Virtual Therapy: Using Tele-Video to Promote Aging in Place

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Virtual Therapy Using Tele-Video to Promote
Aging in Place
Jon A. Sanford, M.Arch Helen Hoenig,
MD Supported by grant E2806T Rehabilitation
RD Service, Dept. of Veterans Affairs
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Background

• Difficult for individuals aging in place to
  access appropriate services, particularly those
  living in remote areas
• Many services not provided in-home due to cost
  and/or lack of capacity to provide services
• Difficult to get to centralized medical
  facilities for treatment or outpatient follow-up
• Clinicians often have limited insight into how
  individual is functioning in home environment

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Potential Solutions

• Provide on-site in-home services (e.g., OT/PT)
• Cost prohibitive, particularly in remote
  locations
• Difficult to involve same clinicians who worked
  with individuals on either in- or out-patient
  basis
• Provide teleconference in-home services
• Less costly
• Can involve clinicians

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Pilot Project Remote Home Assessment

• 3 step process
• Photographs
• Triage
• Tele-video assessment

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Tele-visit Detailed Information
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Virtual Therapy Using Televideo to Support OT
PT Services

• RCT to evaluate efficacy of therapeutic
  interventions delivered by tele-visit and
  site-visit vs. no intervention
• Collaborators Atlanta VA, Durham VA and
  Shepherd Center

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Purpose

• Document that providing in-home therapy will
  produce health-related and functional gains
  compared to the current standard of care
• Delivery of this care via telerehabilitation to a
  patient at home will be a lower cost delivery
  modality

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3 Groups

• Usual Care only receive physician ordered
  therapy
• Home Care in-home visits 1x week for 4
  consecutive weeks
• Remote Care tele-video visits 1x week for 4
  consecutive weeks

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Year 1 Develop Data Collection and Intervention
Protocols

• Demographic and Health Status Data
• Video Observation Data _at_ Baseline (wk 1)
• Intervention Data
• Activity Log
• Falls Journal
• Video Observation Data - immediate post
  intervention (wk 6) and longitudinal post
  intervention (6 months)

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Demographic and Health Status

• Demographic Information Form
• Self-report Mobility Disability Scale
• Mini Mental Status Examination
• Self-report Medical Conditions/Meds

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Baseline Observation Data (Wk 1)

• Single Chair Stand
• Videotape of Mobility/Transfer Activities
• Getting on and off toilet
• Getting in and out of shower
• Getting in and out of bed
• Moving from room to room
• Using the refrigerator (maneuvering)
• Getting in and out of the house

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Intervention (Wks 2-5)

• Exercises
• Standardized Transfer/Mobility Protocol
• observation/assessment
• individualized exercise protocol
• training
• Recommendations for
• removal of environmental barriers
• modifications to home
• additional AT

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Exercises

• Based on Sit to Stand Performance from Wk 1
• Level of Exercises
• Unable to Sit
• Can Sit but Can't Stand
• Can Stand but Can't Walk
• Can Walk
• Level of Assistance
• Unable
• Physical Assistance
• Verbal Assistance
• Independent

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Exercise Handouts

• adapted from Alexander (JAGS, 11/2001,Vol.49, No
  11, pgs 1417-1421) and FIT project.

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Observation Protocol

• Assess subject carrying out transfer/mobility to
  identify problems
• Intervention Wk 1 Activities
• Getting on and off the toilet
• Getting in and out of tub or shower
• Getting in and out of bed
• Subsequent Visits
• Review progress
• Engage in next protocol

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Problem Identification
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Recommendations Adaptive Prescriptions

• Adaptive Equipment
• Changing the Environment
• Transfer techniques Mobility Methods

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Adaptive Prescription Equipment
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Adaptive Prescriptions Environment
Methods/Strategies
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Adaptive Prescription Handouts
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Handouts Transfer Techniques
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Handouts Mobility Methods
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Activity Log
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Activity Log Week 1
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Activity Log Week 2
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Falls Journal
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Video Observation Data (Baseline, Post,
Longitudinal)

• Motor FIM
• Enviro-FIM
• Maneuverability Scale
• Task Completion Time

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Motor FIM

• Level of Assistance Key
• 7-Complete Independence
• 6-Modified Independence
• 5-Supervisions or Set-Up
• 4-Minimal Contact Assistance
• 3-Moderate Assistance
• 2-Maximal Assistance
• 1-Total Assistance

