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Aust. J. Rural Health (2015) ••, ••–••
Quality Improvement Reports Integrating telehealth services into a remote allied health service: A pilot study Rebecca O’Hara, BBus(Marketing), BBus(Honours), Post Graduate Certificate (Health Promotion) and Sarah Jackson, BPhty(Hons), Post Graduate Certificate (Pelvic Floor Physiotherapy) Mount Isa Centre for Rural and Remote Health, James Cook University, Mount Isa, Queensland, Australia
Abstract Problem: The continuity of care for people with neurological conditions in a remote northwest Queensland town as services are currently only available intermittently. Design: Mixed methods design using questionnaires and staff review of the program and processes. Setting: Intermittent community rehabilitation service for clients with neurological conditions has been offered in Mount Isa and is supported by a similar fulltime service in Townsville. Both services use a unique client-centred, student-assisted, interprofessional model of care. Key measures for improvement: Understanding participant experiences by obtaining feedback from clients, students and allied health professionals (AHPs) regarding their experiences of using telehealth in this setting. Strategy for change: Previous clients of the North West Community Rehabilitation service were offered a review assessment using telehealth by an interprofessional team. Effects of change: Using telehealth enabled the client, remote AHP and students in Mount Isa to be connected to expert assistance in Townsville. Lessons learnt: The findings suggest that telehealth was useful in a community rehabilitation setting to provide review services for clients. This improved continuity of care for these clients because without this telehealth assessment, the clients would have had to wait up to 12 months for the next service period in Mount Isa or travel to a major urban centre to access a similar service. Feedback from clients, students and AHPs was positive; Correspondence: Ms Rebecca O’Hara, Monash Injury Research Institute, Building 70 Monash University, Clayton, Victoria, VIC 3168, Australia. Email: beck.ohara@ monash.edu; [email protected] The project was undertaken at: James Cook University – Mount Isa Centre for Rural and Remote Health, PO Box 2572, Mount Isa, Queensland, 4825, Australia. Accepted for publication 26 February 2015. © 2015 National Rural Health Alliance Inc.
however, some challenges were identified. Recommendations for future service delivery using telehealth are outlined in the paper. KEY WORDS: clinical education, community rehabilitation, telehealth.
Context Health services in rural and remote communities are challenged by limited staffing capacity and capability, geographic isolation and access to specialist resources.1 Residents of northwest Queensland with a neurological condition can access intermittent community rehabilitation services through North West Community Rehabilitation (NWCR). NWCR is funded to provide an interprofessional, student-assisted service for 10 weeks per year. It is based in Mount Isa, a remote town located 900 km west of Townsville. A larger, full-time service, Community Rehabilitation northern Queensland (CRnQ), is based in Townsville. Both services offer a student-assisted, interprofessional approach to rehabilitation, as directed by each client’s goals. AHPs from CRnQ and NWCR work together in Mount Isa during the 10 weeks of funded service delivery. Benefits of this unique service learning model include upskilling local allied health professionals (AHPs), providing highquality student placements and offering clients with a neurological condition a rehabilitation service otherwise not available in the Mount Isa region. Residents can access generalist public and private allied health services in Mount Isa; however, NWCR is the only dedicated community rehabilitation service available locally. Telehealth has been suggested as a potential mode of service delivery for improving clinical outcomes for people living in rural areas by improving access to quality services while upskilling AHPs in these areas.2,3 Recent studies have demonstrated its successful use in providing rehabilitation services4,5 and supporting less experienced clinicians by increasing access to experts not available onsite.6 Prior to this pilot, telehealth had not been used formally in the NWCR service. doi: 10.1111/ajr.12189
2
Outline of the problem We set out to improve the continuity of care for people with neurological conditions living in Mount Isa by conducting review assessments via telehealth. Without using telehealth, clients would be required to wait up to 12 months until the next service delivery period in Mount Isa or travel to a major urban centre (e.g. Townsville) to access similar services. An evaluation was conducted as part of this pilot to explore the experiences of using this technology for clients, AHPs and students.
