Abstract
Introduction:
Older Veterans with multimorbidity experience physical, mental, and social factors which may negatively impact health and healthcare access. Physical function, behavior change skills, and loneliness may not be addressed during traditional physical rehabilitation. Thus, a multicomponent telerehabilitation program could address these unmet needs. This program evaluation assessed the safety, feasibility, and change in patient outcomes for a multicomponent telerehabilitation program.
Methods:
Individuals were eligible if they were a Veteran/spouse, age ≥ 50, and had ≥ 3 comorbidities. The telerehabilitation program included four core components: 1) high-intensity rehabilitation, 2) coaching interventions, 3) social support, and 4) technology. Physical therapists delivered the 12-week program and collected patient outcomes at baseline, 4, 8, and 12 weeks. Program evaluation measures included safety events (occurrence and type), feasibility (adherence), and patient outcomes (physical function). Safety and feasibility outcomes were analyzed using descriptive statistics. The mean pre-post program difference and 95% confidence interval (CI) for patient outcomes were generated using paired t-tests.
Results:
Twenty-one participants enrolled in the telerehabilitation program; most were male (81%), white (72%), and non-Hispanic (76%), with an average of 5.7 (3.0) comorbidities. Prevalence of in-session safety events was 3.2% (0.03 events/session). Fifteen (71.4%) participants adhered to the program (attended ≥ 80% of sessions). Mean (95% CI) improvements for physical function are as follows: 4.7 (2.4 to 7.0) repetitions for 30 second sit to stand, 6.0 (4.0 to 9.0) and 5.0 (2.0 to 9.0) repetitions for right and left arm curl respectively, and 31.8 (15.9 to 47.7) repetitions for the 2-minutes step test.
Conclusion:
The telerehabilitation program was safe, feasible, and demonstrated pre to post program improvements in physical function measures while addressing unmet needs in a vulnerable population. These results support a randomized clinical trial while informing program and process adaptations.
INTRODUCTION
Approximately 90% of older Veterans receiving care from the Veterans Health Administration (VA) have ≥ 3 chronic medical conditions [1]. Multiple chronic conditions—multimorbidity—is associated with various health consequences, negatively influencing a Veteran’s health and life participation. Multimorbidity—more common in older Veterans than older non-Veterans [2]—is associated with impaired physical function [2] and loneliness [3]. Physical function impairment is associated with falls, physical inactivity, and loss of physical independence [4]. Further, both physical function and loneliness are predictive of hospitalization and mortality [4, 5]. These multifaceted and interrelated factors contribute to a cycle of progressive health decline.
Increasing daily physical activity is protective against health decline and loss of independence among all older adults [4], yet many older Veterans receiving care from the VA do not meet recommended levels of physical activity [6]. While physical rehabilitation can address physical function limitations contributing to physical inactivity, traditional episodes of care are insufficient to facilitate lasting behavior change, nor do they address social health needs such as loneliness. Alternate approaches, such as teaching self-management skills, show promise for managing clinical measures of chronic conditions [7]. However, studies are mixed regarding their usefulness for maintaining physical function and physical activity [7, 8] likely because older adult populations also experience financial and social vulnerabilities [9].
Factors such as geographic location, social support, and access to transportation can also negatively influence timely and continued access to in-person rehabilitation services [10]. Continued access, commonly referred to as adherence, is especially important for physical rehabilitation because multiple visits are necessary to adjust plans of care according to patient response, ameliorate physical function limitations, and reduce risk of further health decline. One potential solution to access barriers is telerehabilitation. While telerehabilitation is becoming more acceptable, healthcare providers have expressed concerns about delivering services to older patients with multimorbidity [11]. Concerns include patient safety and belief that older patients will have difficulty or be unable to use various technologies [11].
Older Veterans with multimorbidity experience several vulnerabilities that negatively influence their overall health and impede access to physical rehabilitation services. Thus, we sought to address these care gaps by developing, piloting, and evaluating a multicomponent telerehabilitation program. This program evaluation aimed to determine safety, feasibility, and pre- to post-program change in patient health outcomes.
MATERIALS AND METHODS
Program Evaluation Design & Context
The multicomponent telerehabilitation program was embedded within the infrastructure of the local VA Medical Center in partnership with the local University. This prospective cohort program evaluation was conducted during the COVID-19 pandemic (January 2021 to August 2021). This paper follows the Standards for QUality Improvement Reporting Excellence (SQUIRE) reporting guidelines [12].
Ethical Considerations
This clinical program evaluation was intended to assess our specific program and was not intended to be generalizable. Thus, the Institutional Review Board determined that the program evaluation was not human subjects research.
