The effects of telehealth use for post-acute rehabilitation patient outcomes

Abstract

Introduction

Previous research has shown that home telehealth services can reduce hospitalisations and emergency department visits and improve clinical outcomes among older adults with chronic conditions. However, there is a lack of research on the impact of telehealth (TH) use on patient outcomes in post-acute rehabilitation settings. The current study examined the effects of TH for post-acute rehabilitation patient outcomes (i.e. discharge setting and change in functional independence) when controlling for other factors (e.g. cognitive functioning).

Methods

For this retrospective study, electronic medical records (EMRs) of 294 patients who were discharged from a post-acute rehabilitation unit at a skilled nursing facility were reviewed. Only patients with an admitting condition of a circulatory disease based on ICD-9 classification were included. Main EMR data extracted included use of TH, cognitive functioning, admission and discharge functional independence, and discharge setting (returning home vs. returning to acute care/re-hospitalisation).

Results

Results from a regression analysis showed that although TH use was unrelated to post-acute rehabilitation care transition, it was significantly related to change in functional independence. Patients who used TH during their stay had significantly more improvement in functional independence from admission to discharge when compared to those who did not use TH.

Discussion

Findings indicate that TH use during post-acute rehabilitation has the potential to improve patient physical functioning.

Keywords

Telehealth post-acute rehabilitation functional independence care transitions

Introduction

The population of adults over age 65 is expected to increase by 65% in the next 25 years, including a doubling of those aged 85 and older.¹ However, a longer life does not necessarily mean a healthier life. With advanced age, the likelihood of acquiring at least one chronic health condition (e.g. heart disease, sensory impairments) or multiple chronic health conditions increases as well.² In fact, the percentage of people over age 65 with multiple chronic conditions has been shown to range from 55–98%,³ with nearly 80% of adults aged 80 or over experiencing multiple conditions.⁴ Additionally, chronic condition incidence and multimorbidity extend to middle-aged adults as well.⁵ Due to the rapid growth of the ageing population, the number of people with multiple chronic health conditions will surge in the near future. These conditions tend to result in a decline of physical functioning and disability,³ which contributes to negative clinical outcomes, such as hospitalisations. Taken together, these experiences can substantially reduce individuals’ autonomy as well as quality of life. Thus, it is important to develop interventions that support ageing adults’ self-management of chronic conditions in order to maintain health, autonomy and a high quality of life.

One type of supportive self-management intervention that has been utilised in the older adult population and examined for positive health outcomes includes telehealth (TH) services. These services provide remote disease-specific patient education and symptom management, as well as video consultation capabilities in some cases. Typically, TH devices allow individuals to take their own vital function measurements (e.g. blood pressure, weight), which are then sent to a database where health care providers can access them and contact the patient if a dangerous change in status is noticed. Additionally, many TH services are individualised to each patient’s specific medical condition(s) and provide relevant disease-specific education. Traditionally, TH devices were designed for, and are used by, homebound patients. Research has shown that TH use in the home is associated with positive outcomes in many studies, including fewer hospitalisations and improved physical health among older adults. For instance, a meta-analysis found that the majority of studies that assessed the effectiveness of TH use among patients with pulmonary and cardiac conditions showed a significant decrease in hospital admissions, emergency department (ED) visits and length of hospital stay.⁶ Additionally, another study found that, for adults with chronic heart failure, TH services reduced hospital admission rates due to chronic heart failure by 21% and mortality risk by 20%, as compared with patients who received usual care.⁷

Although TH use has typically been shown to be beneficial with regards to the above clinical outcomes, studies determining the impact of TH on functional ability have been less clear. One study found that adults who completed a 6-week intervention combining TH with usual care following coronary artery bypass surgery showed more energy expenditure and moderate to high intensity exercise as compared to a control group who received usual care.⁸ However, a different study did not find a significant improvement in physical functioning following a 6-month TH intervention for older Hispanic men, although there was a trend toward improvement for participants who utilised TH services as instructed at least 40% of the time.⁹