Strategy for change Clients who had previously accessed the NWCR service were offered a telehealth review assessment by an interprofessional team (of physiotherapy and occupational therapy). Clients were prioritised by AHPs based on their clinical need for a review. The assessment lasted approximately 90 minutes per client and included both a client interview and physical assessment, which could be viewed through the videoconferencing system. Telehealth was provided using a Tandberg TTC7-14 videoconferencing system (Cisco Systems Inc, San Jose, CA, USA) in Mount Isa and a Polycom HDX 7000 system (Polycom Inc, San Jose, CA, USA) in Townsville connected via a Telstra hosted Bridge (Telstra Corporation Limited, Melbourne, Australia). The bridge is used to connect videoconference systems across different networks. Students in Mount Isa assisted in delivering the service while students in Townsville observed (Fig. 1). A total of 10 clients participated in the telehealth service. Following the review, clients were invited to evaluate the use of telehealth as part of the NWCR service. All clients who participated in the pilot had met the AHPs from
R. O’HARA AND S. JACKSON
Townsville, in person, during a previous service delivery period.
Key measures for improvement We set out to understand the experiences of the clients, AHPs and students in using telehealth in terms of the technology, interaction via videoconferencing, comfort, confidentiality, and the accessibility of expert services, clinical knowledge and skills.
Process of gathering information All participants were invited to participate, supplied with an overview of the project and provided their written consent. The project was approved by the James Cook University – Human Research Ethics Committee (number: H5318). A questionnaire and AHPs review session were used to collect evaluation data for this project. Clients chose to respond verbally to the questionnaire, while AHPs and students completed the written questionnaire. The questionnaire contained a series of questions using a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5) and open-ended questions. The open-ended questions invited clients, AHPs and students to comment on: what was good; what was not so good; how could the service be improved; whether they would use the telehealth service again; and whether they would recommend the telehealth service to friends and family. A range of questionnaires available online and described in current research were reviewed to identify measures that evaluate the participant’s experience with telehealth. The final questionnaire was adapted for this setting in consultation with research and health professional staff associated with NWCR.
FIGURE 1: Videoconferencing set-up. CRnQ, Community Rehabilitation northern Queensland; NWCR, North West Community Rehabilitation.
© 2015 National Rural Health Alliance Inc.
3
TELEHEALTH IN COMMUNITY REHABILITATION
Analysis and interpretation Participant profile Three AHPs and four students, from the disciplines of physiotherapy and occupational therapy, completed the evaluation across NWCR and CRnQ. Ten adults who had previously accessed NWCR participated in the pilot. Clients had been diagnosed with the following conditions: • • • • •
Cerebrovascular accident (5) Cerebellar ataxia (2) Spinocerebellar ataxia (1) Spinal cord injury (1) Acquired brain injury (1).
Evaluation results Client feedback was typically positive with ratings between ‘neutral’ and ‘strongly agree’ for each of the statements (Table 1). Clients provided lower ratings for
TABLE 1:
being able to hear people via videoconference, which might be explained by the audio delay that occurred during some sessions. Clients were asked to rate if using telehealth saved them time, travel costs and fit in more easily with their other commitments. Initially, these questions were designed for clients to contrast their experience of using telehealth in Mount Isa with travelling to a distant centre (e.g. Townsville) for a face-toface review. Clients commented that they did not see a distinction between face-to-face services available at NWCR and using telehealth. This might be because clients still accessed the facility in Mount Isa where a local AHP was present. In the open-ended questions, clients reported they liked the telehealth service because it was convenient, they liked connecting with AHPs and enjoyed using the technology. Clients typically did not report anything negative about the service, except for one client who commented on the delay in audio. Eight of the 10 clients indicated they would use telehealth again because it was convenient, to ‘get better’ and to access rehabilitation services in Mount Isa. However, two people preferred
Participant feedback
