Case Report Home Clinical Video Telehealth Promotes Education and Communication with Caregivers of Veterans with TBI
Haniel Hernandez, DPT, Joel Scholten, MD, and Elsie Moore, LCSW Polytrauma/TBI Rehabilitation, Physical Medicine and Rehabilitation Service, Washington D.C. Veterans Affairs Medical Center, Washington, D.C.
Abstract Ongoing communication and care coordination are essential among patients, their family, and interdisciplinary rehabilitation team members to address the complex and changing rehabilitation needs of traumatic brain injuries. Family members of patients with traumatic brain injury commonly assume a caregiver role following discharge from inpatient rehabilitation. The Department of Veterans Affairs has adopted clinical video telehealth to promote access to care, and use of clinical video telehealth for rehabilitation is expanding. Recent implementation of home clinical video telehealth can assist with the ongoing management and treatment of patients in their home setting. This report demonstrates enhanced education and care coordination by using clinical video telehealth with a Veterans Affairs–eligible beneficiary receiving treatment for traumatic brain injury. Key words: traumatic brain injury, polytrauma, telehealth, rehabilitation, telerehabilitation, clinical video telehealth, longterm care, family and caregiver support, chronic disease care
Introduction
A
s of May 2013, approximately 57,000 Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) service members have been wounded or killed in action, and approximately 280,734 new cases of traumatic brain injury (TBI) have been diagnosed since 2000, according to the Defense and Veterans Brain Injury Center.1 Care of patients with TBI requires a coordinated interdisciplinary approach with ongoing communication among the patient, family, and members of the interdisciplinary treatment team. Recent evidence indicates that the residual effects of TBI may evolve and change with time and are not static after
DOI: 10.1089/tmj.2014.0155
initial recovery, as previously believed.2 To enhance the emerging concept of TBI as a chronic condition, new methods of follow-up care and case management are being explored. A wide variety of conditions that range from pneumonia to circulatory problems may occur in the chronic phase following TBI.3 Ongoing medical and rehabilitation evaluation of the patient with TBI after inpatient rehabilitation can be challenging due to unique needs, geographic access to care, and demands on caregivers. Rehabilitation efforts should be monitored and updated periodically to address the evolving needs of the patient. Along the spectrum of care the responsibilities of caretaking often shift from institutionally provided formal care to family-provided informal caregiving.4 Research has shown that the role of caregiver is most often taken on by the parent(s) of the injured patient, and these caregivers may require assistance and support related to emotional issues, navigating healthcare benefits, managing pain, and aiding therapies and assistive devices.5 Caregivers of patients with TBI require ongoing education on various topics, including understanding the purpose of rehabilitation and how it facilitates recovery to caring strategies and recognizing changes in the medical status of the patient.6 Timing of education for caregivers is also important. Typically the majority of education for caregivers is provided during the inpatient rehabilitation phase, and this timing has been found to be an ineffective method of caregiver education. Studies have shown caregivers of individuals with TBI reported not being able to retain or implement information given to them because they were not in an emotional state to learn and the information did not apply to their situation at the time it was being provided.6 As a relatively new mode of healthcare, telehealth is being used in the management of patients with chronic brain injury in order to provide assessment, evaluation, and communication to better fit the chronic disease model of care. Telehealth is a cost-effective method to provide follow-up care while minimizing the burden of travel for patients who are encumbered by disability or geography.7 Veterans Affairs (VA) telehealth services were first established in 2003 as a national pilot program in five Veteran Integrated Service Networks to support new models of care using the leading-edge health
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information technologies to address pressing health needs of veterans.8 The VA has recently added Clinical Video Telehealth (CVT) to Home (CVTHm), which is a viable method of supporting veterans who may be isolated by disability, geography, or poverty.9 Rehabilitation team support and case management/care coordination via CVTHm can help address the concerns of caregivers and provide assistance with the issues that are being faced in the home setting. Telehealth in the VA is defined as follows: ‘‘The wider application of care and case management principles to the delivery of health care services using health informatics, disease management and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.’’10 All forms of telehealth serve a great purpose in providing timely communication between patients and healthcare providers and facilitating the delivery of healthcare information. Telehealth is used in two general ways in the VA: 1. CVT. This mode of communication is defined as the use of real-time interactive videoconferencing (sometimes with supportive peripheral technologies) to assess, treat, and provide care to a patient remotely. Typically, CVT links patients at a clinic to the providers at another location. CVT can also provide video connectivity between a provider and a patient at home (CVTHm).10 2. Home telehealth. The term home telehealth applies to the use of telecommunications technologies to provide clinical care and promote patient self-management as an adjunct to traditional face-to-face care. Health information is exchanged from the patients’ home or other location to the VA care setting, thus alleviating the constraints of time and distance.8 The goal of this variation of telehealth is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for patients in post-acute care settings and high-risk patients with chronic disease.10 Home messaging devices are used with scripts tailored to a specific disease model that assist patients in managing a chronic disease condition such as diabetes, congestive heart failure, etc. OEF/OIF/OND veterans with TBI require varying intensity and duration of rehabilitation. Factors that may influence a clinician’s decision regarding long-term rehabilitation include severity of injury/impairment, the available support system of the veteran, and potential for functional improvement. Following discharge from acute inpatient rehabilitation, the burden of care is shifted to the family/caregiver. Effective communication and education for caregivers are
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needed to promote continued advances in functional abilities of the veteran and to support caregivers. Although telerehabilitation is relatively new to the field of telehealth, it has been emerging and developing slowly within the VA over the past decade.11 Telerehabilitation care involves the use of electronic information and telecommunication technologies when patients and providers are separated by geographic distances; this includes teleconferencing with therapists at polytrauma system of care locations with a veteran patient at the local VA community-based outpatient clinic, or using home telehealth technologies to connect with patients at home to monitor their functional status and equipment needs.12 This case report describes the utilization of CVT to enhance treatment, communication, and education for a VA-eligible beneficiary receiving treatment for TBI and his caregivers and its implication in telerehabilitation.