The above studies have examined the use and impact of TH services on clinical outcomes for patients who used TH at home. But not all patients are discharged home immediately following an acute care hospital stay. Around 40% of Medicare recipients are discharged to a post-acute rehabilitation setting before returning home.^10,11 Post-acute rehabilitation settings provide supportive therapies (e.g. occupational and physical therapy) that are specifically designed for medically complex patients. Patients who receive post-acute rehabilitation are generally older adults who are recovering from surgery, an illness or an injury, and no longer need hospitalisation, but require comprehensive care to prepare them to return home. Due to frailty, requirements for therapies provided in this setting include less rigour as compared to therapies offered in traditional rehabilitation units of hospitals and rehabilitation centres.

Since lack of compliance regarding the regular use of TH has been found to be associated with reduced effectiveness,⁹ a post-acute rehabilitation setting provides an opportunity to not only train patients in the use of a TH device but also to provide reminders and support for TH use. Unfortunately, little is known about how TH use in a post-acute rehabilitation setting influences patient outcomes. Thus, the present retrospective study investigated if the use of TH technology by post-acute rehabilitation patients is associated with more optimal clinical outcomes (i.e. greater likelihood of returning home as opposed to being re-hospitalised) and improved functional independence at discharge when controlling for other factors (e.g. cognitive functioning).

Methods

Sample and procedures

For this retrospective study, electronic medical records (EMRs) of 294 patients who were discharged from a post-acute rehabilitation unit of a skilled nursing facility of a large geriatric healthcare system were reviewed. Additional study inclusion criteria were: (1) an admitting condition of a circulatory disease based on ICD-9 classification; and (2) a discharge setting of either returning home with or without organised home care or returning to acute care (being re-hospitalised). All data were extracted from patients’ EMRs with most information taken from the Minimum Data Set (MDS) 3.0. Extracted EMR data were compiled into an analytic data set. The study protocol was approved by the Institutional Review Board from each author’s institution (two).

Telehealth (TH) system and use

The TH system IDEAL Life (IDEAL Life, Inc., Toronto, Canada) was utilised. This system provides educational dialogues for chronic conditions and is equipped with a weighing scale, blood pressure monitor and pulse oximeter (to measure blood glucose levels). Physical measurements taken and the specific dialogue provided were individualised according to each patient’s health conditions. Patients in the current sample were encouraged to take daily measurements of blood pressure, heart rate, oxygen saturation and weight. Dialogues present disease-specific health information and prompt users to answer questions regarding the educational information as well as their current health behaviours. Physical measurements and non-compliant, potentially dangerous health behaviours (e.g. lack of medication adherence) were directly sent to a database where a TH nurse reviewed them daily, and alerted the nursing staff if dangerous symptoms, behaviours or change in physical status were observed. Patients also answered questions about symptoms relating to their condition(s) and what they learned through the dialogue. In the current sample, measurements, dialogue and questions corresponded to each patient’s circulatory disease.

The post-acute admission team first identifies a newly admitted patient as a potential TH participant. Only patients without severe cognitive impairments and those who are ambulatory enough to either walk or to be escorted (e.g. in a wheel chair) to the TH terminal/kiosk are recommended for TH use. The team then alerts the TH nurse, who reviews the client’s diagnosis and discharge information from the transferring facility and registers the patient as eligible for TH use. The TH nurse also informs the nurse manager on the floor so he/she can inform the prospective TH client about the programme when discussing available services to the patient shortly after admission. The nurse manager also provides feedback to the TH nurse on whether it is appropriate for the patient to use the technology. Even if patients initially declined to use TH, they could choose to use it at a later time. Patients who may have initially declined but used TH later on were included in this study. Shortly after admission, a TH nurse provided each patient with instructions on how to use the TH device (which was located in the hallway of each post-acute floor within the geriatric care site), and Certified Nursing Assistants encouraged the patients to use it daily. TH device utilisation (Yes/No) in the rehabilitation unit was recorded during each patient’s post-acute stay in the TH database. Information from the database for the current sample was then provided to the researchers by the TH director. Although data on whether patients used the TH device at least once during their post-acute stay was available, data on frequency and length of use was unavailable to the researchers.