Statement I could hear the people clearly on the video I could see the people clearly on the video I was comfortable with talking to the people on the screen I was comfortable with being seen on video I felt I could ask questions (client only) I knew why I was having video consultation instead of face to face (client only) I knew why each of the people was in the room and on the video (client only) I felt comfortable that my confidentiality was safe (client only) The video consultation saved me time compared to a face to face visit (client only) The video consultation saved me money on potential travel costs (client only) The video consultation meant it was easier to fit it in with my other commitments (client only) I found the technology easy to use (all staff) Telehealth is a valuable way of providing community rehabilitation services (all staff) The video consultation allowed me to participate in delivering a specialist service locally (NWCR staff or students only) The video consultation enabled me to gain new clinical knowledge or skills (NWCR staff or students only) I felt more confident in delivering rehabilitation service with access to videoconferencing with expert clinicians (NWCR staff or students only) The video consultation allowed me to participate in delivering a specialist service remotely (CRnQ staff or students only) The video consultation enabled me to share new clinical knowledge or skills (CRnQ staff or students only)
Staff/student Client average average 3.7 (n = 10) 4.0 (n = 10) 4.2 (n = 10) 4.1 (n = 10) 4.1 (n = 10) 4.0 (n = 10) 4.2 (n = 10) 4.5 (n = 10) 3.6 (n = 10) 3.6 (n = 10) 3.7 (n = 10) N/A N/A N/A
4.0 (n = 7) 4.1 (n = 7) 4.4 (n = 7) 4.4 (n = 7) N/A N/A N/A N/A N/A N/A N/A 4.3 (n = 7) 4.3 (n = 7) 4.3 (n = 3)
N/A
5.0 (n = 3)
N/A
4.7 (n = 3)
N/A
4.3 (n = 3)
N/A
4.0 (n = 3)
CRnQ, Community Rehabilitation northern Queensland; N/A, Not applicable; NWCR, North West Community Rehabilitation. © 2015 National Rural Health Alliance Inc.
4
face-to-face delivery/hands-on consultation and would prefer the expert AHPs from Townsville to come to Mount Isa. Eight of the 10 clients indicated they would recommend telehealth to their friends and family. AHPs and students typically rated each of the statements higher than clients indicating ‘agree’ to ‘strongly agree’ for each statement (Table 1). AHPs and students reported that telehealth was beneficial because it allowed the provision of rehabilitation services to a remote location and was useful to follow up previous clients who would not ordinarily have access to the services. Access to expert AHPs (in Townsville) benefited clients, local AHPs and students by providing access to advanced knowledge and skills. This enabled a higher quality service to be provided to clients in realtime, while upskilling remote AHPs and students. Challenges were identified by the AHPs and students in relation to client position and camera angle. It was not always possible for the expert AHPs to be able to see both the client and the activity they were performing, without interference while simultaneously positioning the client to be able see the expert AHPs. Some activities required the camera to be zoomed in (e.g. fine motor finger movements) or out (e.g. timed 10 m walk). Camera control was available only at the Mount Isa site, that is, the expert AHPs were not able to adjust the camera view. There were some audio challenges reported during the pilot. In one assessment with a client who has speech difficulties, the audio was poorly received by the Townsville site. The audio equipment was adjusted (volume and position), without improvement. There was a significant delay in audio transmission, which made assessments slower to complete, caused interruptions and created difficulties when communicating between sites. During the review session held with AHPs, it was acknowledged that having previously established rapport with the clients was useful in delivering the service and helped to counter technical difficulties. During the pilot, it was identified that a dedicated videoconferencing unit and room were required at each site to ensure client privacy and provide an optimal learning environment. The AHPs noted that some clients took some time to feel comfortable with this method of service delivery. One client reported being unsure of what was expected of them in this situation because they had not used telehealth before. All AHPs and students involved in the pilot reported that they would use telehealth again to provide services to a range of clients in remote areas. It was suggested that videoconferencing was useful in a community rehabilitation setting to improve access to expert services and develop the clinical knowledge and skills of remote AHPs.