Materials and Methods CASE DESCRIPTION Mr. S is a 28-year-old OEF/OIF/OND veteran who sustained a severe TBI following a stateside motor vehicle accident in 2010. Initial brain computed tomography scan revealed predominant right hemisphere diffuse hemorrhagic contusion with intraventricular hemorrhage and right subdural hematoma. Following 3 months of acute medical hospitalization he was transferred to an acute rehabilitation facility for 2 months. He was then treated for 4 months in a residential rehabilitation program for persistent cognitive deficits and then discharged home with his parents. This veteran initially received his care at Walter Reed National Military Medical Center and then had his care transferred over to the Baltimore VA. The Washington DC VA Medical Center (DCVA), the polytrauma network site for Veteran Integrated Service Network 5, became involved to assist in meeting the advanced rehabilitation needs of this veteran. At the time of discharge from residential rehabilitation, Mr. S was able to ambulate household distances utilizing a walker with close supervision. Wheelchair use for community distances was required for traveling due to fatigue. His functional status significantly declined following a seizure and upper respiratory infection. Mr. S presented to the DCVA for evaluation and recommendations for ongoing rehabilitation. His parents noted that he was requiring assistance with all transfers, mobility, and self-cares and were concerned that they would have difficulty providing this enhanced level of care long term. A care plan to regain lost function was developed that included outpatient physical, occupational, and speech therapy. This plan focused on maximizing independence with bed
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mobility (i.e., rolling, supine to sit, and sit to supine), transfers, and gait training, as well as addressing fatigue secondary to neurological dysfunction and strength deficits of lower extremities. As is standard with TBI patients in the VA, there is a dedicated team of rehabilitation clinicians who collaborate on treatment plans for each patient. In this case the TBI team consisted of a physiatrist, a physical therapist, and a licensed clinical social worker. This dedicated team communicated on a weekly basis while Mr. S was receiving care at the VA. A weekly team meeting was held to address any needs, concerns, or issues that Mr. S or his parents were having. Trunk alignment and postural control deficits also required intervention as the veteran struggled with sitting in an upright posture and would maintain a forward flexed posture with sustained left lateral trunk flexion and rotation in both seated and standing positions. In addition, the care plan included occupational therapy, speech therapy, and vision therapy twice per week. One session each week was dedicated to gait training using an antigravity support system, whereas the other session was focused on improving bed mobility, posture, and transfer ability. Occupational therapy focused on counting sums of coins and/or bills and on improving other instrumental activities of daily living skills, including appointment management. Speech therapy focused on dysarthria and speech recognition. It is important to note that the caregivers in this case were the parents of the patient, and when the term caregiver is used, it meant to describe those who are taking care of the patient on a daily basis and providing him with assistance when he requires it. Mr. S’s parents, who also function as his caregivers, noted challenges traveling to DCVA due to distance. In addition, intermittent medical issues limited his tolerance to travel, including seizures and respiratory infections. The caregivers had many concerns regarding how missing treatment visits would hinder his progress. Among those concerns, the caregivers were also worried about how Mr. S would be able to transfer from various positions and furniture within the home and when his home exercise program would be updated. Home CVT was added to the rehabilitation plan of care, which included individual visits with the physiatrist and physical therapist from the DCVA. Through the CVT visits these concerns were addressed via home inspection, which allowed the therapist to better instruct the caregivers on the most efficient method of transfers from various surfaces, for example, from bed to chair or from chair to bathtub, etc. CVT also allowed for updates to the home exercise program by instructing the caregivers on the exercises that should be performed and at what frequency and volume. A local community provider was used for physical therapy, while the patient and family remained in communication with the
DCVA TBI/polytrauma staff to keep up and to coordinate care and to provide support for the patient’s homecare givers. At this point home CVT was scheduled with a frequency of once every 2–3 weeks along with a CVT meeting whenever the caregivers requested one, for a total of five CVT visits over the course of 3 months postdischarge. Each session lasted approximately a half hour and was initiated by the VA care team. The VA care team would agree on a meeting time with the patient and his family and then call into the patient’s home. The patient had a Webcam that was connected to the home desktop that allowed for the CVT sessions to begin. The VA care team would call in to the family at its home, and the family would answer the request. This was done using a Jabber (www.jabber.org/) account from the VA. Communication between the stakeholders in the care of the patient was performed via telehealth, phone calls, and e-mail. The VA treatment team was unable to communicate with the local care team of the patient, but the caregivers of the patient updated the VA team as to the improvements and daily status of the patient. The family caregivers in this case were the parents of the patient, and their input was always included into the care plan. CVT visits were primarily used to assess current status of the patient and to discuss any concerns with the caregivers related to the patient’s function, medications, or any other issues related to his injury. There were no notable connectivity issues throughout the sessions as the family had a reliable Internet connection in the home, as did the VA Medical Center.