Participants
Eligible individuals were U.S. Veterans or Veteran’s spouse, age ≥ 50 years with ≥ 3 chronic medical conditions, referred for outpatient physical therapy at a VA facility, and volunteered for the program. Use of supplemental oxygen was not exclusionary. Individuals were excluded if they had a medical condition that would preclude safe participation in high-intensity rehabilitation (e.g., unstable angina), an acute or progressive neurological condition, or moderate to severe cognitive decline (Telephone Montreal Cognitive Assessment (MoCA) score < 11) [13].
Intervention
The 12-week multicomponent program was delivered by licensed physical therapists and one physical therapy assistant (Figure 1), all of whom had ≥ 5 years of in-person clinical experience. Two physicians (a geriatrician and an emergency medicine physician) provided medical context and insight for virtual care procedures. The program included 4 components: 1) high-intensity rehabilitation, 2) coaching, 3) social support, and 4) technologies. To begin the program, Veterans participated in 10–12 individual telerehabilitation sessions and then transitioned into 20–24 group telerehabilitation sessions.
Figure 1.
Overview of the Multicomponent Telerehabilitation Program
Component 1: High-Intensity Rehabilitation
During all telerehabilitation sessions, clinicians instructed participants how to achieve high intensity for all strengthening and functional exercises. We defined high intensity as achieving an 8-repetition maximum (RM), which is approximately 80% of a 1-RM [14].
Component 2: Coaching
A physical therapist who was trained in motivational interviewing (MI) techniques [15] and did not complete individual or group sessions, delivered eight 30-minute coaching sessions to facilitate program engagement and physical activity behavior change. The interventionist participated in a 2-day (4 hours total) MI training workshop with ongoing consultation from an MI expert and demonstrated MI-consistent behavior through role-play exercises prior to any patient sessions.
Component 3
Social support was integrated into the group telerehabilitation sessions and facilitated by program staff. Each session began with a question of the day, which facilitated low-stakes socialization. Spontaneous peer-to-peer conversation and encouragement was also facilitated during the group sessions. Groups consisted of 1 to 5 Veterans.
Component 4
Technology supports included a 1) secure platform for video appointments (VA Video Connect); 2) text messaging protocol delivered by the VA’s web-based program called Annie, 3) activity monitoring, and 4) data sharing facilitated by the VA’s mobile application Sync My Health Data (SMHD). Annie delivered both one-way and two-way text messages over the 12-week program (Supplemental Material 1), supporting coaching interventions. Two different two-way text messages collected data about step counts (sent once daily) and falls (sent once per week). Veterans who did not already own an activity monitor received a Fitbit Versa 2 (San Francisco, California). SMHD transferred activity monitor data to a secure web-based platform called Virtual Care Manager, which program staff accessed using their secured-login.
Supplemental Material 2 contains additional details of the intervention.
Measures
Demographics and Participant Characteristics
Demographics and participant characteristics included rural status, miles saved, age, sex, body mass index (BMI), functional comorbidity index [16], race, ethnicity, highest level of education, military branch of service, cognitive status, and mobile device proficiency. Rurality (yes vs. no) was determined based on the participant’s zip code and the Federal Office of Rural Health Policy Eligible Zip Codes file [17]. Miles saved was defined as the round-trip driving distance from the Veteran’s physical address to the nearest VA facility. Cognitive function was assessed using Telephone MoCA; scores range from 0 to 22, and scores of ≥ 18 are considered non-impaired [13]. Baseline technology skills were assessed using the Mobile Device Proficiency Questionnaire (MDPQ)-16 [18]. This 16-item survey measures a person’s capability to perform different tasks on a mobile device using a 1 to 5 Likert-type scale (1-never tried to 5-very easily); summative scores range from 8 to 40.
Safety
At each session, clinicians asked Veterans if they experienced any falls, had any emergency visits or hospitalizations, or developed any new or worsening symptoms since the prior session. All in- and out-of-session safety events were documented in the patient’s medical record. Date(s), details, and staff response were collected for all safety events. A clinician categorized events by type (unusual circumstance, fall, emergency department visit, hospitalization, and other) and relatedness to the program’s intervention protocol.
Feasibility
The program’s primary feasibility outcome was adherence to sessions, and individuals were adherent if they attended ≥ 80% of sessions. Secondary feasibility outcomes included technology feasibility, Feasibility of Intervention Measure (FIM) [19], Intervention Appropriateness Measure (IAM) [19], patient satisfaction, and enrollment and retention. Technology feasibility was measured by the number and proportion of responses to Annie two-way text messages, and the number and proportion of Veterans who successfully enrolled in SMHD. The FIM and IAM consist of 4 items rated on a 5-point Likert-type scale ranging from (1) completely disagree to (5) completely agree. Both providers and patients completed the FIM and IAM surveys. Patient satisfaction was assessed via the VA’s approved survey, V-signals. It consists of 11 items rated on a 5-point Likert-type scale from (1) strongly disagree to (5) strongly agree, where higher scores indicate better satisfaction. All surveys were emailed from REDCap (Research Electronic Data Capture [20]) to patients following completion of the program. Enrollment was the total number of individuals enrolled and the average enrollment per month. Retention was calculated as the percentage of individuals who completed the 12-week program.