R. O’HARA AND S. JACKSON
Interpretation and lessons learnt This paper has highlighted the use of telehealth in the NWCR service in Mount Isa to conduct review assessments of clients between service periods. While there were some challenges experienced during the pilot, the feedback was positive from clients, AHPs and students, which is in accordance with other research to date.7 Limitations of this pilot included the small sample size and potential response bias of AHPs and students. It should be noted that the survey was developed specifically for this project and had not been previously validated or piloted. This pilot focused on the participants’ experiences of using telehealth; however, further research is required to assess the clinical efficacy of this approach using standardised outcome measures. Using telehealth offered an alternative means to conduct follow-up assessments between service delivery periods at NWCR, thus improving access to services for clients in this remote setting. The benefits of such a program include being able to connect remote clients, AHPs and students with AHPs who have advanced skills without having to travel away from their support networks or community.6 It also assists clients to overcome challenges faced in accessing specialist services, which might relate to physical impairment, distance from a specialist service and travel costs.8 Telehealth enabled the provision of a review service that otherwise would not have been available to these clients, improving continuity of care for current clients. An important component of this pilot was the established rapport that the AHPs had with the clients which assisted to overcome some of the challenges associated with using telehealth. This finding is consistent with other studies that have found that rapport is key to the use of and engagement with this technology.9 In addition, telehealth enabled the upskilling of local AHPs and students, which could translate into higher quality care for future clients. The opportunity to offer student placements with advanced clinical support in a remote context might lead to improved AHP recruitment and retention.10 The pilot identified challenges requiring further investigation for integrating the telehealth approach in a remote community rehabilitation setting. Based on lessons learnt from this pilot, the following improvements are suggested: • Additional cameras providing multiple angles (e.g. overhead, side-on, front-on) to ensure a better view of clients with both sites being able to adjust camera angles. This might require a more advanced videoconference model; • Improved scheduling to ensure AHPs have more time for assessments and more time between tasks to allow for feedback to students; © 2015 National Rural Health Alliance Inc.
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TELEHEALTH IN COMMUNITY REHABILITATION
• Dedicated resources at both sites (e.g. room space, videoconference unit) ready for immediate use; • Develop a handout or demonstration video for clients to understand how telehealth works for dissemination prior to their telehealth appointment; • Training for AHPs and students in the use of telehealth and appropriate etiquette; • Investigate the causes of audio delay and options available to minimise the impact on service delivery. If this cannot be improved, it is suggested that AHPs and clients be pre-warned of the delay as part of the briefing; • Investigate alternative options for audio contact (e.g. headsets versus desktop microphone); and, • Have a direct connection between videoconference units (i.e. avoid using a bridge).
Next steps This pilot suggests that the use of telehealth might be an acceptable alternative for review assessments between NWCR service delivery periods. Based on this small pilot, it is recommended that the following be considered when integrating telehealth in a community rehabilitation setting: • Incorporate the changes from ‘lessons learnt’ into program design; and, • Investigate the use of telehealth for community rehabilitation in assessment and in delivering interventions, including the application of outcome measures to determine the clinical efficacy of telehealth.
Acknowledgements The authors would like to thank the clients, AHPs and students that participated in the telehealth pilot. The authors acknowledge Shaun Solomon for assisting in collecting evaluation data and providing guidance during the project. NWCR is funded by the Australian Government Department of Health and Ageing through Queensland Health under a National Partnership Agreement. This service is a collaboration among Mount Isa Centre for Rural and Remote Health, James Cook University, Queensland Health, Central and North West Queensland Medicare Local and Townsville-Mackay Medicare Local.
© 2015 National Rural Health Alliance Inc.
Author contributions Rebecca O’Hara: study design, data collection, analysis and preparation of manuscript. Sarah Jackson: study design, delivery of pilot program and interpretation and preparation of manuscript.