Results CVTHm sessions were used to observe, modify, and update the home exercise program as well as support and educate the parents/caregivers. During CVTHm sessions there were no issues with connectivity or picture quality; this is crucial for a meeting to go successfully. Mr. S was noted to be more alert and less fatigued when visualized in his home setting, which allowed the physical therapist to adjust the home exercise program accordingly. Home modification recommendations were also made following direct visualization of the bathroom, narrow doorways, grab bar placement, and bedroom (furniture rearrangement to improve safety and enhance implementation of the home exercise program). CVTHm was also used to conduct family meetings. Mr. S and his parents were present in their home, and the DCVA treatment team gathered in a conference room to discuss progress in his treatment plan, to identify new goals, and to review home exercise plans. His caregivers reported being extremely satisfied with use of CVTHm to promote communication and coordinate care and requested that CVT remain a part of Mr. S’s overall treatment plan.
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Prior to initiating the telehealth sessions the caregivers had concerns regarding performance of transfers between the wheelchair and bed, wheelchair to toilet, and vice versa, if the home exercises were being performed appropriately and when updates and modifications would be necessary to the home exercise program. By using CVTHm it allowed for the assessment of the patient to be performed, although in an indirect fashion because there was no physical contact. Assessments included observation of the patient’s transfer and ambulating abilities with guarding and supervision of the caregivers (in this case, the parents). Throughout the sessions there were no connectivity issues considering the patient had a reliable Internet connection within the home.
Discussion There is growing evidence that TBI is a dynamic condition that may result in changes years after the initial injury.2 For most of the 20th Century TBI was considered an event with a final outcome of damage to the brain, as opposed to the beginning of a disease process.3 The TBI Model Systems national database suggests that change of the residual effects of TBI is more common than stability for long-term global outcomes of persons with moderate or severe TBI who require rehabilitation.2 This potential fluctuation in status necessitates that TBI be approached as a chronic health condition that includes training in self-management, identification of risk and protective factors, and evidence-based preventive and ameliorative treatment.2 This also calls for improved communication between caregivers of patients with TBI and clinicians in order to provide education on status changes of the veteran and to aid caregivers in understanding the best choices of continued care. Using CVT/home telehealth for patients with TBI complements the approach of a chronic care model by allowing for a greater frequency of follow-ups and continuity of care from the comfort of the patient’s home. As chronic conditions should be monitored regularly, so should TBI, even if it is via CVT to the patient’s home with his or her caregivers. This method also allows for an efficient way of education and care coordination with the family of the patient. This serves as an excellent adjunct to face-to-face treatments for patients with disabilities that require long-term follow-up such as stroke or TBI, thereby assisting in increased functional gains and social re-integration.12 BENEFITS OF CVTHM As mentioned previously, one of the many benefits of using CVT in the TBI patient population is that it allows for a less cumbersome means of communication among the patient, family, and interdisciplinary team. This also allows for
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the entire family to participate in the telehealth sessions from the home if desired by the veteran. Using CVT/home telehealth allows the interdisciplinary team to call in from the facility and communicate with the patient and family in their home environment. This can be of great benefit to patients who have difficulty traveling to the medical center due to issues related to illness, financial burden, or geographical burden. Minimizing the burden of travel for the veteran and family can potentially allow for a higher frequency of follow-ups. Common benefits reported by VA’s home telehealth patients include increased emotional support from their healthcare team, a decrease in healthcare costs while maintaining a high satisfaction with healthcare, and a greater sense of access and security with their health status.9 From a care coordination perspective, home telehealth has been shown to improve instrumental activities of daily living along with cognitive function in noninstitutionalized frail elderly veterans with chronic disease.13 CVT is also an excellent means of supervising, modifying or updating home exercise rehabilitation programs while providing clinicians with visual insight into potential environmental barriers the veteran faces at home (i.e., size of door frame, number of steps into home, availability of handrails, etc.). There is also evidence of cost savings related to home telehealth, as CVT use has been shown to result in reduced hospitalizations, fewer emergency department visits, and improved quality of life.8 In addition to the benefits already listed, clinical-based telehealth services are designed to achieve increased access to specialist consultations, improved access to primary and ambulatory care, reduced waiting times, and decreased fee base care costs.14 CVT is a simple and efficient means to enhance communication and allow for coordination and delivery of care and education of patients and their caregivers. CVTHm can be used for delivery of rehabilitation care, as well as to engage patients and their caregivers in family care conferences. To our knowledge this is the first reported case of using CVTHm to conduct family conferences for a veteran with TBI. Delivery of true interdisciplinary care involves veteran/family input and integration of this information to develop shared treatment goals. Each member of the team provides input, and a consensus decision is made regarding the best direction of continued care. Telehealth can also be used to provide education to the veteran and caregivers on medical and rehabilitation issues. A home exercise program can easily be supervised, modified, and updated via CVTHm, and modifications to the home environment can be provided by the clinician.
