituitary adrenal axis including higher levels of salivary cortisol. Patients who are frail in the setting of congestive heart failure are more likely to die or be admitted to the hospital. Patients who are frail in the setting of COPD are at increased risk of recurrent hospitalizations. Patients who are frail in the setting of a recent hospital discharge are at greater risk for all-cause readmissions. Patients who are frail and undergo a surgical procedure have a two-fold increase in perioperative complications. Patients who are frail in the setting of cancer have more complications from treatments like chemotherapy and worse overall outcomes. Patients who are frail and become infected with SARS-CoV-2 infection have higher death rates as compared to other patients within their same age group with similar comorbidities. So this is from a study that was done at 10 hospitals in the U.K. between February and April of 2020. They looked at 1,564 patients who were diagnosed with COVID-19. The median age was 74. Specialist COVID-19 teams were formed to characterize patients on a fit-to-frail continuum upon admission. The teams utilized a fit-to-frail scoring system to see if they could predict the risk of poorer outcomes. And they found that mortality rates were better predicted by relative degree of frailty than by either age or comorbidity alone. In other words, relative fitness versus frailty predicted the mortality outcomes better than just age and comorbidities with mortality rates at 56% for severely frail patients early on in the pandemic versus 7.7% for those that were very fit. So as a predictive model that may be suitable for telehealth intervention that potentially can be identified through phenotyping, let's expand on this fit-to-frail model that was originally put forth by Ken Rockwood and studied as part of the Canadian Study on Health and Aging. Dr. Rockwood and his team proposed this more expansive phenotypic model. He called this the clinical frailty scale. His research team in 1991 looked at 10,263 older Canadians aged 65 and older through a five-year prospective cohort study. They utilized examination data from this cohort to build and study a relatively simple rules-based definition of frailty and the prior stages that potentially could be targeted for prevention. Their goal was to create a validated tool that could be used at the bedside to stratify patients 65 and older as to the relative degree of vulnerability to poor outcomes. They characterized the stages leading to frailty as very fit. These were patients that were robust, active, energetic, well-motivated, and fit... most fit for their age group. Well, these were patients that... without active disease, but less fit than people in the first category. Well with treated comorbid disease. These were patients with comorbid disease, but disease symptoms were well controlled. Apparently vulnerable or pre-frail. These were patients who, although not frankly dependent, they commonly complained of being slowed up or had disease symptoms. Mildly frail. These were patients who required limited help with IADLs in general. Moderately frail. These were patients who required extensive help with IADLs and ADLs and severely frail. These were patients that were completely dependent on others for ADLs or they were terminally ill. So to assess the construct validity of this phenotypic scale, the authors compared the assigned phenotypic scores to other previously validated tools that measured degree of frailty. In the third arm of the study, which began in 2001, Rockwood and team evaluated those patients that remained alive and found that patients with higher scores on the clinical frailty scale were older, more likely to be female, cognitively impaired, and incontinent. They were more likely to fall, to have impaired mobility and overall function, to have more comorbid illnesses than those with lower scores. They also had the highest rates of mortality and institutionalization. So based on the clinical frailty scale, to better inform us on what happened to Randy, we can place Randy in the apparently vulnerable or pre-frail category prior to his COVID exposure. Randy had comorbid disease, was slowed up, but was still independent in IADLs and ADLs. And if Randy had received a telehealth physiatry consult at home prior to being exposed to COVID, he could have had the opportunity to build fitness and functional capacity in order to improve his diabetes, renal insufficiency, and pre-frail health status. He could have referred to physiatry to oversee and prescribe a multimodal rehabilitation care pathway that would address the underlying determinants or risk factors for weight gain, hypertension, hyperlipidemia, diabetes, and related sedentary behaviors. He could have received a modified version of home-based cardiac rehabilitation utilizing the same telehealth framework that I previously described in Randy's case study to help improve his metabolic parameters as well as his fitness. Home-based cardiac rehab that targets metabolic risk factors has been shown to be as effective as center-based approaches and the American Heart Association is now supporting this approach for better addressing risk factors for cardiovascular disease. So it's not surprising that Randy didn't get treatment for his pre-frail condition, since as we discussed, both fitness and frailty remain the most important outcome measures not routinely assessed within clinical practice. If Randy was stratified earlier as pre-frail and linked to an evidence-based rehabilitation care pathway, perhaps delivered through telehealth at home, it is possible that over time he could have reduced his overall risk for poor outcomes after being exposed to a stressor like SARS-CoV-2 virus. So this idea of modifying or personalizing cardiac rehab for older patients, often with comorbidities, is illustrated in this active clinical trial that is based at the University of Pittsburgh and it's led by Daniel Foreman who is a geriatric cardiologist and he is also a lead author on the American Heart Association's scientific statements that I previously referenced. And here also is a 2021 overview of effective frailty