References 1 Humphreys J, Wakerman J, Wells R. What do we mean by sustainable rural health services? Implications for rural health research. The Australian Journal of Rural Health 2006; 14: 33–35. 2 Moffatt JJ, Eley DS. The reported benefits of telehealth for rural Australians. Australian Health Review 2010; 34: 276–281. 3 Graham SK, Cameron ID. Meeting the rehabilitation service needs in rural and remote Australia: a focus group workshop with rehabilitation service health care providers. The Australian Journal of Rural Health 2009; 17: 109– 110. 4 Huijbregts M, McEwen S, Taylor D. Exploring the feasibility and efficacy of a telehealth stroke self-management programme: a pilot study. Physiotherapy Canada 2009; 61: 210–220. 5 Russell T, Buttrum P, Wootton R, Jull G. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty. The Journal of Bone and Joint Surgery 2011; 93: 113–120. 6 Schutte J, Gales S, Filippone A, Saptono A, Parmanto B, McCue M. Evaluation of a telerehabilitation system for community-based rehabilitation. International Journal of Telerehabilitation 2012; 4: 15–24. 7 Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilisation and costs associated with telerehabilitation. Disability and Rehabilitation 2009; 31: 427–447. 8 Middleton J, McCormick M, Engel S et al. Issues and challenges for development of a sustainable service model for people with spinal cord injury living in rural regions. Archives of Physical Medicine and Rehabilitation 2008; 89: 1941–1947. 9 Buckley K, Tran B, Prandoni C. Receptiveness, use and acceptance of telehealth by caregivers of stroke patients in the home. The Online Journal of Issues in Nursing 2004; 9: 9. [Cited 12 Dec 2014]. Available from URL: http://www.nursingworld.org/MainMenuCategories/ ANAMarketplace/ANAPeriodicals/OJIN/ TableofContents/Volume92004/No3Sept04/ ArticlePreviousTopic/TelehealthforStrokePatients.aspx 10 Schoo A. Successful recruitment: what now? The Australian Journal of Rural Health 2008; 16: 187–188.
Aust. J. Rural Health (2015) ••, ••–••
Quality Improvement Reports Integrating telehealth services into a remote allied health service: A pilot study Rebecca O’Hara, BBus(Marketing), BBus(Honours), Post Graduate Certificate (Health Promotion) and Sarah Jackson, BPhty(Hons), Post Graduate Certificate (Pelvic Floor Physiotherapy) Mount Isa Centre for Rural and Remote Health, James Cook University, Mount Isa, Queensland, Australia
Abstract Problem: The continuity of care for people with neurological conditions in a remote northwest Queensland town as services are currently only available intermittently. Design: Mixed methods design using questionnaires and staff review of the program and processes. Setting: Intermittent community rehabilitation service for clients with neurological conditions has been offered in Mount Isa and is supported by a similar fulltime service in Townsville. Both services use a unique client-centred, student-assisted, interprofessional model of care. Key measures for improvement: Understanding participant experiences by obtaining feedback from clients, students and allied health professionals (AHPs) regarding their experiences of using telehealth in this setting. Strategy for change: Previous clients of the North West Community Rehabilitation service were offered a review assessment using telehealth by an interprofessional team. Effects of change: Using telehealth enabled the client, remote AHP and students in Mount Isa to be connected to expert assistance in Townsville. Lessons learnt: The findings suggest that telehealth was useful in a community rehabilitation setting to provide review services for clients. This improved continuity of care for these clients because without this telehealth assessment, the clients would have had to wait up to 12 months for the next service period in Mount Isa or travel to a major urban centre to access a similar service. Feedback from clients, students and AHPs was positive; Correspondence: Ms Rebecca O’Hara, Monash Injury Research Institute, Building 70 Monash University, Clayton, Victoria, VIC 3168, Australia. Email: beck.ohara@ monash.edu; [email protected] The project was undertaken at: James Cook University – Mount Isa Centre for Rural and Remote Health, PO Box 2572, Mount Isa, Queensland, 4825, Australia. Accepted for publication 26 February 2015. © 2015 National Rural Health Alliance Inc.
however, some challenges were identified. Recommendations for future service delivery using telehealth are outlined in the paper. KEY WORDS: clinical education, community rehabilitation, telehealth.
Context Health services in rural and remote communities are challenged by limited staffing capacity and capability, geographic isolation and access to specialist resources.1 Residents of northwest Queensland with a neurological condition can access intermittent community rehabilitation services through North West Community Rehabilitation (NWCR). NWCR is funded to provide an interprofessional, student-assisted service for 10 weeks per year. It is based in Mount Isa, a remote town located 900 km west of Townsville. A larger, full-time service, Community Rehabilitation northern Queensland (CRnQ), is based in Townsville. Both services offer a student-assisted, interprofessional approach to rehabilitation, as directed by each client’s goals. AHPs from CRnQ and NWCR work together in Mount Isa during the 10 weeks of funded service delivery. Benefits of this unique service learning model include upskilling local allied health professionals (AHPs), providing highquality student placements and offering clients with a neurological condition a rehabilitation service otherwise not available in the Mount Isa region. Residents can access generalist public and private allied health services in Mount Isa; however, NWCR is the only dedicated community rehabilitation service available locally. Telehealth has been suggested as a potential mode of service delivery for improving clinical outcomes for people living in rural areas by improving access to quality services while upskilling AHPs in these areas.2,3 Recent studies have demonstrated its successful use in providing rehabilitation services4,5 and supporting less experienced clinicians by increasing access to experts not available onsite.6 Prior to this pilot, telehealth had not been used formally in the NWCR service. doi: 10.1111/ajr.12189
2
Outline of the problem We set out to improve the continuity of care for people with neurological conditions living in Mount Isa by conducting review assessments via telehealth. Without using telehealth, clients would be required to wait up to 12 months until the next service delivery period in Mount Isa or travel to a major urban centre (e.g. Townsville) to access similar services. An evaluation was conducted as part of this pilot to explore the experiences of using this technology for clients, AHPs and students.