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FUTURE OF TELEREHABILITATION The potential for telerehabilitation is very promising, as technology advances and provides more seamless forms of communication. Telerehabilitation efforts have increased dramatically over the past several years as rehabilitation professionals identify rehabilitation interventions suitable for delivery via telehealth. Rural areas with rehabilitation specialist shortages can benefit from the utilization of telehealth. It should be noted that the intention of telehealth within the home is to supplement the face-to-face care that patients receive. In the future caregivers may be educated about caring for the veteran at home throughout the subacute and chronic phase of TBI rehabilitation. CVTHm can enhance the delivery and timing of family/caregiver education. This allows for a better understanding of the needs of the patient in the home setting. CVTHm will be an important area for further development as the VA seeks to manage patients with TBI and support their caregivers using the chronic disease model.
Conclusions Ongoing communication and care coordination are essential among patients, family, and interdisciplinary rehabilitation team members to address the complex and changing needs of patients with TBI. Family members of patients with TBI commonly assume a caregiver role following discharge from inpatient rehabilitation. VA has adopted CVT to promote access to care, and use of CVT for rehabilitation is expanding. CVTHm can assist with the ongoing management and treatment of patients in their home setting. Using CVTHm to enhance education and communication with the families/ caregivers of injured patients minimizes the burden of travel and allows for greater frequency of interaction among the family, veteran, and the interdisciplinary rehabilitation team. This case report suggests that CVT, particularly CVTHm, is a great complement to the delivery of interdisciplinary care. This mode of care is ready for expanded use, although there are some limitations that come along with it. Any follow-up visits being conducted over telehealth require that a caregiver be present with the patient in the same room to provide any assistance or perform any actions necessary over the course of the telehealth session. This is something that should be required of each visit, especially when dealing with a patient population that involves TBIs. Also, before initiating any telehealth sessions, there should be a documented emergency plan that includes information like the closest hospital to the site of telehealth for the patient, emergency contact information, e-mail address, and all contact information of the primary care physician in the event an incident occurs, such as
a fall or sudden seizure. It is also important to note that the patient must have access to a secure and reliable Internet connection for a fluid and effective telehealth session to take place. Although this mode of care is ready for widespread use within the VA healthcare system, it is not certain how health insurance companies would compensate nonfederal hospitals for this type of follow-up care. Caution is needed when determining which patients would be a good candidate for CVT and furthermore on how facilities would be reimbursed. There is a need for future research into the differences in outcomes between telerehabilitation and in-person follow-up care. There is also a need for evidence on how telehealth should be implemented as far as frequency and types of interventions and/or assessments that are most effective and valid through this mode of intervention.
Acknowledgments Funding for this project was provided by the VA Office of Academic Affiliations (38 U.S.C 7406) and the VA Office of Research and Development.
Disclosure Statement No competing financial interests exist. Writing and editing were contributed by all three of the authors along with participating in the activities listed in this case report.
REFERENCES 1. Polytrauma & blast-related injuries fact sheet. 2013. Available at www.hsrd.researc.va.gov/queri (last accessed December 9, 2013). 2. Corrigan JD, Hammond FM. Traumatic brain injury as a chronic health condition. Arch Phys Med Rehabil 2013;94:1199–1201. 3. Masel B. Conceptualizing brain injury as a chronic disease. Vienna, VA: Brain Injury Association of America, 2009. 4. Griffin JM, Friedemann-Snchez G, Hall C, Phelan S, van Ryn M. Families of patients with polytrauma: Understanding the evidence and charting a new research agenda. J Rehabil Res Dev 2009;46:879. 5. Griffin JM, Friedemann-Sa´nchez G, Jensen AC, et al. The invisible side of war: Families caring for US Service Members with traumatic brain injuries and polytrauma. J Head Trauma Rehabil 2012;27:3–13. 6. Paterson B, Kieloch B, Gmiterek J. ’They never told us anything’: Postdischarge instruction for families of persons with brain injuries. Rehabil Nurs 2001;26:48–53. 7. Darkins A. Changing the location of care: Management of patients with chronic conditions in Veterans Health Administration using care coordination/home telehealth. J Rehabil Res Dev 2006;43(4):vii. 8. VHA Telehealth Services. Home telehealth operations manual. 2013. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 9, 2013). 9. Girard P. Military and VA telemedicine systems for patients with traumatic brain injury. J Rehabil Res Dev 2007;44:1017–1026.
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10. About us—VHA telehealth services intranet. Available at http:// vaww.telehealth.va.gov/about/index.asp (last accessed December 9, 2013). 11. VHA Telehealth Services. Telerehabilitation operations manual supplement. 2012. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 10, 2013). 12. Telerehabilitation—Polytrauma/TBI system of care. Available at www.polytrauma.va.gov/Telerehabilitation.asp (last accessed August 25, 2014). 13. Chumbler NR, Mann WC, Wu S, Schmid A, Kobb R. The association of hometelehealth use and care coordination with improvement of functional and cognitive functioning in frail elderly men. Telemed J E Health 2004;10: 129–137. 14. VHA Telehealth Services. Clinic based telehealth operations manual. 2012. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 9, 2013).
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Address correspondence to: Haniel Hernandez, DPT Polytrauma/TBI Rehabilitation Physical Medicine and Rehabilitation Service Washington D.C. Veterans Affairs Medical Center 50 Irving Street NW Washington, DC 20422 E-mail: [email protected] Received: July 28, 2014 Revised: November 23, 2014 Accepted: November 24, 2014
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Haniel Hernandez, DPT, Joel Scholten, MD, and Elsie Moore, LCSW Polytrauma/TBI Rehabilitation, Physical Medicine and Rehabilitation Service, Washington D.C. Veterans Affairs Medical Center, Washington, D.C.