interventions illustrating the importance of delivering a multi-component exercise intervention consistent with best practices from cardiopulmonary rehabilitation. The authors point out that the importance of personalizing exercise prescriptions based on a patient's degree of relative frailty, relevant comorbidities, and degree of functional capacity, very important. So back to Randy. Once Randy was hospitalized with COVID-19 he was likely exposed to additional frailty risk factors connected to the hospital experience itself. Common hospital-acquired risk factors for systemic vulnerability include enforced immobility, poor nutrition, complex medication regimens, disrupted sleep, and stressful environments. These known adverse hospital experiences have been characterized as post-hospital syndrome and this was published in the New England Journal of Medicine by Harlan Krumholz at Yale and this was a condition that he described that reflected a condition of generalized risk similar to frailty or another syndrome, post-intensive care syndrome, which is written about a lot in the critical care literature. And these hospital-acquired syndromes of vulnerability can lead to what has been called hospitalization-associated disability and this was published in JAMA. So cardiac and pulmonary rehabilitation that targets improved functional capacity, improved cardiorespiratory fitness, and improved self-reports of quality of life as principal endpoints utilizing a multimodal self-management support approach, I think could really be beneficial for Randy. If Randy had received a physiatry consult at the time he was transferred from the ICU to a regular hospital bed, he could have begun a care pathway centered around evidence-based best practices from cardiac and pulmonary rehabilitation that would have included extensive self-management education, appropriate bedside exercises, and enhanced support. It is possible that this rehabilitation care pathway could have been initiated utilizing mobile technology in the hospital and then continued into the home or within a skilled nursing facility after discharge. Of note and to reiterate, while traditional hospitals, skilled nursing facilities, home care agencies, and nurse navigator programs connect hospitalized patients to traditional medical and rehabilitation services, they often fail to integrate standardized best practices derived from evidence-based and multimodal preventive models of care like cardiac and pulmonary rehabilitation. In particular, they do not routinely measure and monitor cardiorespiratory fitness or self-reported quality of life during and after a hospitalization. They're also lacking in self-management education and support for chronic conditions and lifestyle, crucial interventions to maximize mobility and mentation within aging populations wherever they reside. So once Randy was discharged home, he still required oxygen and was limited in mobility. Home care was delayed in supporting his transition. Randy felt alone and was somewhat traumatized from the experience of being in a hospital and in the ICU for the first time. He was unsure about his future and his ability to do the things that mattered most to him. And without the use of home telehealth technology, he would have likely not received the additional evidence-based core components from cardiopulmonary rehabilitation that he required for optimal recovery. Multiple gaps in Randy's care management would have likely not been addressed. But because Randy received transitional care telephysiatry services, Randy was able to get help in connecting to a pulmonologist and a home physical therapist. Randy and his wife were also empowered to use their smartphones to receive enhanced self-management support consistent with best practices from cardiopulmonary rehab that enabled Randy to build fitness and functional capacity at home on his own in the face of his COVID-19 pulmonary conditions, his diabetes, his hypertension, his renal insufficiency, and his post-hospital syndrome. So utilizing a mobile telehealth app, Randy was able to keep his physiatrist informed of his daily health status by utilizing a simple pulse oximeter and a pedometer. So in conclusion, the fit-to-frail model that characterizes overall vulnerability to poor outcomes serves as a potential unifying paradigm for an overall health assessment that can be carried out utilizing telehealth. Since it reflects the systemic vulnerability of a patient and can be characterized phenotypically using a rules-based approach and since it can include vital signs and other types of monitoring, it wouldn't be necessarily... It wouldn't necessarily require a complex physical exam and therefore could be amenable to telehealth assessment and intervention consistent with best practices from modified versions of cardiopulmonary rehabilitation. And since staging risk has always been a part of what we do in healthcare and since relative fitness compared to relative frailty, in a medical context, serves as important measures of risk for poor outcomes that are not routinely assessed, physiatrists have an important role to play in home settings where hospital-at-home initiatives are rapidly accelerating. There's at least 92 hospital-at-home programs approved by CMS, but this is only the beginning. We as physiatrists can help hospital systems working within these models transform their older workflows centered around condition management to newer workflows centered around cardiopulmonary and frailty telerehabilitation. We can help them shift beyond medications and remote patient monitoring of vital signs to remote telerehabilitation of overall systemic poor health. Since outcome studies from home-based cardiac and pulmonary rehabilitation reveal similar outcomes to center-based models, telehealth offers the great promise of transforming the future of home-based care and hopefully physiatrists can play a leading role. So thank you and I will leave this slide up for... to foster discussion or any questions. Great. Well, thank you, Steve. Let's do a round of applause. Um, why don't everybody stand up a little bit, because we've been listening a lot and I need to stand. So let's do