Strategy for change Clients who had previously accessed the NWCR service were offered a telehealth review assessment by an interprofessional team (of physiotherapy and occupational therapy). Clients were prioritised by AHPs based on their clinical need for a review. The assessment lasted approximately 90 minutes per client and included both a client interview and physical assessment, which could be viewed through the videoconferencing system. Telehealth was provided using a Tandberg TTC7-14 videoconferencing system (Cisco Systems Inc, San Jose, CA, USA) in Mount Isa and a Polycom HDX 7000 system (Polycom Inc, San Jose, CA, USA) in Townsville connected via a Telstra hosted Bridge (Telstra Corporation Limited, Melbourne, Australia). The bridge is used to connect videoconference systems across different networks. Students in Mount Isa assisted in delivering the service while students in Townsville observed (Fig. 1). A total of 10 clients participated in the telehealth service. Following the review, clients were invited to evaluate the use of telehealth as part of the NWCR service. All clients who participated in the pilot had met the AHPs from
R. O’HARA AND S. JACKSON
Townsville, in person, during a previous service delivery period.
Key measures for improvement We set out to understand the experiences of the clients, AHPs and students in using telehealth in terms of the technology, interaction via videoconferencing, comfort, confidentiality, and the accessibility of expert services, clinical knowledge and skills.
Process of gathering information All participants were invited to participate, supplied with an overview of the project and provided their written consent. The project was approved by the James Cook University – Human Research Ethics Committee (number: H5318). A questionnaire and AHPs review session were used to collect evaluation data for this project. Clients chose to respond verbally to the questionnaire, while AHPs and students completed the written questionnaire. The questionnaire contained a series of questions using a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5) and open-ended questions. The open-ended questions invited clients, AHPs and students to comment on: what was good; what was not so good; how could the service be improved; whether they would use the telehealth service again; and whether they would recommend the telehealth service to friends and family. A range of questionnaires available online and described in current research were reviewed to identify measures that evaluate the participant’s experience with telehealth. The final questionnaire was adapted for this setting in consultation with research and health professional staff associated with NWCR.
FIGURE 1: Videoconferencing set-up. CRnQ, Community Rehabilitation northern Queensland; NWCR, North West Community Rehabilitation.
© 2015 National Rural Health Alliance Inc.
3
TELEHEALTH IN COMMUNITY REHABILITATION
Analysis and interpretation Participant profile Three AHPs and four students, from the disciplines of physiotherapy and occupational therapy, completed the evaluation across NWCR and CRnQ. Ten adults who had previously accessed NWCR participated in the pilot. Clients had been diagnosed with the following conditions: • • • • •
Cerebrovascular accident (5) Cerebellar ataxia (2) Spinocerebellar ataxia (1) Spinal cord injury (1) Acquired brain injury (1).