Abstract Ongoing communication and care coordination are essential among patients, their family, and interdisciplinary rehabilitation team members to address the complex and changing rehabilitation needs of traumatic brain injuries. Family members of patients with traumatic brain injury commonly assume a caregiver role following discharge from inpatient rehabilitation. The Department of Veterans Affairs has adopted clinical video telehealth to promote access to care, and use of clinical video telehealth for rehabilitation is expanding. Recent implementation of home clinical video telehealth can assist with the ongoing management and treatment of patients in their home setting. This report demonstrates enhanced education and care coordination by using clinical video telehealth with a Veterans Affairs–eligible beneficiary receiving treatment for traumatic brain injury. Key words: traumatic brain injury, polytrauma, telehealth, rehabilitation, telerehabilitation, clinical video telehealth, longterm care, family and caregiver support, chronic disease care
Introduction
A
s of May 2013, approximately 57,000 Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) service members have been wounded or killed in action, and approximately 280,734 new cases of traumatic brain injury (TBI) have been diagnosed since 2000, according to the Defense and Veterans Brain Injury Center.1 Care of patients with TBI requires a coordinated interdisciplinary approach with ongoing communication among the patient, family, and members of the interdisciplinary treatment team. Recent evidence indicates that the residual effects of TBI may evolve and change with time and are not static after
DOI: 10.1089/tmj.2014.0155
initial recovery, as previously believed.2 To enhance the emerging concept of TBI as a chronic condition, new methods of follow-up care and case management are being explored. A wide variety of conditions that range from pneumonia to circulatory problems may occur in the chronic phase following TBI.3 Ongoing medical and rehabilitation evaluation of the patient with TBI after inpatient rehabilitation can be challenging due to unique needs, geographic access to care, and demands on caregivers. Rehabilitation efforts should be monitored and updated periodically to address the evolving needs of the patient. Along the spectrum of care the responsibilities of caretaking often shift from institutionally provided formal care to family-provided informal caregiving.4 Research has shown that the role of caregiver is most often taken on by the parent(s) of the injured patient, and these caregivers may require assistance and support related to emotional issues, navigating healthcare benefits, managing pain, and aiding therapies and assistive devices.5 Caregivers of patients with TBI require ongoing education on various topics, including understanding the purpose of rehabilitation and how it facilitates recovery to caring strategies and recognizing changes in the medical status of the patient.6 Timing of education for caregivers is also important. Typically the majority of education for caregivers is provided during the inpatient rehabilitation phase, and this timing has been found to be an ineffective method of caregiver education. Studies have shown caregivers of individuals with TBI reported not being able to retain or implement information given to them because they were not in an emotional state to learn and the information did not apply to their situation at the time it was being provided.6 As a relatively new mode of healthcare, telehealth is being used in the management of patients with chronic brain injury in order to provide assessment, evaluation, and communication to better fit the chronic disease model of care. Telehealth is a cost-effective method to provide follow-up care while minimizing the burden of travel for patients who are encumbered by disability or geography.7 Veterans Affairs (VA) telehealth services were first established in 2003 as a national pilot program in five Veteran Integrated Service Networks to support new models of care using the leading-edge health
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information technologies to address pressing health needs of veterans.8 The VA has recently added Clinical Video Telehealth (CVT) to Home (CVTHm), which is a viable method of supporting veterans who may be isolated by disability, geography, or poverty.9 Rehabilitation team support and case management/care coordination via CVTHm can help address the concerns of caregivers and provide assistance with the issues that are being faced in the home setting. Telehealth in the VA is defined as follows: ‘‘The wider application of care and case management principles to the delivery of health care services using health informatics, disease management and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.’’10 All forms of telehealth serve a great purpose in providing timely communication between patients and healthcare providers and facilitating the delivery of healthcare information. Telehealth is used in two general ways in the VA: 1. CVT. This mode of communication is defined as the use of real-time interactive videoconferencing (sometimes with supportive peripheral technologies) to assess, treat, and provide care to a patient remotely. Typically, CVT links patients at a clinic to the providers at another location. CVT can also provide video connectivity between a provider and a patient at home (CVTHm).10 2. Home telehealth. The term home telehealth applies to the use of telecommunications technologies to provide clinical care and promote patient self-management as an adjunct to traditional face-to-face care. Health information is exchanged from the patients’ home or other location to the VA care setting, thus alleviating the constraints of time and distance.8 The goal of this variation of telehealth is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for patients in post-acute care settings and high-risk patients with chronic disease.10 Home messaging devices are used with scripts tailored to a specific disease model that assist patients in managing a chronic disease condition such as diabetes, congestive heart failure, etc. OEF/OIF/OND veterans with TBI require varying intensity and duration of rehabilitation. Factors that may influence a clinician’s decision regarding long-term rehabilitation include severity of injury/impairment, the available support system of the veteran, and potential for functional improvement. Following discharge from acute inpatient rehabilitation, the burden of care is shifted to the family/caregiver. Effective communication and education for caregivers are
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needed to promote continued advances in functional abilities of the veteran and to support caregivers. Although telerehabilitation is relatively new to the field of telehealth, it has been emerging and developing slowly within the VA over the past decade.11 Telerehabilitation care involves the use of electronic information and telecommunication technologies when patients and providers are separated by geographic distances; this includes teleconferencing with therapists at polytrauma system of care locations with a veteran patient at the local VA community-based outpatient clinic, or using home telehealth technologies to connect with patients at home to monitor their functional status and equipment needs.12 This case report describes the utilization of CVT to enhance treatment, communication, and education for a VA-eligible beneficiary receiving treatment for TBI and his caregivers and its implication in telerehabilitation.