that. Get a little active here. Okay. Get some blood flowing. So at this point we've got about 20 minutes of time together and I want to take advantage of that time to kind of have some discussion, some dialogue with each other. I'm going to be moderating at this point and there are some questions coming in through the online app and then what I'd like... I think would probably be more practical is if you guys in the audience can give us your questions and I'm going to repeat them into the mic so that they... to make sure I first of all get the question right and then make sure it gets in the recording. Okay. Because we... You know, this is a... I mean, you know, when I listen to Steve I'm like, oh my gosh, so much information, right? But you can take this talk and really do something with it, right? There's a lot of value in how well he's organized the literature and I think these are things that we intrinsically understand as rehab docs. I mean, we've seen it so often and it's frustrating that other physicians don't necessarily really understand what we do. So, you know, a lot of times you just have to show them, right? And you know, many times my experience in my career has been if a physician's family... But, I think what we're good at as a specialty is making things simple in a way that people, you know, can meet people where they are. And I would just say one of the most powerful things that I learned from Steve is that, you know, because when I went through residency, yeah, I learned about cardiac rehab. And so, I think it's pretty clear that that center-based idea of everybody coming in and doing it isn't going to work. Okay, I don't think we need to argue on that one. And so, you know, how can we bring these services into people where they are, right? Into their homes. And that's just such a powerful idea. And it's unifying. And if we can think about really how to... So, at this point, I'm going to start with the online question, and then open it up to everybody else. So, I'm going to go ahead and read our first question from Erica David, and her question is, do you have thoughts on the use Yeah, so that's a great question, because Todd and I, we grew up in a fee-for-service world where our ability to deliver care was somewhat constrained by what... We strive to get better outcomes for the patient. We monitor those outcomes and we figure out the processes that achieve those outcomes, irregardless of the CPT codes that limit us in some ways. And so I think one thing to think about is as a physiatrist, if someone hands you a thousand patients and says, you get paid X dollars, but you get to keep whatever money is left over if you can coach that patient to health over the next year. How would that affect what you did as a physiatrist? Start to think about that, because that's kind of a little bit of that value-based proposition. And other things to think about, you know, we all grew up with disease-specific guidelines centered around specialists, but for older patients, if you have five comorbidities, the system puts you on five evidence-based guidelines at the same time without looking at the overall systemic health of the patient. And that's why the fit-to-frail paradigm is that unifying value-based population health way to think about the patient. A lot of the older population health initiatives were still centered around disease registries, but we know that for older patients who have diabetes, some are running marathons and some are frail. And so just being on a diabetes list doesn't necessarily tell you the systemic overall health of the patient, number one. Number two, it appears that exercise capacity may be the number one risk factor for chronic disease in the population and it may turn out to be a crucial component of outcomes that we choose for value-based care. And so the thing on my mind and what launched my journey over eight years ago of starting to think about this is, who in healthcare is going to take charge of functional capacity and exercise capacity, related exercise capacity? Is it going to be primary care? So I was on a big advisory board with primary care with 25 physicians and after several years of thinking about how to help with outcomes, I realized that primary care, which is expanding in the U.S. and they're going to be the quarterback of care going forward, they need help in this fit-to-frail delivery model to make patients more resilient. And fitness is... Rockwood looked at this concept of resilience as fitness. Linda Freed, who wrote the original paper, who's now the Dean of Public Health at Columbia Mailman School, she calls it resilience. So... And resilience is basically, you may be okay at rest, but if you're faced with a stressor, how do you respond to that stressor? So that's the delirium. That's the falls. That's the hospital readmissions, most likely. And so I think that to answer your question, I believe that the value... that the shift to value-based care, to me, is a shift to functional capacity. And I'm not just talking about physical functional capacity. I'm also talking about cognitive functional capacity, because we also know from the Lancet Commission report that about 30% or so of Alzheimer's disease is felt to be preventable or at least delayed. So... So Steve, can I add my two cents to that one? Sure. So... And it's really clear that Steve is such a deep expert on this and we're really fortunate to have him in our specialty and I feel good, because I brought him back into the Academy. Because for years he had been disconnected from the Academy like I had been. I think my disconnection was through my informatics career and I think rediscovering at this point in our lives, you know, the value of getting back together. And I'm really glad that I got him to come back into the fold, you know, to help us. So I'm going to give a slightly different take on kind of this value-based care thing. Value-based care has really kind of been this thing that's been sitting there out there for a lot of us, right? You know, we're sitting there hearing about value-based... I think that the primary care docs, you know, appropriately have been the center of a lot of the