Outcome measures

Change in functional independence

Functional independence was measured at admission to, and at discharge from, post-acute rehabilitation via the functional independence measure of the Activities of Daily Living Scale adapted for the MDS (MDS-ADL).¹² The scale allows clinicians to rate a resident’s degree of difficulty in performing 11 ADL tasks, including bathing and dressing. Ratings for each task can range from 0 (independent) to 4 (total dependence), with lower scores denoting more functional independence. A weighted score was calculated for each patient by adding the scores of the items that were answered for each patient by the number of items answered for each patient. This yielded functional independence scores with values ranging from 0 to 4 for both admission and discharge functional independence measures. A change score was then calculated by subtracting discharge ADL score from admission ADL score, with a higher score indicating more change toward functional independence.¹³

Discharge setting/post-acute rehabilitation care (PARC) transition

Potential care transitions upon discharge from the post-acute unit were: (1) return to patient’s home with or without home care; and (2) return to acute care/re-hospitalisation. Based on EMR data, a PARC transition variable was created, with the outcome of ‘returning home’ coded as ‘1’ and PARC transition outcome of ‘returning to acute care/re-hospitalisation’ coded as ‘0’.

Covariate measures

Demographic characteristics

Patients’ age, gender and race/ethnicity were extracted from the admissions MDS. Race/ethnicity was dichotomised to form a variable that indicated whether a patient is a member of a minority group (Yes; including African Americans, Hispanics and Asians) or not (No; including Whites).

Cognitive functioning

Cognitive functioning was assessed at admission via the Brief Interview for Mental Status (BIMS). This five-item instrument is part of the MDS and measures cognitive function by assessing word repetition, recall and temporal orientation. A summary score across the five items was created (range 0–15). Higher BIMS scores indicate better cognitive functioning.

Comorbidities

Comorbidities represent the number of health conditions in addition to the admitting condition. These data were extracted from the MDS completed at admission and from the doctor’s notes, which are also captured in the EMR.

Social support

Whether the patient had social support from family members or friends (Yes/No) was ascertained by examining clinical notes in the EMR. Having received social support (Yes) was determined if clinical notes indicated that family member and/or friend either visited during post-acute stay or that family member or friend attended the patient’s care plan meeting(s).

Data analyses plan

Descriptive statistical analyses were run for sample demographic variables. Next, t-tests and chi-square analyses were utilised to examine potential differences in demographics, admission cognitive functioning, admission functional independence, number of comorbidities and social support between TH users and TH non-users. Then, Pearson correlation analyses were conducted to examine relationships among study variables. Finally, two regression analyses were run to examine the effects of TH on the two outcome variables. Specifically, a logistic regression analysis was conducted to examine the extent to which TH use during post-acute rehabilitation is related to the likelihood of returning home or to acute care (re-hospitalisation). A multiple regression was conducted to assess the extent to which TH use predicted functional independence change. Both regressions included TH and covariates that were significantly correlated with the respective outcomes.

Results

Sample characteristics

Table 1 provides sample descriptive characteristics for all study variables by TH group (users vs. non-users). Unpaired t-tests and chi-square analyses showed no significant differences between TH users and non-users in regards to age, gender, minority status, functional independence at admission, cognitive functioning at admission, number of comorbidities and social support. These results indicate that TH users when compared to non-users were not healthier or more functionally independent upon admission to post-acute rehabilitation.

Table 1.

Sample descriptive characteristics.

