Telehealth shows promise at Alabama rehab facility
Program uses FOCUS model
When hospital lengths of stay were longer, the idea of telehealth rehab might not have seemed feasible, but in the current health care environment it is an attractive prospect for keeping tabs on discharged patients’ progress.
"We’re trying to provide services of care in an expedient fashion, using a health promotional model," says Timothy Elliott, PhD, associate professor and psychologist at the University of Alabama at Birmingham. Elliott directs psychological services at Spain Rehabilitation Center in Birmingham.
Addressing transportation problems
Focus groups said patients and families often failed to attend outpatient rehab clinics because of transportation problems.
"We realized that many of our family caregivers were unable to make transportation arrangements to come in and see us," Elliott says. "Many might be 200 miles away, and a trip to Birmingham is a major undertaking for these people, particularly if you have a loved one with a severe disability."
Telemedicine, using televisions, cable lines, and telephones, provided a practical solution to this obstacle to patient follow-up.
Spain Rehabilitation Center still provides extensive inpatient rehab services, which often have to focus on patients’ pulmonary problems, neurological problems, hypertension, and fatigue, as well as offering traditional rehab therapy, says Amie Jackson, MD, professor and chair of the department of physical medicine and rehabilitation at the University of Alabama at Birmingham.
Also, the rehab facility has developed a strong outpatient program, but there still is a need for additional follow-up services, including telephone contact and telemedicine, Jackson says.
"Telemedicine is a little better because of the visual contact," Jackson says. "It’s a step to providing education and support and letting the family know that we are still there and they can rely on us when they have problems."
Here’s how the program works:
1. Invest in telemedicine equipment.
Most patients of the rehab facility did not have access to computer and Internet technologies, so the telemedicine program needed to use television sets for visual communication, Elliott says.
"Our system is based upon a relatively inexpensive mobile unit that hooks up to a person’s television through their cable jack and plugs into the telephone jack," Elliott explains. "Theoretically, it has a refresh rate that is comparable to television, but it’s dependent on the quality of telephone lines, and most lines in this state are antiquated."
The refresh rate is how quickly a screen changes. Computer video images often appear to stutter because they have slower refresh rates.
However, if the refresh rate is slow, it’s not a problem because the telemedicine program is not designed to provide exercise motions via video, Elliott adds.
The equipment has come down in price to less than $100 per unit, and the program receives grant funding to pay for it.
Caregivers assessed along with patients
2. Set appointments and treatment strategy.
The program schedules monthly follow-up appointments with spinal cord injury patients and has patients and/or caregivers sign consent forms. At each session, which lasts 15-20 minutes, caregivers are asked about their health and well-being and are assessed for problem-solving ability, and patients are assessed for problem-solving ability and physical well-being with regard to pressure sores, says Patricia Rivera, PhD, rehabilitation psychology fellow at the University of Alabama at Birmingham.
Because the project is part of a study, participants are randomly assigned to an intervention program that includes an hour-long educational session and training in a five-step problem-solving model that is developed from work by Art Nezu, PhD, a psychologist at Hahnemann University in Philadelphia.
The five-step model is represented by the acronym FOCUS:
- Facts;
- Optimism;
- Creativity;
- Understanding;
- Solve.
"We believe if caregivers know the facts and are optimistic and creative, they can better understand problems and solve them effectively," Rivera says.
3. Educate caregivers.
The intervention program begins by giving caregivers strategies for identifying major problems, Rivera says.
"We define the problem as specifically as possible and get as much information as we can about it," Rivera says.
For example, if the problem has to do with bladder management, the strategy is to find out what might be causing the problem, such as dietary factors and medication.
Teach caregivers to relax
Next, Rivera will teach caregivers about the relationship between their own emotions and the outcomes. "If they’re in a negative frame of mind, angry, or stressed out, they won’t be very effective in solving problems," Rivera says.
"So we’ll teach them brief relaxation exercises, including guided imagery and progressive relaxation that incorporates deep breathing," Rivera explains.
Then, caregivers are taught how to brainstorm effectively.
"It’s difficult because caregivers are stressed," Rivera says. "We make them relax and encourage them to be optimistic so they’ll be less inhibited and can elicit some creative responses."
This part of the training is both the most challenging and the most rewarding, Rivera notes.
"The caregivers see how many solutions they’ve come up with, and it gives them a sense that they’re not as boxed in as they felt they were," she says.