Materials and Methods CASE DESCRIPTION Mr. S is a 28-year-old OEF/OIF/OND veteran who sustained a severe TBI following a stateside motor vehicle accident in 2010. Initial brain computed tomography scan revealed predominant right hemisphere diffuse hemorrhagic contusion with intraventricular hemorrhage and right subdural hematoma. Following 3 months of acute medical hospitalization he was transferred to an acute rehabilitation facility for 2 months. He was then treated for 4 months in a residential rehabilitation program for persistent cognitive deficits and then discharged home with his parents. This veteran initially received his care at Walter Reed National Military Medical Center and then had his care transferred over to the Baltimore VA. The Washington DC VA Medical Center (DCVA), the polytrauma network site for Veteran Integrated Service Network 5, became involved to assist in meeting the advanced rehabilitation needs of this veteran. At the time of discharge from residential rehabilitation, Mr. S was able to ambulate household distances utilizing a walker with close supervision. Wheelchair use for community distances was required for traveling due to fatigue. His functional status significantly declined following a seizure and upper respiratory infection. Mr. S presented to the DCVA for evaluation and recommendations for ongoing rehabilitation. His parents noted that he was requiring assistance with all transfers, mobility, and self-cares and were concerned that they would have difficulty providing this enhanced level of care long term. A care plan to regain lost function was developed that included outpatient physical, occupational, and speech therapy. This plan focused on maximizing independence with bed
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mobility (i.e., rolling, supine to sit, and sit to supine), transfers, and gait training, as well as addressing fatigue secondary to neurological dysfunction and strength deficits of lower extremities. As is standard with TBI patients in the VA, there is a dedicated team of rehabilitation clinicians who collaborate on treatment plans for each patient. In this case the TBI team consisted of a physiatrist, a physical therapist, and a licensed clinical social worker. This dedicated team communicated on a weekly basis while Mr. S was receiving care at the VA. A weekly team meeting was held to address any needs, concerns, or issues that Mr. S or his parents were having. Trunk alignment and postural control deficits also required intervention as the veteran struggled with sitting in an upright posture and would maintain a forward flexed posture with sustained left lateral trunk flexion and rotation in both seated and standing positions. In addition, the care plan included occupational therapy, speech therapy, and vision therapy twice per week. One session each week was dedicated to gait training using an antigravity support system, whereas the other session was focused on improving bed mobility, posture, and transfer ability. Occupational therapy focused on counting sums of coins and/or bills and on improving other instrumental activities of daily living skills, including appointment management. Speech therapy focused on dysarthria and speech recognition. It is important to note that the caregivers in this case were the parents of the patient, and when the term caregiver is used, it meant to describe those who are taking care of the patient on a daily basis and providing him with assistance when he requires it. Mr. S’s parents, who also function as his caregivers, noted challenges traveling to DCVA due to distance. In addition, intermittent medical issues limited his tolerance to travel, including seizures and respiratory infections. The caregivers had many concerns regarding how missing treatment visits would hinder his progress. Among those concerns, the caregivers were also worried about how Mr. S would be able to transfer from various positions and furniture within the home and when his home exercise program would be updated. Home CVT was added to the rehabilitation plan of care, which included individual visits with the physiatrist and physical therapist from the DCVA. Through the CVT visits these concerns were addressed via home inspection, which allowed the therapist to better instruct the caregivers on the most efficient method of transfers from various surfaces, for example, from bed to chair or from chair to bathtub, etc. CVT also allowed for updates to the home exercise program by instructing the caregivers on the exercises that should be performed and at what frequency and volume. A local community provider was used for physical therapy, while the patient and family remained in communication with the
DCVA TBI/polytrauma staff to keep up and to coordinate care and to provide support for the patient’s homecare givers. At this point home CVT was scheduled with a frequency of once every 2–3 weeks along with a CVT meeting whenever the caregivers requested one, for a total of five CVT visits over the course of 3 months postdischarge. Each session lasted approximately a half hour and was initiated by the VA care team. The VA care team would agree on a meeting time with the patient and his family and then call into the patient’s home. The patient had a Webcam that was connected to the home desktop that allowed for the CVT sessions to begin. The VA care team would call in to the family at its home, and the family would answer the request. This was done using a Jabber (www.jabber.org/) account from the VA. Communication between the stakeholders in the care of the patient was performed via telehealth, phone calls, and e-mail. The VA treatment team was unable to communicate with the local care team of the patient, but the caregivers of the patient updated the VA team as to the improvements and daily status of the patient. The family caregivers in this case were the parents of the patient, and their input was always included into the care plan. CVT visits were primarily used to assess current status of the patient and to discuss any concerns with the caregivers related to the patient’s function, medications, or any other issues related to his injury. There were no notable connectivity issues throughout the sessions as the family had a reliable Internet connection in the home, as did the VA Medical Center.