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Enviro-FIM
E-FIM Scoring Key 10-Independent/ no
assistance 9-Additional time 8-Assistive
device 7-Modified environment 6-Safety
considerations 5-Supervision/set-up 4-Minimal
contact assistance 3-Moderate assistance 2-Maximal
assistance 1-Total assistance 0-Activity not
completed
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Maneuverability Scales
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Task Completion Time
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Initial Impact on Subjects (n10)

• Improved usage of prescribed equipment and
  recommendations for modifications new equipment
  for all Ss enrolled
• Placement of tub transfer bench corrected (n2)
• Grab bars added to replace use of towel bars
  (n2)
• Safety frame provided for toilet transfer (n1)
• Handrail added to facilitate going up outside
  stairs (n1)
• Recommendations to clear obstructed pathways or
  remove hazards (n4)
• Replacement of a old hospital bed (n1)
• Correction of transfers as post-surgery hip
  precaution (n1)

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Subjects Responses

• It was much easier than having to travel to the
  VA hospital
• Helped me to stop and think for myself
• Helped me to plan what to do and how Im going
  to do it so that I dont fall
• I have more endurance since Ive been doing the
  exercises the therapist recommended

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Future Use of Televideo

• Low Vision Activity Training
• Community Falls Prevention Programs
• Workplace Assessment

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Thank you.

• Questions?
• Jon A. Sanford, M.Arch
• Research Architect
• RRD Center, Atlanta VA
• jon.sanford_at_med.va.gov

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(No Transcript)
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Subjects (n 150)

• Older veterans (Durham VA) and SCI patients with
  paraplegia (Shepherd Center)
• New mobility device users (lt 2 mos. experience)
• Dependencies in basic ADLs, but capacity for
  improvement
• Not require continuing, long term rehab
• Cognitively intact

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Intervention Data (all Ss)

• Within 1 week of discharge
• Home visit by RA trained to implement activity
  protocol
• Videotape record of performance

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Project Journal Data (all Ss)

• Pre-coded forms will be developed to record
• wheelchair accidents
• pressure sores
• home modifications
• AT purchased
• outpatient therapy
• RAs will call Ss weekly to obtain information
  (IOW to remind Ss to complete forms)

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Intervention (I1 and I2 Ss)

• Delivered by therapists either by site- or
  tele-visit to Ss in 2 intervention gps
• Control gp receives no therapy other than
  physician ordered

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Repeat Measurement Battery (all gps)

• At 6 weeks and 6 months
• Home visit by RA
• Videotape record of performance in activity
  protocol

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Score Videotapes

• All data sent to Atlanta coordinating site
• Therapists blinded to gp assignment will score
  observation protocol
• Scoring will not begin until after all data
  collected for an individual Ss
• Audio portion of tape turned off
• No time/date stamp

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Data Analysis

• H1 Changes in activity performance
• Primary repeated measures ANOVA of a 3 group,
  randomized trial to assess the change in FIMTM
  and Enviro-FIM scores from baseline to 6 weeks
• Secondary compare changes from baseline to 6
  months and 6 weeks to 6 months to test for
  long-term differences and retention of gains,
  respectively
• Secondary Analysis of cost data to determine the
  additional costs associated with instituting a
  program of in-home follow-up care compared to
  standard care and differences in cost between a
  conventional in-home program and the cost of
  telerehabilitation in-home program

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Data Analysis

• H2 Wheelchair use and environmental barriers
• logistic regression analyses for ordinal level
  variables of perceived wheelchair fit and
  maneuverability
• multiple linear regression or analysis of
  covariance for continuous dependent variables of
  physical wheelchair fit, mobility, and percentage
  of environmental barriers modified

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Data Analysis

• H3 Caregiver assistance
• Multiple linear regression or analysis of
  covariance will be used for the continuous
  dependent variable of hours of caregiver
  assistance
• H4 Health care utilization
• Multiple linear regression or analysis of
  covariance for continuous health status variables
  including, number of re-hospitalizations, nursing
  home stays, and outpatient visits.
• If preliminary analysis demonstrates the efficacy
  of the intervention, a formal analysis of cost
  effectiveness (C/E ratios), comparing
  telerehabilitation to usual care will be pursued.

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So stay tuned

• Thank you.