Information and communication technology in home-based rehabilitation – a discussion of possibilities and challenges

Abstract

Background: Information and communication technology (ICT) has been proven to have effect in terms of providing alternative ways to deliver rehabilitation services. The intention with this paper is to serve as a foundation for discussions regarding the future development, design, and delivery of home-based rehabilitation, including ICT.

Aim: To reflect on and discuss the possibilities and challenges of using ICT in home-based rehabilitation services.

Method and material: We use experiences and results from various projects to reflect on and discuss possibilities and challenges related to the use of ICT in home-based rehabilitation.

Findings and discussion: We exemplify how ICT present new possibilities that can increase the quality of the rehabilitation process and improve access to services. We reflect on some challenges in the use of ICT, related to non-user-friendly solutions, to the specific rehabilitation situation, and a lack of technical support. At an organisational level, readiness to use ICT can impact the extent to which new solutions are integrated into practice.

Conclusion: We emphasise that ICT has the potential to develop and improve service delivery and contribute to increased quality and accessibility of home-based rehabilitation.

Keywords:

• e-health
• intervention
• occupational therapy
• older adults
• technology
• telehealth

Introduction

Healthcare systems need to address and respond to the demographic and epidemiological trends of an ageing population that is living longer and with disability, and rehabilitation is proposed as a key health strategy to manage future healthcare demands [1]. In Sweden, organisations in primary care and community-based health- and social care are in the beginning of a transition towards accessible care that is close to citizens. A person-centred, proactive approach is emphasised in this care, as well as the development of e-health to provide services [2]. As more healthcare services are provided through the municipality, rehabilitation in the person’s home i.e. home-based rehabilitation makes it possible to focus interventions on daily activities in the persons own home environment and surroundings [3]. Research has shown that home-based rehabilitation seems to be as effective as other forms of rehabilitation [4,5]. To meet the transition towards accessible care close to citizens, home-based rehabilitation requires new working methods and solutions to effectively deliver interventions. Services making use of information and communication technology (ICT) have been highlighted as having the potential to be useful in meeting these challenges and providing rehabilitation at a distance [6]. However, the use of ICT poses increasing demands on organisations and professionals regarding how to deliver rehabilitation services that develop innovative working methods and continually expand upon ICT’s inherent potential. There are many terms used to describe the use of ICT such as eHealth, mHealth, telehealth, telerehabilitation and telemedicine and these terms are often used interchangeably. In this paper we use the term ICT.

While ICT holds potential in terms of providing alternative ways to deliver rehabilitation services [7–9] the use of ICT as a part of home-based rehabilitation has up to now been described to a limited extent. In a Swedish study, including 2397 clients in 34 municipalities, ICT solutions were used in only few cases [10]. This implies that there are challenges hindering this development that need to be overcome to make use of the extensive potential that ICT might hold. For this to take place, our experiences are that health-care organisations, as well as those delivering and receiving the service, need to be involved in the early stages or outset of ICT utilisation, which has also previously been highlighted [11]. Taken together, we argue that there is a need for a changed focus i.e. to develop new working methods and interventions where ICT is an integrated part of occupational therapy and home-based rehabilitation services. Occupational therapists have a particularly important role in supporting people to make everyday life work in an increasingly digital home environment. More digital solutions for managing everyday life are being developed and available and this also affects how society organises its service [12]. This need for a changed focus in service has been further accentuated in connection with the outbreak of the COVID-19 pandemic early in the spring of 2020. The potential benefits of an increased use of ICT in terms of improved communication, as well as the means to coordinate health care staff, has also been clearly emphasised by the World Health Organisation [WHO] [13]. Consequently, it is not a choice regarding whether we want to be a part of this development or not. Instead, there is a need to embrace the possibilities that ICT holds for rehabilitation services and to act proactively as occupational therapists and rehabilitation professionals. Therefore, the aim is to reflect on and discuss the possibilities and challenges of using ICT in home-based rehabilitation services.

Material and methods

To address the aim of this discussion paper, we drew upon our experiences of implementing projects where ICT was a tool integrated in interventions and/or a medium for provision of services. All projects were situated in home-based rehabilitation settings, three of them in Sweden, and involved testing ICT for increased productivity, improved service, and enhanced outcomes. Context, participants, and ICT included in the projects are shortly presented below. We refer to the original publications for further information about these different projects and their outcomes [14–18]. The authors of this paper are researchers in occupational therapy, investigators in the different projects and represent different research groups in Sweden which has enrichened the discussions and minimised risk of bias. The findings discussed in this paper are built upon collegial discussions among the authors and within research groups and networks regarding challenges in transforming rehabilitation services to make use of ICT. The starting point for our discussion paper was in 2018 when participating in a meeting within the international ReAble network [19]. This network represents academics and clinicians in the field of rehabilitation and meets on regular basis. One of the topics discussed was how to implement technical solutions in rehabilitation services. During this network meeting the authors formed a discussion group which has continued to meet regularly, three to four times a year, to share experiences from their different projects on ICT and rehabilitation services. Thoughts and ideas identified at these discussions have been documented, forming an evolving draft of this paper that has been subject to collegial discussions within the authors’ own research groups. These back-and-forth discussions within the different research contexts form the basis of this paper.

