As a general rule, home telehealth programs for post-stroke patients are delivered by physiotherapists and nurses. The prominence of the former is due to the frequency with which home telehealth is used for post-stroke rehabilitation. In cases where home telehealth is used in oral anticoagulation therapy, for education, or for emotional support, the health care provider is more typically a nurse.
There is little information available on the role of care coordination in home telehealth for post-stroke patients. While there are some models of care in which a specialist or physician provides expert consulting services, primary responsibility for day-to-day patient care in these cases still rests with nurses. Information on the level of commitment demanded of the supporting personnel in home telehealth – technical staff and patients’ general practitioners, for instance – is elusive.
Provider time requirements appear most predictable in rehabilitation interventions. These programs often use the same appointment pattern as usual care: 5 1-hour sessions per week for a total of 20 hours per month per patient. Time commitments for remote monitoring interventions tend to be lower (~10 hours per months), but far more variable. Daily time per patient may be over 30 minutes or under 2 minutes. This is determined in part by the content of patients’ data transmissions. Some remote monitoring systems are used in conjunction with a decision support tool that automates part of the clinical assessment and feedback process. While this feature might be expected to reduce providers’ overall workload, its effects have not been adequately quantified.
Provider experiences are a large gap in the literature. A number of studies involve research personnel in the home telehealth intervention. Though this choice may be dictated by external circumstances, it presents a clear conflict of interest and poses a barrier to realistic assessment of provider uptake.
Uptake and Use of Technology
Summary: Only 2 studies reported on provider experiences and uptake of technology (Ryan et al., 2009; Salvador et al., 2008). While both found high levels of acceptance, the rarity with which these outcomes are reported is a notable shortcoming of the stroke literature.
Study Details: In 1 study, pharmacists involved in delivering stroke care accepted dosage recommendations by the expert system in 97.2% of situations (Ryan et al., 2009). This suggests either high levels of trust in the system or strong likelihood of agreement between the decisions made by the programmed algorithm and the pharmacists. Salvador et al. (2008) reported on provider compliance with the intervention protocol and found that over 90% of physicians in the study responded to patients within 1 to 3 days of receiving patient test results.
|And on the qualitative side . . .Therapists in Damianakis et al. (2008) were surveyed about their perceptions of a web-conferencing system for group therapy sessions with caregivers of stroke patients. A number of respondents commented on technical issues. These comments included the observation that a lot of pre-work and discussion of logistical details was needed to set up the sessions, entailing a constant flow of communication between the therapist and participants. However, this work decreased as everyone became more comfortable with the technology. Interestingly, several participants commented that working through the technical difficulties during the session actually created a sense of unity and helped with group bonding. Therapists thought the sessions were very positive and successful despite the technical difficulties. Most therapists believed that they could deliver care in online sessions as effectively as in face-to-face meetings.|
Effects on Practice and Patient Care
No cost or time savings outcomes were reported in the quantitative studies retrieved.
|And on the qualitative side . . .Responses from the 9 therapists surveyed in Damianakis et al. (2008) give insight into the perceived effects of web-conferencing on group therapy sessions. The quality of discussion was generally viewed as high. Therapists reported that the online system actually enhanced communication, as only 1 person was allowed to speak at a time. As a result, other participants were more attentive and the group as a whole strayed off-topic less than in face-to-face sessions.
The video feature meant that participants could still see body language and visual cues. However, therapists also noted that the set-up sometimes led to lack of spontaneity, as the therapist was in control of who talked and participants could not interrupt.
Interestingly, the level of group bonding in online sessions was seen as equal or even greater to that achieved in face-to-face sessions. Participants felt that groups were quite bonded after the first 3 to 4 sessions. Some felt that there was greater emotional disclosure in the online environment.
Survey respondents also recognized the importance of the therapist as a facilitator. The therapist’s role required them to clarify and summarize emerging themes for participants. All therapists surveyed agreed that facilitating sessions through web-conferencing was a bit more work than doing so face-to-face, especially since participants had to be trained to use the technology.
Cost and Time Savings
No cost or time savings outcomes were reported.