Results CVTHm sessions were used to observe, modify, and update the home exercise program as well as support and educate the parents/caregivers. During CVTHm sessions there were no issues with connectivity or picture quality; this is crucial for a meeting to go successfully. Mr. S was noted to be more alert and less fatigued when visualized in his home setting, which allowed the physical therapist to adjust the home exercise program accordingly. Home modification recommendations were also made following direct visualization of the bathroom, narrow doorways, grab bar placement, and bedroom (furniture rearrangement to improve safety and enhance implementation of the home exercise program). CVTHm was also used to conduct family meetings. Mr. S and his parents were present in their home, and the DCVA treatment team gathered in a conference room to discuss progress in his treatment plan, to identify new goals, and to review home exercise plans. His caregivers reported being extremely satisfied with use of CVTHm to promote communication and coordinate care and requested that CVT remain a part of Mr. S’s overall treatment plan.
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Prior to initiating the telehealth sessions the caregivers had concerns regarding performance of transfers between the wheelchair and bed, wheelchair to toilet, and vice versa, if the home exercises were being performed appropriately and when updates and modifications would be necessary to the home exercise program. By using CVTHm it allowed for the assessment of the patient to be performed, although in an indirect fashion because there was no physical contact. Assessments included observation of the patient’s transfer and ambulating abilities with guarding and supervision of the caregivers (in this case, the parents). Throughout the sessions there were no connectivity issues considering the patient had a reliable Internet connection within the home.
Discussion There is growing evidence that TBI is a dynamic condition that may result in changes years after the initial injury.2 For most of the 20th Century TBI was considered an event with a final outcome of damage to the brain, as opposed to the beginning of a disease process.3 The TBI Model Systems national database suggests that change of the residual effects of TBI is more common than stability for long-term global outcomes of persons with moderate or severe TBI who require rehabilitation.2 This potential fluctuation in status necessitates that TBI be approached as a chronic health condition that includes training in self-management, identification of risk and protective factors, and evidence-based preventive and ameliorative treatment.2 This also calls for improved communication between caregivers of patients with TBI and clinicians in order to provide education on status changes of the veteran and to aid caregivers in understanding the best choices of continued care. Using CVT/home telehealth for patients with TBI complements the approach of a chronic care model by allowing for a greater frequency of follow-ups and continuity of care from the comfort of the patient’s home. As chronic conditions should be monitored regularly, so should TBI, even if it is via CVT to the patient’s home with his or her caregivers. This method also allows for an efficient way of education and care coordination with the family of the patient. This serves as an excellent adjunct to face-to-face treatments for patients with disabilities that require long-term follow-up such as stroke or TBI, thereby assisting in increased functional gains and social re-integration.12 BENEFITS OF CVTHM As mentioned previously, one of the many benefits of using CVT in the TBI patient population is that it allows for a less cumbersome means of communication among the patient, family, and interdisciplinary team. This also allows for
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the entire family to participate in the telehealth sessions from the home if desired by the veteran. Using CVT/home telehealth allows the interdisciplinary team to call in from the facility and communicate with the patient and family in their home environment. This can be of great benefit to patients who have difficulty traveling to the medical center due to issues related to illness, financial burden, or geographical burden. Minimizing the burden of travel for the veteran and family can potentially allow for a higher frequency of follow-ups. Common benefits reported by VA’s home telehealth patients include increased emotional support from their healthcare team, a decrease in healthcare costs while maintaining a high satisfaction with healthcare, and a greater sense of access and security with their health status.9 From a care coordination perspective, home telehealth has been shown to improve instrumental activities of daily living along with cognitive function in noninstitutionalized frail elderly veterans with chronic disease.13 CVT is also an excellent means of supervising, modifying or updating home exercise rehabilitation programs while providing clinicians with visual insight into potential environmental barriers the veteran faces at home (i.e., size of door frame, number of steps into home, availability of handrails, etc.). There is also evidence of cost savings related to home telehealth, as CVT use has been shown to result in reduced hospitalizations, fewer emergency department visits, and improved quality of life.8 In addition to the benefits already listed, clinical-based telehealth services are designed to achieve increased access to specialist consultations, improved access to primary and ambulatory care, reduced waiting times, and decreased fee base care costs.14 CVT is a simple and efficient means to enhance communication and allow for coordination and delivery of care and education of patients and their caregivers. CVTHm can be used for delivery of rehabilitation care, as well as to engage patients and their caregivers in family care conferences. To our knowledge this is the first reported case of using CVTHm to conduct family conferences for a veteran with TBI. Delivery of true interdisciplinary care involves veteran/family input and integration of this information to develop shared treatment goals. Each member of the team provides input, and a consensus decision is made regarding the best direction of continued care. Telehealth can also be used to provide education to the veteran and caregivers on medical and rehabilitation issues. A home exercise program can easily be supervised, modified, and updated via CVTHm, and modifications to the home environment can be provided by the clinician.