Context, participants, and ICT in the included projects

The first research project involved two studies aiming to evaluate the feasibility of F@ce-, a person-centred, team-based intervention for rehabilitation after stroke in Sweden [14] and in Uganda [15] and experiences of using ICT [16]. In Sweden a single group study was conducted, comprising of persons recruited from one inpatient rehabilitation unit and two corresponding primary care rehabilitation units. In Uganda, a randomised controlled trial design was used with an intervention group and a control group. In these studies, the technology was tested in several different ways. In Sweden, a webpage was created to support the team members as a structure for the workshop by providing the content of the intervention. Both in Sweden and Uganda, an online database was used for data-collection to enable the therapists and the participants to complete an assessment on a tablet. A web-platform was developed to give researchers access to monitor the rehabilitation process of the intervention and for the occupational therapists to follow the process. Mobile phones were used to deliver the rehabilitation intervention. Today, a F@ce 2.0 version is being evaluated in full-scale trails in both Uganda and Sweden.

The second research project [17] aimed to develop and design new ways to deliver rehabilitation services using ICT to support older citizens ageing in place in a municipality in Sweden. The goal was to develop and use enabling ICT, to create a platform for interaction and communication, implement interventions and follow-ups, and thereby secure a more effective rehabilitation. The study had a participatory action research design and the participants consisted of rehabilitation professionals, computer engineers, stakeholders from different levels of the municipality organisation, and older persons living at home in need of rehabilitation. The ICT that was applied, comprised sound and video communication through a tablet by using Skype. The technology was used for interaction and communication during rehabilitation e.g. assessments, instructions, and follow-ups. Depending on the situation, this was carried out together with the older person, but could also include a next of kin and/or home help staff. The usability of the chosen ICT was important, and adaptations were made based on the actual needs and conditions of the older persons.

The clinical development project [18] was conducted in one Swedish municipality during the early phase of the COVID-19 pandemic in the spring of 2020. Due to physical distancing, digital meetings were tested as an alternative way to conduct home visits for clients with neuropsychiatric diagnoses. Over a period of one week, two occupational therapists offered clients the possibility to receive digital meetings instead of pre-planned ordinary home visits. To participate in the meetings enabled by ICT, the clients received an e-mail including an invitation to a Teams-meeting and a step-by-step instruction on how to conduct the meeting using a computer, tablet, or mobile phone. After each meeting the occupational therapist filled out a web-survey addressing the purpose of the study: to explore the use of digital meetings in relation to (i) possibilities/challenges, and (ii) time use.

Findings and discussion

This section is organised under two headings where we reflect on and discuss, i) how ICT can contribute to increased quality and improved accessibility of rehabilitation services, and ii) challenges and lessons learned, based on findings from the different projects. We also pose some questions we consider to be of importance when testing ICT as a new way to design and deliver home-based rehabilitation services.

How ICT can contribute to increased quality and improved accessibility of rehabilitation services

The quality of rehabilitation when using ICT involves the whole context of rehabilitation services. Namely, professionals, clients, and others involved in the rehabilitation, as well as access to the internet, the technology used, and technical support. ICT was associated with possibilities to maintain high quality in rehabilitation interventions, plan and use time efficiently, and assure client confidentiality. ICT was also associated with service accessibility e.g. availability when clients contacted rehabilitation professionals for feedback and to ask questions. These results correspond to research suggesting that ICT may improve older people’s access to healthcare services [20]. In addition, the use of ICT improved communication and interaction between professionals and others involved in the ongoing rehabilitation process, e.g. relatives and home help staff.

The experiences from our projects show that it was possible to maintain high quality in the rehabilitation services when using ICT. Overall, using ICT was regarded as positive and enabled continual communication with tighter follow-ups. Continuity in communication and the possibility for a quick response made it easy to revise the rehabilitation plan and encouraged progress in the client’s rehabilitation. The opportunity to meet at a distance in real time, with sound and video by using a tablet and Skype, supported and motivated the clients to work on, and achieve, their goals. The clients felt more confident in how to perform exercises or daily activities as they had access to feedback when they felt insecure or needed to confirm instructions. Also, the use of a mobile phone for goal setting and SMS reminders supported and motivated the clients to regain their daily activities and the follow-up system proved to be beneficial in the rehabilitation process. It inspired and motivated the clients to perform activities and to improve their participation in daily activities. In line with this, a newly published scoping review found that delivering interventions through ICT to improve participation in everyday life could be a valid option in rehabilitation [21]. Another positive aspect was the possibility to involve relatives and/or home help staff in the rehabilitation e.g. by providing instruction and guiding them in how to support the client to work towards the goals.