Evaluation results Client feedback was typically positive with ratings between ‘neutral’ and ‘strongly agree’ for each of the statements (Table 1). Clients provided lower ratings for
TABLE 1:
being able to hear people via videoconference, which might be explained by the audio delay that occurred during some sessions. Clients were asked to rate if using telehealth saved them time, travel costs and fit in more easily with their other commitments. Initially, these questions were designed for clients to contrast their experience of using telehealth in Mount Isa with travelling to a distant centre (e.g. Townsville) for a face-toface review. Clients commented that they did not see a distinction between face-to-face services available at NWCR and using telehealth. This might be because clients still accessed the facility in Mount Isa where a local AHP was present. In the open-ended questions, clients reported they liked the telehealth service because it was convenient, they liked connecting with AHPs and enjoyed using the technology. Clients typically did not report anything negative about the service, except for one client who commented on the delay in audio. Eight of the 10 clients indicated they would use telehealth again because it was convenient, to ‘get better’ and to access rehabilitation services in Mount Isa. However, two people preferred
Participant feedback
Statement I could hear the people clearly on the video I could see the people clearly on the video I was comfortable with talking to the people on the screen I was comfortable with being seen on video I felt I could ask questions (client only) I knew why I was having video consultation instead of face to face (client only) I knew why each of the people was in the room and on the video (client only) I felt comfortable that my confidentiality was safe (client only) The video consultation saved me time compared to a face to face visit (client only) The video consultation saved me money on potential travel costs (client only) The video consultation meant it was easier to fit it in with my other commitments (client only) I found the technology easy to use (all staff) Telehealth is a valuable way of providing community rehabilitation services (all staff) The video consultation allowed me to participate in delivering a specialist service locally (NWCR staff or students only) The video consultation enabled me to gain new clinical knowledge or skills (NWCR staff or students only) I felt more confident in delivering rehabilitation service with access to videoconferencing with expert clinicians (NWCR staff or students only) The video consultation allowed me to participate in delivering a specialist service remotely (CRnQ staff or students only) The video consultation enabled me to share new clinical knowledge or skills (CRnQ staff or students only)
Staff/student Client average average 3.7 (n = 10) 4.0 (n = 10) 4.2 (n = 10) 4.1 (n = 10) 4.1 (n = 10) 4.0 (n = 10) 4.2 (n = 10) 4.5 (n = 10) 3.6 (n = 10) 3.6 (n = 10) 3.7 (n = 10) N/A N/A N/A
4.0 (n = 7) 4.1 (n = 7) 4.4 (n = 7) 4.4 (n = 7) N/A N/A N/A N/A N/A N/A N/A 4.3 (n = 7) 4.3 (n = 7) 4.3 (n = 3)
N/A
5.0 (n = 3)
N/A
4.7 (n = 3)
N/A
4.3 (n = 3)
N/A
4.0 (n = 3)
CRnQ, Community Rehabilitation northern Queensland; N/A, Not applicable; NWCR, North West Community Rehabilitation. © 2015 National Rural Health Alliance Inc.
4
face-to-face delivery/hands-on consultation and would prefer the expert AHPs from Townsville to come to Mount Isa. Eight of the 10 clients indicated they would recommend telehealth to their friends and family. AHPs and students typically rated each of the statements higher than clients indicating ‘agree’ to ‘strongly agree’ for each statement (Table 1). AHPs and students reported that telehealth was beneficial because it allowed the provision of rehabilitation services to a remote location and was useful to follow up previous clients who would not ordinarily have access to the services. Access to expert AHPs (in Townsville) benefited clients, local AHPs and students by providing access to advanced knowledge and skills. This enabled a higher quality service to be provided to clients in realtime, while upskilling remote AHPs and students. Challenges were identified by the AHPs and students in relation to client position and camera angle. It was not always possible for the expert AHPs to be able to see both the client and the activity they were performing, without interference while simultaneously positioning the client to be able see the expert AHPs. Some activities required the camera to be zoomed in (e.g. fine motor finger movements) or out (e.g. timed 10 m walk). Camera control was available only at the Mount Isa site, that is, the expert AHPs were not able to adjust the camera view. There were some audio challenges reported during the pilot. In one assessment with a client who has speech difficulties, the audio was poorly received by the Townsville site. The audio equipment was adjusted (volume and position), without improvement. There was a significant delay in audio transmission, which made assessments slower to complete, caused interruptions and created difficulties when communicating between sites. During the review session held with AHPs, it was acknowledged that having previously established rapport with the clients was useful in delivering the service and helped to counter technical difficulties. During the pilot, it was identified that a dedicated videoconferencing unit and room were required at each site to ensure client privacy and provide an optimal learning environment. The AHPs noted that some clients took some time to feel comfortable with this method of service delivery. One client reported being unsure of what was expected of them in this situation because they had not used telehealth before. All AHPs and students involved in the pilot reported that they would use telehealth again to provide services to a range of clients in remote areas. It was suggested that videoconferencing was useful in a community rehabilitation setting to improve access to expert services and develop the clinical knowledge and skills of remote AHPs.
