Model for telerehabilitation services for stroke survivors:

experiences of CLEAR project

Francesco BenvenutiDipartimento Riabilitazione-Fragilità

AUSL11, Empoli

Research brokerage workshop in Lodz10-11 September 2013

Aims was CLEAR project

• To evaluate a tele-rehabilitation service provided through the Habilis platform.

• The study was focused on the end users (patients and clinicians):– Satisfaction with the tele-rehabilitation

application– Clinical effectiveness of the service – Time investment for providing and receiving

the tele-rehabilitation service

ConsortiumCoordinatoreSigno Motus

Designers

SITUS (IT)

UPM (ES)

RRD(NL)

Clinici

AUSL11 (IT)

FPING (SP)

RCR (NL)

MUW (PO)

Gruppo validazione

ISS (IT)

IE-UAB (ES)

TIC –Salut (ES)

RETOS (IT)

CSIOZ (PO)

MENZIS (NL)

CoordinatorSigno Motus

Clinical Centers AssessorsDesigners

Cinical studies

COPD , Chronic back pain, 

Whiplash

Cognitive disordersAcquired Brain

Injury

Osteoarthritis of hip or knee before

and after total joint replacement

Upper limb paresis after stroke

Telerehab vs. ConventionalTreatment

Effectiveness Similar or superiorSafety Similar

Customer satisfaction Good/very good

Time investment for clinicians and patients

Reduced

CLEAR Results

Different rehabilitation treatment scenarios

Partial replacement

Time augmentation

Conventional

Addition

Conventional rehab sessionsTele-rehab sessions

Stroke Epidemiology• Incidence: 220/100000• Survival:

• 1 year: 60-75%• 3 years: 40-68%• 10 years: >35%

• Prevalence: 600-800/100000• Severely disabled: 35-40%

Recovery plateau

What we observe….

Reh

abili

tatio

n

Reh

abili

tatio

n

Reh

abili

tatio

n

Reh

abili

tatio

n

Time from strokeAcute &

SubacuteChronic

What we learn…..

Recovery plateau

Time from strokeAcute &

SubacuteChronic

Aims of CLEAR project in AUSL11:•To extend rehabilitation in the subacute phase of the disease•To maintain/improve function in the chronic phase

Methods

Hospital

Home Kiosk3 times/week 2 times/week

Treatment duration3 months

Kiosks installed

HOSPITALs & KIOSKs LOCATION

Hospitals

Montelupo F.no

Clinical resultsSafety

No significant ACEs associated to the treatment program have been

observed in both groups

Clinical resultsEffectiveness: analysis at individual level

Improved (>10%)Unchanged (0-9%)Worse (<0%)

Chi2 testP=0.00011

Chi2 testP=0.01924

Nine Hole Peg Test

0%20%40%60%80%

100%

Usual care group Treatment group

Motricity Index

0%20%40%60%80%

100%

Usual care group Treatment group

Clinical resultsLogistic Regression Analyses

OR 95%CI Female Gender 2.30 1.58 3.34 UL Paresis (Motricity Index) 0.94 0.92 0.96Spasticity (Ashworth scale) 0.67 0.58 0.78 Adherence 2.39 1.77 3.21

Predictors of effectiveness

OR 95%CIHome-kiosk distance 0.85 0.78 0.91No help needed to go to kiosk 10.88 6.27 18.88

Predictors of Adherence

Clinical resultsPatients’ Satisfaction

Satisfaction questionnaire: scores post-interventionn=160

Component Low (score 1-2)

Average (score 3-5)

High(score 6-7)

Ease of use 3% 89% 8%

Usefulness 11% 51% 38%

Attitude 1% 96% 3%

Social Norm 2% 60% 38%

Self-efficacy 10% 90% 0%

Intention 3% 78% 19%

Satisfaction 2% 53% 45%

78% found the exercise program useful for them70% patients found the Habilis platform well implemented75% would recommend the Habilis service to othersAverage patient grading of the Habilis service 7.4 (SD 1.8)

Clinical resultsTime investment

Home-Kiosk-HomeMedian (min-max)

Home-Hospital-HomeMedian (min-max)

Single treatment sessiontravel distance (km)

5.8 (0.4-43.6) 22.2 (0.6-68.0)

3-months travel distancefor 22 treatment sessions(km)

127.6 (9.2-959.2) 488.4 (13.2-1496.0)

3-months travel cost for22 treatment sessions*(€)

25.5 (1.8-191.8) 97.7 (2.6-299.2)

Median travel distance and cost per patient (n=165)

*0,20€/km

Clinical resultsTime investment

Usual Care During CLEAR 

Project

Optimization after CLEAR Project

Physical Therapisttime/patient 

(hour)time/patient 

(hour)time/patient 

(hour)

patient's assessment at baseline 1 1,42 1

patient's training to the use of Habilis platform 0 2 2

first week of treatment 0 1,75 1

successive 11 weeks of treatment 22 16,5 11

patient's final assessment 1 1 1

Total for Physiotherapist 24.0 22,67 16.0

Physiotherapist time investment for usual care, CLEAR project, and optimization of treatment protocol

Future workLimits Possible Corrective actions

•Problems of transportation and social support to attend kiosks

•Increase geographical distribution of kiosks•Assisted transportation•Home tele-rehabilitation (using equipment already available at home?)

•Very difficult to find space from no profit organizations

•Economic support by Regional Health Authority•Participation to costs by participants

•Limited number of patients •Extend the program to other conditions•Integration with conventional treatment programs

•Poor connectivity in rural areas •Wide band

•Patients ICT interactions •Paedagocic incentive

•Exercise program very similar to that performed at home

•Instrument the Habilis platform•Serious games

•Limited computer skill of participants •More friendly interface

About kiosk experience

Main critical issues:

1. Acceptance;2. Policy;3. Infrastructures (broadband and places);4. Organizational problems;5. Lack of a contextual framework allowing continuity of care.

Fracture and main interventionarea: management from hospital to

territory

Telerehab service future scenarios

Health HouseDistrict

• Information on continuity of care• Empowerment• Rehabilitation treatment (Kiosk like)• Tele consultation/ videoconference

Home• Rehabilitation treatment:

o stroke (bag+ Habilis)o frailty (Otago libraries + Habilis)o orthopaedics (libraries + Habilis)o BPCO (libraries BPCO + Habilis)o cognitive (libraries + Habilis)

•Teleconsultation / videoconference•Telemonitoring

HOSPITAL

• Information on continuity of care • Empowerment• Initial treatment (sub acute phase)• Tele consultation/ videoconference

GP/ACCESS POINTS

• Information on continuity of care• Patient management

Habilis

Habilis

HABILIS Service Centre

•Treatment management

Service acces points

Treatment provision

Patient routing

Horizon 20203. Advancing active and healthy ageing

– 3b Service and social robotics in support of active and independent living

4. Integrated, sustainable, citizen-centred care – 4d Advanced ICT systems and services for

Integrated Care – 4f Citizen engagement in health, wellbeing and

prevention of diseases – 4g mHealth for disease management – 4h Patient empowerment

Thank You!

Francesco BenvenutiDipartimento Territorio-FragilitàUOC Cura e Riabilitazione delle FragilitàAzienda Unità Sanitaria Locale 11 di Empolif.benvenuti@usl11.toscana.itwww.usl11.toscana.it

www.habiliseurope.eu

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