	Telehealth users (N = 79)					Telehealth non-users (N = 206)
Variable	M	SD	Range	N	Percentage	M	SD	Range	N	Percentage
Sex
Male				38	48.1				93	43.3
Female				41	51.9				122	56.7
Race/ethnicity
White				38	48.1				121	56.3
Black/African American				25	31.6				59	27.4
Hispanic/Latino				13	16.5				32	14.9
Asian/Pacific Islander				3	3.8				2	0.9
Marital status
Never married				21	26.6				56	26.0
Married				23	29.1				52	24.2
Widowed				25	31.6				80	37.2
Separated				0	0				6	2.8
Divorced				10	12.7				19	8.8
Age (years)	78.49	9.10	55–97			80.56	9.82	48–99
Under age 65				6	7.6				14	6.5
Cognitive functioning at admission	13.28	3.22	3–15			12.96	3.22	3–15
Comorbidities	12.00	7.50	0–33			11.61	7.68	0–35
Social support (yes)				61	77.2				157	73.0
Functional independence change	.33	.36	−0.64–1.45			.23	.34	−0.21–2.29
Functional independence at admission	2.87	.27	2.18–3.33			2.87	.38	1.18–4.00
Functional independence at discharge	2.54	.46	1.18–3.33			2.66	.54	0.82–4.00
PARC transition outcome
Home				63	79.7				165	76.7
Re-hospitalisation				16	20.3				50	23.3

Correlations

Table 2 provides correlations for TH use, sociodemographic variables, patient outcomes and covariates. TH was not significantly correlated with PARC transition, but was marginally correlated with functional independence change.

Table 2.

Correlations among PARC transition, telehealth use, sociodemographic and functioning variables.

	1	2	3	4	5	6	7	8	9
1. Age	1
2. Sex (female)	.05	1
3. Minority (yes)	−.28**	.06	1
4. Social support (yes)	.07	.00	.12*	1
5. Cognitive functioning admission score	−.15*	.05	−.09	−.07	1
6. Comorbidities	−.13*	−.09	.14*	−.00	−.10	1
7. Telehealth use (yes)	−.10	−.04	.08	.04	.04	.02	1
8. PARC transition (home)	−.05	.09	−.06	.15*	.17*	−.20**	.03	1
9. Functional independence change score	−.02	−.01	−.03	−.06	.08	−.22**	.13^†	.29**	1

†

p < .10; *p < .05; **p < .01.

Effect of telehealth on PARC transition and functioning change

To further investigate the potential effect of TH use on PARC transition/discharge setting, a logistic regression was performed with TH use (Yes/No) and covariates significantly correlated with PARC transition outcome – namely social support, comorbidities, cognitive functioning and functional independence change – as predictors. Results showed that TH use was unrelated to PARC transition outcome. Those who used TH during their post-acute stay were not significantly more likely to return home than those who did not use TH (see Table 3). However, higher cognitive functioning and more change toward functional independence emerged as significant predictors of returning home.

Table 3.

Logistic regression coefficients for PARC transition outcome.

Variable	B	SE	Wald	Exp(B)
Social support	.80	.45	3.20^†	2.23
Cognitive functioning admission score	.14	.06	5.23**	1.15
Comorbidities	−.01	.09	.02	.99
Functional independence change score	3.43	.99	11.98**	30.91
Telehealth	.47	.56	.69	1.60

Cox and Snell R²= .14; Nagelkerke R²= .23 (^†p < .10; **p < .01).

Table 4 shows the effect of TH use on change in functional independence from admission to discharge. Number of comorbidities was included in the analysis along with TH use due to its significant correlation with the functional independence change score. Results revealed that TH use was significantly associated with change in functional independence. Specifically, patients who used TH experienced significantly more change toward functional independence during their post-acute stay than those who had not used TH.

Table 4.

Regression coefficients for functional independence change.

Variable	B	SE B	β
Comorbidities	−.03	.01	−.22**
Telehealth (yes)	.11	.06	.14*

R²= .07 (*p < .05; **p < .01).