R. O’HARA AND S. JACKSON
Interpretation and lessons learnt This paper has highlighted the use of telehealth in the NWCR service in Mount Isa to conduct review assessments of clients between service periods. While there were some challenges experienced during the pilot, the feedback was positive from clients, AHPs and students, which is in accordance with other research to date.7 Limitations of this pilot included the small sample size and potential response bias of AHPs and students. It should be noted that the survey was developed specifically for this project and had not been previously validated or piloted. This pilot focused on the participants’ experiences of using telehealth; however, further research is required to assess the clinical efficacy of this approach using standardised outcome measures. Using telehealth offered an alternative means to conduct follow-up assessments between service delivery periods at NWCR, thus improving access to services for clients in this remote setting. The benefits of such a program include being able to connect remote clients, AHPs and students with AHPs who have advanced skills without having to travel away from their support networks or community.6 It also assists clients to overcome challenges faced in accessing specialist services, which might relate to physical impairment, distance from a specialist service and travel costs.8 Telehealth enabled the provision of a review service that otherwise would not have been available to these clients, improving continuity of care for current clients. An important component of this pilot was the established rapport that the AHPs had with the clients which assisted to overcome some of the challenges associated with using telehealth. This finding is consistent with other studies that have found that rapport is key to the use of and engagement with this technology.9 In addition, telehealth enabled the upskilling of local AHPs and students, which could translate into higher quality care for future clients. The opportunity to offer student placements with advanced clinical support in a remote context might lead to improved AHP recruitment and retention.10 The pilot identified challenges requiring further investigation for integrating the telehealth approach in a remote community rehabilitation setting. Based on lessons learnt from this pilot, the following improvements are suggested: • Additional cameras providing multiple angles (e.g. overhead, side-on, front-on) to ensure a better view of clients with both sites being able to adjust camera angles. This might require a more advanced videoconference model; • Improved scheduling to ensure AHPs have more time for assessments and more time between tasks to allow for feedback to students; © 2015 National Rural Health Alliance Inc.
5
TELEHEALTH IN COMMUNITY REHABILITATION
• Dedicated resources at both sites (e.g. room space, videoconference unit) ready for immediate use; • Develop a handout or demonstration video for clients to understand how telehealth works for dissemination prior to their telehealth appointment; • Training for AHPs and students in the use of telehealth and appropriate etiquette; • Investigate the causes of audio delay and options available to minimise the impact on service delivery. If this cannot be improved, it is suggested that AHPs and clients be pre-warned of the delay as part of the briefing; • Investigate alternative options for audio contact (e.g. headsets versus desktop microphone); and, • Have a direct connection between videoconference units (i.e. avoid using a bridge).
Next steps This pilot suggests that the use of telehealth might be an acceptable alternative for review assessments between NWCR service delivery periods. Based on this small pilot, it is recommended that the following be considered when integrating telehealth in a community rehabilitation setting: • Incorporate the changes from ‘lessons learnt’ into program design; and, • Investigate the use of telehealth for community rehabilitation in assessment and in delivering interventions, including the application of outcome measures to determine the clinical efficacy of telehealth.
Acknowledgements The authors would like to thank the clients, AHPs and students that participated in the telehealth pilot. The authors acknowledge Shaun Solomon for assisting in collecting evaluation data and providing guidance during the project. NWCR is funded by the Australian Government Department of Health and Ageing through Queensland Health under a National Partnership Agreement. This service is a collaboration among Mount Isa Centre for Rural and Remote Health, James Cook University, Queensland Health, Central and North West Queensland Medicare Local and Townsville-Mackay Medicare Local.
© 2015 National Rural Health Alliance Inc.
Author contributions Rebecca O’Hara: study design, data collection, analysis and preparation of manuscript. Sarah Jackson: study design, delivery of pilot program and interpretation and preparation of manuscript.
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