Another step involves understanding.
"Mostly we want them to understand what the consequences are for each of the possible solutions," Rivera says.
For example, one possible solution for the patient’s bowel problems would be to do nothing. So Rivera will help the caregiver examine that strategy and understand its consequences.
Caregivers are asked to write down these strategies and solutions, and when they decide one will not work, they can cross it off their list.
Finally, the caregiver will solve the problem by choosing one of the solutions. This doesn’t always result in success, but the idea is that the caregiver has come up with a plan.
"It may be a solution that I as a professional know is doomed for failure, but that’s within their learning experience," Rivera says. "Of course, I won’t let them do anything that’s dangerous to themselves or their loved ones."
The whole idea of the program is to empower patients and caregivers and turn all of their experiences into opportunities to learn, Elliott says.
Considerable problems with depression
4. Structure the program as a continuum of care model.
The program’s value lies in how it helps caregivers, as well as patients, cope with the injuries and stay mentally and physically fit, Elliott says.
"We have another data set that followed caregivers over the course of a year without any intervention," Elliott says. "Almost 50% of that group of caregivers had scores in the depressive range, indicating they were having considerable problems with depression."
Those caregivers with depression problems were more likely to take medications, Elliott adds.
"Health care systems are continuing to evolve, and there will continue to be reformation through the years," Elliott predicts. "The tragic part is that consumers with any chronic health care condition have less and less input into the system."
This often is due to lack of health care funding and lack of access in rural areas where managed care companies have little competition and therefore can limit services provided to the elderly and chronically ill.
"People usually find this out the hard way, but what happens is that they have to care for an aging or chronically ill patient, and they are amazed by the lack of training, accessibility, caring, and social and public programs for their loved ones," Elliott says.
Home health services provide some nursing services, but that has been drastically cut back in recent years because of the prospective payment system, and Medicaid offers very little help in most states.
"If someone has a disability in one of these poor states, the best thing they can do is to move to another state," Elliott says.
Because the managed care fee-for-service model doesn’t work for services like the telemedicine program, it’s best to design such a program as a continuum-of-care model, Elliott says.
The telemedicine model provides caregivers with the follow-up education that will help them cope with their new role and do a better job of identifying and solving their loved ones’ physical problems.
People don’t just go home and get better’
"We have to be sensitive to the realities of their lives," Elliott says. "Our research indicates that if the caregiver is upset during the patient’s inpatient stay, then they’ll be more so throughout the year because people don’t just go home and get better."
This type of continuum-of-care program could be offered in less expensive models, as well, including simple telephone follow-up.
5. Provide other types of follow-up.
The rehab facility contacts patients by telephone after discharge to see how they are doing during their first few days at home, Jackson says.
Psychologists, therapists, and nurse practitioners will call patients to check on their progress. In some cases, they will e-mail patients with a turnaround time of 24 hours on all questions the patients and caregivers ask.
"And we’ve gotten better with written educational materials," Jackson says. "Now we have everything written on a fourth-grade level."
Research has shown that 80% to 90% of the people in Alabama would understand the educational materials if they are written at the fourth-grade level, Jackson adds.
"We have a whole series of information sheets that deal with all kinds of problems with spinal cord injury and other areas," she says. "We also use videos, audio tapes, and other things."
There also is access to educational programs geared toward consumers through the Internet for patients who own computers.
"We’ve gotten a lot better at disseminating information," Jackson says. "Before, we kept it all in the rehab center, but now we have it available by some other means when people leave rehab."
Each year there is an education day when patients and caregivers can return to the rehab facility. Participants can pose questions to a panel of medical professionals.
Patients also can find answers to their questions over the Internet and through telephone conferencing.
Need More Information?
- Timothy Elliott, PhD, Associate Professor and Psychologist, University of Alabama at Birmingham, Department of Physical Medicine and Rehabilitation, 619 19th St. South, Birmingham, AL 35249-7330. Telephone: (205) 934-3454.
- Amie Jackson, MD, Professor, Chair, Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Spain Rehabilitation Center, 1717 Sixth Ave. South, Birmingham, AL 35233. Telephone: (205) 934-3330.
- Patricia Rivera, PhD, Rehabilitation Psychology Fellow, University of Alabama at Birmingham, Department of Physical Medicine and Rehabilitation, 619 19th St. South, Birmingham, AL 35249-7330. Telephone: (205) 934-3454.
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