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FUTURE OF TELEREHABILITATION The potential for telerehabilitation is very promising, as technology advances and provides more seamless forms of communication. Telerehabilitation efforts have increased dramatically over the past several years as rehabilitation professionals identify rehabilitation interventions suitable for delivery via telehealth. Rural areas with rehabilitation specialist shortages can benefit from the utilization of telehealth. It should be noted that the intention of telehealth within the home is to supplement the face-to-face care that patients receive. In the future caregivers may be educated about caring for the veteran at home throughout the subacute and chronic phase of TBI rehabilitation. CVTHm can enhance the delivery and timing of family/caregiver education. This allows for a better understanding of the needs of the patient in the home setting. CVTHm will be an important area for further development as the VA seeks to manage patients with TBI and support their caregivers using the chronic disease model.
Conclusions Ongoing communication and care coordination are essential among patients, family, and interdisciplinary rehabilitation team members to address the complex and changing needs of patients with TBI. Family members of patients with TBI commonly assume a caregiver role following discharge from inpatient rehabilitation. VA has adopted CVT to promote access to care, and use of CVT for rehabilitation is expanding. CVTHm can assist with the ongoing management and treatment of patients in their home setting. Using CVTHm to enhance education and communication with the families/ caregivers of injured patients minimizes the burden of travel and allows for greater frequency of interaction among the family, veteran, and the interdisciplinary rehabilitation team. This case report suggests that CVT, particularly CVTHm, is a great complement to the delivery of interdisciplinary care. This mode of care is ready for expanded use, although there are some limitations that come along with it. Any follow-up visits being conducted over telehealth require that a caregiver be present with the patient in the same room to provide any assistance or perform any actions necessary over the course of the telehealth session. This is something that should be required of each visit, especially when dealing with a patient population that involves TBIs. Also, before initiating any telehealth sessions, there should be a documented emergency plan that includes information like the closest hospital to the site of telehealth for the patient, emergency contact information, e-mail address, and all contact information of the primary care physician in the event an incident occurs, such as
a fall or sudden seizure. It is also important to note that the patient must have access to a secure and reliable Internet connection for a fluid and effective telehealth session to take place. Although this mode of care is ready for widespread use within the VA healthcare system, it is not certain how health insurance companies would compensate nonfederal hospitals for this type of follow-up care. Caution is needed when determining which patients would be a good candidate for CVT and furthermore on how facilities would be reimbursed. There is a need for future research into the differences in outcomes between telerehabilitation and in-person follow-up care. There is also a need for evidence on how telehealth should be implemented as far as frequency and types of interventions and/or assessments that are most effective and valid through this mode of intervention.
Acknowledgments Funding for this project was provided by the VA Office of Academic Affiliations (38 U.S.C 7406) and the VA Office of Research and Development.
Disclosure Statement No competing financial interests exist. Writing and editing were contributed by all three of the authors along with participating in the activities listed in this case report.
REFERENCES 1. Polytrauma & blast-related injuries fact sheet. 2013. Available at www.hsrd.researc.va.gov/queri (last accessed December 9, 2013). 2. Corrigan JD, Hammond FM. Traumatic brain injury as a chronic health condition. Arch Phys Med Rehabil 2013;94:1199–1201. 3. Masel B. Conceptualizing brain injury as a chronic disease. Vienna, VA: Brain Injury Association of America, 2009. 4. Griffin JM, Friedemann-Snchez G, Hall C, Phelan S, van Ryn M. Families of patients with polytrauma: Understanding the evidence and charting a new research agenda. J Rehabil Res Dev 2009;46:879. 5. Griffin JM, Friedemann-Sa´nchez G, Jensen AC, et al. The invisible side of war: Families caring for US Service Members with traumatic brain injuries and polytrauma. J Head Trauma Rehabil 2012;27:3–13. 6. Paterson B, Kieloch B, Gmiterek J. ’They never told us anything’: Postdischarge instruction for families of persons with brain injuries. Rehabil Nurs 2001;26:48–53. 7. Darkins A. Changing the location of care: Management of patients with chronic conditions in Veterans Health Administration using care coordination/home telehealth. J Rehabil Res Dev 2006;43(4):vii. 8. VHA Telehealth Services. Home telehealth operations manual. 2013. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 9, 2013). 9. Girard P. Military and VA telemedicine systems for patients with traumatic brain injury. J Rehabil Res Dev 2007;44:1017–1026.
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10. About us—VHA telehealth services intranet. Available at http:// vaww.telehealth.va.gov/about/index.asp (last accessed December 9, 2013). 11. VHA Telehealth Services. Telerehabilitation operations manual supplement. 2012. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 10, 2013). 12. Telerehabilitation—Polytrauma/TBI system of care. Available at www.polytrauma.va.gov/Telerehabilitation.asp (last accessed August 25, 2014). 13. Chumbler NR, Mann WC, Wu S, Schmid A, Kobb R. The association of hometelehealth use and care coordination with improvement of functional and cognitive functioning in frail elderly men. Telemed J E Health 2004;10: 129–137. 14. VHA Telehealth Services. Clinic based telehealth operations manual. 2012. Available at http://vaww.telehealth.va.gov/clinic/rehab/trehb/index.asp (last accessed December 9, 2013).
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Address correspondence to: Haniel Hernandez, DPT Polytrauma/TBI Rehabilitation Physical Medicine and Rehabilitation Service Washington D.C. Veterans Affairs Medical Center 50 Irving Street NW Washington, DC 20422 E-mail: [email protected] Received: July 28, 2014 Revised: November 23, 2014 Accepted: November 24, 2014
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