Taken together, ICT has the potential to result in more efficient use of time and resources. Using mobile phone technology was a productive way to implement interventions, resulting in an affordable and accessible rehabilitation service. In some cases, ICT made it possible to provide services that otherwise would have been difficult to achieve e.g. due to long travel distances. Furthermore, decreasing time spent on travelling enabled the professionals to work more efficiently, which led to possibilities to serve more clients and thereby decrease the waiting list. The potential that ICT holds has implications for new ways to deliver rehabilitation services. Further, as all projects in this paper involved occupational therapists, the potential of using ICT has implications for how to increase quality and accessibility of occupational therapy interventions in a new way. These implications contribute to a discussion on how to design innovative projects in clinical settings, and how to develop new research-based interventions in occupational therapy including ICT. However, while our experiences indicate that ICT may well increase quality, both on an individual level as well as in relation to use of resources and service accessibility, furthering studies are needed to establish evidence.

Challenges and lessons learned in using ICT

We have identified some challenges on different levels, i.e. technical, personal, and situational issues related to the use of ICT, that affected the quality and accessibility of rehabilitation services. The technology was not always user-friendly. Sometimes there were problems with the internet connection and the transmission of picture and voice was interrupted or was of bad quality. Therefore, having access to a good internet connection is of great importance. This is an issue of infrastructure, especially in rural areas, to create equal access to rehabilitation using ICT. Some clients had difficulties to use the technology due to limited digital skills and/or cognitive or physical impairments. Those clients with physical or cognitive impairments experienced problems starting the tablet or the Skype app. Further, there were occasional problems with adapting the technology to some activities and interventions that were to be handled in the clients’ home environment. For instance, challenges related to how to place the tablet to capture a situation. These kinds of situations constantly required new ways of thinking to find suitable, user-friendly technical solutions in relation to the clients’ conditions and the rehabilitation situation.

Barriers in the context, as well as technical setbacks, influenced the implementation process when using mobile phone technology. For example, difficulties in reading and answering SMSs due to personal conditions needed to be solved by support from family members. Here, different technical solutions need to be considered. In these cases, the use of another technical solution such as a tablet or smartphone, instead of using the older type of mobile cell phones with buttons, might have proven to be a better solution. We argue that it is important to be client-centred and sensitive to the situation when choosing an adequate type of technology for use in testing ICT. This may also mean including the client’s social network if appropriate.

The quality of home visits using ICT was somewhat comparable to ordinary home visits and there were slight differences related to the quality of rehabilitation services. One notable difference was that ordinary home visits often included informal observations of the home environment and time for socialising i.e. small talk and building relationships. When using ICT, the time was more directed to the specific concerns that were in focus for the intervention. However, a positive aspect with meetings enabled by ICT was that some of the clients experienced physical home visits as an added stressor, which challenged their personal integrity. From that perspective meetings enabled by ICT provided a more considerate alternative. Using ICT with video, in contrast to a meeting by phone, added value through the possibility to pay attention to the persons’ body language, which enhanced the communication and sense of presence. Thus, to some extent, facets that are easily integrated into ordinary home visits may also be integrated into digital meetings e.g. using video. Specifically, in relation to the current COVID-19 pandemic with restrictions of physical distancing, using ICT with video was highlighted as positive. This raises questions about when ICT should be used in the rehabilitation process and for what intervention? Additionally, what kind of ICT contributes most adequately to the quality of the specific service? In line with this, we argue that each situation is unique, and it is thus vital to work in a client centred way. We advocate that further studies are required to bring forward a clarifying, structured pattern of evidence-based indicators. Such indicators would aid the selection and recommendation of a preferred rehabilitation process and format for the visits, i.e. ICT versus home visits. Given the fact that the quality of interventions using ICT in our projects was relatively equal compared to ordinary home visits, the main benefit was that using ICT was less time consuming and did not require transportation.

Overall, using ICT in rehabilitation services has the potential to be cost saving in terms of reduced time required for staff and clients, and reduced costs for transportation, but the evidence base on cost-effectiveness is limited [22]. To expand the knowledge on cost-effectiveness, evidence is warranted on the effects of rehabilitation delivered with ICT versus traditional formats. Evidence is also warranted regarding the costs e.g. for delivery of interventions and costs related to consumption of healthcare services.

