TELE-REHABILITATION: Meeting the needs of persons with intellectual disabilities through the application of technology

by Sean Abbott (Project Leader), Louise Bermingham (Project Worker) Derval McDonagh (Speech and Language Therapy Manager) Marguerite O’Brien (Information Technology Manager) David Worrall (Physiotherapy Manager)

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Introduction

COPE Foundation, which employs over 800 staff, provides a comprehensive range of services for 1600 children and adults with an intellectual disability through its system of early intervention, education, training, adult day services, supported employment, housing, information and advice, at over 60 locations throughout Cork city and county.

The provision of a full range of services to clients at all COPE Foundation locations in a timely and equitable manner is a basic objective of the organisation. However, achieving this can be challenging and requires innovation and creativity, especially where services are provided on an interdisciplinary basis—such as physiotherapy, occupational therapy and speech and language therapy.

Traditionally, the interdisciplinary team has been based in Cork City, however as several of COPE Foundation’s centres are based in County Cork, the time spent travelling to and from these centres (e.g. in Clonakilty and Mallow) can reduce the time available for working directly with clients. The COPEtNet Project team has explored the use of various ways to respond to this challenge through the provision of technology aimed at providing interdisciplinary therapy on a remote basis.

Pilot study

In looking at technological advances in recent years and the opportunities provided to people with an intellectual disability, the team decided to explore the area of tele-rehabilitation in a pilot study during 2008. This involved the use of video-conferencing technologies to create a live video and audio link between two or more sites. While video-conferencing is widely used in business, COPE Foundation wanted to explore its potential and value in the delivery of services to clients. The aim of tele-rehabilitation is to augment and improve existing services, while maintaining face-to-face contact with clients.

The main components of the video-conferencing systems implemented by Cope Foundation are a large TV Monitor, a high-definition camera and a specialised device that sends and receives the information (audio and video) to and from the connected sites. For a real-time, high-quality connection, the development of an Information Communication Technology network was required in order to provide a high-speed link to a number of county locations. The systems work through COPE Foundation’s secure internal network, ensuring that no confidential client information can be accessed. This secure, live, high-quality connection allows a therapist in Montenotte to talk to and see a client in, for example, Clonakilty for a ‘real-time’ consultation.

Tele-rehabilitation project

Funding for initial start-up costs and specialised equipment required for the project was accessed through the Enhancing Disability Services (EDS) programme grant. EDS grants are managed by Pobal on behalf of the Department of Justice, Equality and Law Reform. Additional funding was provided by COPE Foundation and the HSE (South). It was proposed for the purpose of the pilot, that a maximum of two common interventions should be chosen that required an interdisciplinary approach. It was decided by the project team to explore the provision of feeding reviews and seating reviews using the tele.rehabilitation model. Feeding and seating difficulties can require a rapid response (for example, if a client is experiencing difficulties with their wheelchair) and both areas often require an interdisciplinary team assessment.

The following groups were involved in monitoring and guiding the project:

  • Clients, their families and staff members were involved with the direction of the project through focus groups.
  • Project Team consisting of the Project Leader (Head of Client Services), IT Manager, Speech and Language Therapy Manager, Physiotherapy Manager, Occupational Therapy Manager and a full-time project worker.
  • Steering Committee made up of the project team, project accountant and partnership organisations (HSE and Kerry Parents and Friends).

The project was piloted in North Cork and West Cork. Video.conferencing systems were installed in Cork City, Mallow and Clonakilty, thus allowing clients from the adjacent COPE Foundation services to avail of tele-rehabilitation services at their most convenient location. A representative pilot group of 28 COPE Foundation clients were identified as having feeding and/or seating issues. In parallel to choosing a pilot group, open days were held for families, staff and clients with the aim of introducing the project, providing demonstrations and answering any questions or concerns. The pilot group reviews took place over a 4-month period and 26 reviews were completed. The details recorded from each review included quality of the system’s sound and image, discomfort and distraction levels of clients, travel gains/losses and time gains/losses. Feelings and attitudes towards the system were measured through questionnaires and post-review interviews.

Findings

Analysis of the results showed the following benefits for telerehabilitation:

  • Review preparations—prior to a face-to-face consultation, the system can be ideal for a pre-assessment of the clients needs.
  • Follow up reviews—after the initial face-to-face assessment, follow-up reviews can take place over the system to monitor progress and recommended techniques.
  • Full interdisciplinary consults—it can be difficult to arrange a time for the full interdisciplinary team to be present for a consultation at a county location. The system makes this possible with minimum time delay.
  • Mentoring and supervision of the teams by their line managers, leading to greater quality assurance and on-the-job training.
  • Savings on travel expenses, which also include time savings for the therapists at the base site.

Predominately, the limitations of the system were found to be with the room location and set-up. During some reviews, clients showed signs of discomfort and/or distraction. It is hypothesised that this may have been due to the unfamiliar location and room set-up of the tele-rehabilitation review. Time loss came from nursing staff and care assistants having to travel to the systems location from the adjacent centers. Time loss due to room set-up and clean up, prior to and after a review.

Other limitations could be attributed to:

  • The therapists’ view that a face-to-face review was required—where the situation was too complex or warranted a hands-on approach
  • Logistical problems of transferring people between sites
  • The prolonged set-up time for the technology meant the pilot study itself was of a short duration which did not give clients, families or staff adequate time to grow accustomed to the system.

Some of these issues could be avoided or overcome with the following:

  • All initial and/or complex assessments to be carried out face-to-face.
  • Implementing a dedicated room/location for a video.conferencing system at each centre
  • Encouraging and supporting staff in using the system to build up their confidence.
Future for tele-rehabilitation

COPE Foundation is at the pilot stage of discovering how tele-rehabilitation can be used as a method of service delivery. The envisaged outcome for this project was for tele-rehabilitation to be an integral part of service delivery for feeding and seating reviews. However, findings show that only certain cases can be dealt with using the system. Feedback from focus groups and questionnaires has shown many other areas for which the system can be useful, in addition to the already seen benefits. Examples include:

  • Social networking
  • Personal development clubs for clients
  • Meetings
  • Educational sessions for staff, clients and families,eg. communication training
  • Urgent enquiries—If a client needs to be seen immediately, rather than waiting for the scheduled face-to-face contact.
  • Basic reviews
  • Where staff seek further clarification of therapy recommendations
  • In-service training.
Conclusion

Although this project is at the pilot stage, COPE Foundation is happy to talk to any other agencies interested in exploring a similar system. Queries are welcome and we would be happy to demonstrate the system.

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