value-based care payment because, you know, they're supposed to be the quarterback of the patients, but realistically what we're talking about, and we live this all the time, we're in this high... So that, you know, 10 to 20% of the patients at the primary... So I think what we really need to be able to do is to figure out how to reposition ourselves so that we can scale out our services so that we can be relevant to a larger community. So the question I think we all have to ask ourselves is, how are we going to organize in a way that we can be a really valuable service? And in a value-based care world, the easiest definition of value that I've ever heard was quality over cost. So that's what value is, right? And then, you know, so that sounds like a simple equation, but you really have to be measuring and agreeing on what is the quality that you're measuring. And to Steve's credit, he's really laid out some really valuable evidence that says, here's what we should measure, okay? And, you know, something like step count can be a surrogate. and how to re-correlate that with, you know, valuable cost reduction, okay? And so, I always think about just mechanically... Well, how do you do that? Well, you know, we've all watched. that pool of money is predicated. More interesting is that, let's say that you're the top dog and you do the best, and the others don't hit their metrics, you get all their money. Okay, so this is a pool of money. You can get, you're 20% or you can get 100%. So it's very, there's a financial motivation. I'm not saying that's easy to do, but I think Pima and our docs were... but plugged into these really well thought out programs. It's not just like a random telemedicine thing. It's plugged into these programs and that's stuff that Steve and I are working on. Does that... Hopefully that makes sense. That's just kind of a different perspective. We've got a number of other questions coming in and the next one is from Isaac Sirop and he said, so thank you for the great talk. for this. So I'm going to take maybe my first crack at that one and we've got about seven minutes so I want to try to be brief on these answers. So I want to get folks in the room to kind of give us their questions too, because you've been really patient with us. So I would just say that the unifying... the biggest problem is... You talk to folks at places like Cleveland Clinic, they kind of have that, so there's people in a waiting room, there's a check-in process, and the docs can kind of function. So a lot of it isn't so much. So it's not a lot of these platforms have this capability, but we have to think about staffing models And you know what is it that we do? But we get a little more, because telemedicine is new. Okay. So I want to acknowledge one more thing and then we're going to go in the room. And the next one is not a question, but he's, Aziza Kamani wanted to say, thank you for this talk and identifying this gap in care. So many patients are overwhelmed during the initial transition home and although a PCP visit does often occur within the first week, the focus is generally on events that have occurred and not how to move forward or to improve quality of life. So financially many readmissions occurred during that initial transition to home period and so many falls too and this is an excellent idea. Physiatry should be involved, you know, in the transition at home and telehealth. So I really appreciate that comment. That really reinforces. So at this point I want to thank everybody in the room and we've got five minutes and I'd like to hear questions folks have, you know, kind of thoughts, questions. Great. So let me restate that so everybody can hear it in the room and also online and I hope I get this right. So thank you for that. So a really thoughtful comment about, you know, where is this kind of intersection of telehealth, telemedicine, and lifestyle medicine, right? And you know you're discussing kind of the things you guys are doing from an evaluation perspective in lifestyle medicine, like sit to stand testing and you know that kind of work. And then the question that I heard was, you know, where are we on these sensors, these wearables, you know, and you know what is the state of the technology and what should we know about that? Is that kind of a good summary? Okay, great. So I'm going to let Steve address this because I absolutely know he's an expert in this area because we've had a lot of conversation over this. Yeah, so great question. You know, so when you think about telehealth, it's more than just video calls and that's one of the things you're pointing out. And it also could include a mobile app, which could record the measures that you outlined, you know, such as sit to stand and any other outcome measure, including self-reported health measures. So that's unlimited if you have... functional capacity, and then the therapist check... mimic that same model and maybe even do it better if we expand on the number of data points that come into us. So right now I think in terms of, you know, some of it is what would we want to monitor? What is the FDA approved for monitoring? The standard remote patient monitoring right now is mostly built around pulse oximeters, blood pressure cuff, weight scale, but there's a lot of other data points that are valuable, not necessarily cleared by the FDA necessarily, but still emerging as valuable data points. Quality of sleep, details about the sleep, monitoring heart rate and pulse ox overnight to perhaps pick up sleep apnea, certainly habitual physical activity. Intelligence is evaluating voice recognition in the phone to pick up mood as one thing. They're also... So, at this point we're kind of at that 20 second mark and what I'm going to do is invite folks to talk with us more in the hallway if you guys want to talk. And I just want to thank everybody for being here and thank the audience. And I think at this point we're going to stop the recording. Thank you

telehealth

patient-reported outcome measures

mobility

risk management

frailty

assessing frailty

managing frailty

functional capacity

telehealth assessment

cardiac rehabilitation

pulmonary rehabilitation