In addition, ICT has the potential to contribute to more environmentally friendly delivery of healthcare services in terms of reduced carbon emissions. When compared to care as usual, ICT implemented in two rehabilitation contexts reduced carbon emissions per appointment by up to 70 times when emissions related to travel were compared to emissions related to production and use of ICT equipment. The authors concluded that meetings enabled by ICT were the preferred option, not only in rural areas with long distances, but also in urban areas in which travel distances were only a few kilometres [23]. Thus, the benefit from an environmental perspective goes hand in hand with the ongoing transformation towards accessible care, in which ICT needs to become an integrated part of ordinary healthcare services [2].

One important aspect when deciding upon and implementing ICT is to have acceptance and support at an organisational level. In our projects, there was a need for training in the use of the ICT (for both clients and professionals) and technical support provided to the clients by phone during the intervention process. Our experiences are that the organisation and systems used in home-based rehabilitation services are not adapted to handle “unfamiliar” systems, such as new ways of delivering interventions through ICT solutions. We argue that it is crucial to have leadership that both genuinely promotes innovative use of new digital solutions and deals with ambiguities about certain issues. These issues concern law and regulations, such as security, data management, and ethics. New forms of interventions create new ethical and integrity dilemmas, for which guidelines and routines in the work organisation have also previously been highlighted as lacking [24]. Thus, it is essential to have access to technical knowledge and support within the organisation. Having access to support has benefits when it comes to choosing and adapting solutions to fit both the needs of the rehabilitation professionals and the clients’ conditions. In addition, we argue that it is vital for rehabilitation professionals to be prepared and to have the right kind of support within the organisation as new working methods, including ICT, require new competencies.

To summarise

Taken together, using ICT in home-based rehabilitation services has potential benefits for the clients, the rehabilitation professionals and at an organisational level. However, we also address challenges related to technology (poor wi-fi, non-user-friendly technical solutions), to the client (physical and/or cognitive impairments, lack of digital skills), to the rehabilitation situation (difficulties positioning the technology used) and on an organisational/professional level (lack of routines and technical support). Therefore, we emphasise the importance of user-centred and participatory approaches when designing and implementing ICT-based projects. Especially as research has criticised how older adults are given limited involvement and are rarely positioned as equitable partners in the design of research projects [25]. In addition to the projects presented in this paper, evaluation is ongoing in full scale trials for the F@ce intervention both in Uganda and Sweden. A new ICT platform is under development and subject to pilot testing in the innovation and research project DioD – a digital platform to support social participation for older adults [26]. Also, new web-based interventions are under development with ongoing evaluation i.e. Strategies for Empowering activities in Everyday life (SEE 1.0) an Internet-based occupational therapy intervention [27], a counselling intervention [28], and a digital fall prevention application [29]. These new solutions could be integrated as part of rehabilitation services as they can provide intervention content in addition to content provided through traditional modes of delivery. In all, exactly which type of services should be selected for use with ICT and when, remains to be explored further if interventions using ICT are to be sustainable in home-based rehabilitation.

We suggest the following important questions to ask before testing and using ICT in home-based rehabilitation services:

What kind of ICT will match the need for a rehabilitation intervention and how will that solution become available (to clients and professionals)?

Can the ICT create equal access to rehabilitation for the clients?

What kind of support and competencies are available for the different users (clients, professionals and on organizational level) and who is responsible for providing technical support?

What type of modifications would it require to adapt the ICT and make it more user-friendly?

In what type of situations can ICT create more efficient use of time and cost-efficient use of resources?

Conclusion

The intention with this discussion paper is to serve as foundation for further discussions about the development, design and delivery of home-based rehabilitation services including ICT. As argued previously [24] and we agree, digitalisation will have an impact on how we design and deliver rehabilitation services. Occupational therapists were involved in the projects discussed and we argue that the profession has an important role in proactively utilising the potential of ICT to advance rehabilitation and occupational therapy interventions.

Significance

We emphasise that ICT has the potential to develop and improve the quality, accessibility and user-friendliness of home-based rehabilitation services and thereby contribute to environmentally friendly solutions.

Ethical approval

Ethical approval was not requested for this paper. However, the paper builds on data where ethical approval was granted for the different research projects (the Regional Ethics Committee in Stockholm 2017/1414–32); (the Uganda National Council for Science and Technology reg. HS703 and by Mulago hospital’s ethical board date: 12/1–2011) and (the Regional Ethical Review Board in Umeå Dnr: 2016/292-31).

Acknowledgements

The authors would like to thank the ReAble network (https://reable.auckland.ac.nz/) for supporting this work. Furthermore, we are grateful to all clients, professionals and researchers contributing to the results being presented and discussed in this paper.

Disclosure statement

The authors confirm that there is no conflict of interest.