Discussion

The current study provides insights into how TH use relates to patient outcomes in a post-acute rehabilitation setting. Previous research has focused on the effects of TH use in the home on clinical outcomes such as hospital admissions and physical functioning. The current study focused on the potential effects of TH use on two outcomes (PARC transition type and change in functional independence) and found promising preliminary results. Specifically, although findings revealed that TH use did not relate to PARC transition outcome upon discharge, it was significantly related to increased change toward functional independence from admission to discharge.

There are several potential reasons that TH use was unrelated to PARC transition outcome in the current sample. First, there are other factors that appear to be more influential than TH use on PARC transition, such as functional independence change. More change toward independence was significantly related to an increased likelihood of returning home. It should be noted that since TH use was significantly related to functional independence change, it might be indirectly associated with returning home following post-acute rehabilitation. Second, the number and types of comorbidities participants had could have influenced the effectiveness of TH services. Previous research has shown that, although TH use is often associated with better clinical outcomes for adults with one chronic condition, it can be ineffective in reducing hospital admissions and ED visits for older adults with multiple conditions.^14,15 The mean number of comorbidities was nearly 12 in the current sample, indicating that many of the participants had multiple conditions. Third, a factor that could have influenced our findings was that the number of patients who were re-hospitalised (n = 66) was much smaller than those who returned home (n = 228).

Results also showed TH use to be significantly related to functional independence change from admission to discharge. Specifically, those who used TH during their post-acute stay became more functionally independent as compared with those who did not use TH. This finding is especially notable given the small number of participants who used TH during their post-acute stay (n = 79). Improvements in functional independence with TH use could have occurred through facilitating symptom management and education. Specifically, participants who used TH were provided with both education on ways to manage their symptoms and questions asking about current symptoms through the device. These could have created a greater awareness of symptoms and also enhanced symptom management skills. Additionally, participants who used TH were providing instant information of their health status to a TH nurse, who could then alert nursing staff who could speedily attend to patients whose symptoms indicated cause for concern. This type of higher level of monitoring during rehabilitation could prevent setbacks in functioning.

Limitations and future directions

One important limitation of the current study was that no information on frequency of TH use was available. Frequency of use and its relation to communication with medical professionals has been shown to relate to important health outcomes, including mortality.¹⁶ However, we were unable to see whether frequency and duration of use impacted outcomes in the current study. Another limitation is that retrospective medical record data were used. Future studies should aim to assess the role of TH use frequency on functional outcomes as well as implement interventions within this setting to examine the effects of TH use on these outcomes. Future research could also look at long-term outcomes of TH use during post-acute rehabilitation including re-hospitalisations and functional independence after transitioning home. An additional limitation is that only a small number of patients utilised TH services in the current study. A larger number of TH users would have provided more representative results of the effects of TH use on functional independence change and PARC transition outcome. Frequent contact with nurses in the post-acute rehabilitation setting could be one reason TH was not utilised by more patients. Additionally, patients may have found the device difficult or inconvenient to use as usage required leaving their room and working with a Certified Nursing Assistant down the hall. Satisfaction with TH services within this setting is as yet unknown. Future research on reported ease of use and satisfaction with TH services by post-acute patients could provide insights into likelihood of usage and compliance rates.

Conclusions

The present study shows preliminary evidence that TH use in post-acute rehabilitation may be beneficial for improving functional independence in middle-aged and older adults. However, results did not show that those who used TH were more likely to transition home than those who did not use it. To the best of our knowledge, this study is the first to examine the role of TH in a post-acute rehabilitation setting and can serve as a starting point for more in-depth investigations of the ways in which TH can support adults with chronic conditions in this rehabilitation setting.

Footnotes

Acknowledgements

The authors would like to thank the administration and staff of The New Jewish Home, in particular Sheila Molarto, Telehealth RN; Bridget Zimmermann, Director of the Cardiopulmonary Rehabilitation Program; and Regina Melly, SVP for Business Development, for their support of this research as well as Audrey Weiner, CEO, and Joann P. Reinhardt, Director of Research, for comments on earlier versions of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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