Patient-Centered Outcomes
Patient-centered outcomes were selected to align with each program component (Table 1), measuring change in the expected problems or unmet needs. The treating physical therapist collected measures at baseline, 4-, 8-, and 12-weeks according to the typical timeframe for physical therapy re-evaluations.
Table 1.
Patient-Centered Outcome Measures by Intervention Component.
| Intervention Component | Example Problems | Outcome Measures | Positive Change |
|---|---|---|---|
|
Component 1 Progressive, high-intensity rehabilitation |
• Multimorbidity • Muscle weakness • Reduced walking ability • Falls |
Physical Function • 30 second sit to stand • Arm curl test • 2-minute step test Surveys • AM-PAC • PROMIS-29+2 Profile v2.1 |
Physical Function • Increased repetitions Surveys • Higher scores |
|
Component 2 Biobehavioral intervention |
• Lacking skills to support behavior change | • Self-Efficacy for Exercise Scale | • Higher scores |
|
Component 3 Group Physical Therapy Sessions |
• Loneliness | • 3-Item Loneliness scale | • Lower scores |
|
Component 4 Technology Supports |
• Reduced access to in-person care • Inability to maintain physical activity behavior |
• Response rate to Annie • Enrollment in SMHD |
N/A |
|
Components 1–4 Behavior Change |
• Reduced participation in routine physical activity | • Average daily steps | • Increased number of daily steps |
Abbreviations: AM-PAC: Activity Measure for Post-Acute Care Outpatient Short Form; N/A: not applicable; PROMIS: Patient-Reported Outcomes Measurement Information System; SMHD: Sync My Health Data
Physical Function Performance Measures
All performance measures were tested by the treating physical therapist as part of the standard physical therapy re-evaluation, and all surveys were emailed to individuals on the same day. Physical function was measured using the 30 second sit to stand test for lower extremity strength, arm curl test for upper extremity strength, and the 2-minute step test for aerobic endurance [21]; higher scores indicated better physical function.
Surveys
The Activity Measure for Post-Acute Care (AM-PAC) Outpatient Short Form [22] consists of 18 items measured on a 4-point Likert-type scale (1-unable to 4-none); items are rated based on the prompt “how much difficulty do you currently have…”. The Patient-Reported Outcomes Measurement Information System (PROMIS)-29+2 Profile v2.1 measures physical and mental health [23]. It is a 29-item questionnaire, and most items are rated on a 5-point Likert-type scale. There is one pain intensity item rated on a 0 (no pain) to 10 (worst pain imaginable) scale. The Self-Efficacy for Exercise Scale [24] is a nine-item questionnaire used to measure an individual’s self-efficacy for exercising under different conditions. Each item is rated on a scale of 0 (not confident) to 10 (confident). Loneliness was measured by the 3-item Loneliness scale [25]. This scale has three items measured on a 3-point Likert-type scale; scores range from 3 to 9.
Physical Activity
Physical activity was measured by average daily step counts recorded by the participant’s consumer wearable device. Step count data was manually extracted from Virtual Care Manager for 7 days at the beginning (week 1) and end (week 12) of the program.
Statistical Analysis
Descriptive statistics were calculated for all outcomes and reported using mean (SD) and counts (%). Median (IQR) was reported for non-normally distributed continuous outcomes. The mean difference (post- minus pre-program) and 95% confidence interval (CI) were generated using a paired t-test, or a Wilcoxon rank sum test for non-normally distributed outcomes, and only included individuals with complete data. Analyses were performed in SAS v9.4 (SAS Institute Inc., Cary, North Carolina).
RESULTS
Demographics and Patient Characteristics
Twenty-one Veterans or spouses enrolled in the program of whom 14 completed all 12 weeks (finishers). The mean number of comorbidities was 5.7 and Table 2 displays the most common medical conditions. Approximately one quarter were classified as rural residents, and median [IQR] miles saved per person was 34 [12, 49] miles per visit and 734 [337, 977] miles for all visits.
Table 2.
Baseline Characteristics of Participants Enrolled in the Telehealth Program (n=21)
| Characteristics | Values | |
|---|---|---|
| Age, mean ± SD | 64 ± 9.4 | |
| Biological Sex: (male, n (%)) | 17 (81%) | |
| Body Mass Index, mean ± SD | 28.9 ± 4.8 | |
| Rural (yes, n (%)) | 5 (24%) | |
| Functional Comorbidity Index, mean ± SD | 5.7 ± 3.0 | |
| Most frequent comorbidities from Functional Comorbidity Index, n (%) | ||
| Arthritis | 15 (72%) | |
| Degenerative Disc Disease | 14 (67%) | |
| Diabetes | 9 (43%) | |
| Depression | 8 (38%) | |
| Anxiety | 7 (33%) | |
| Race, n (%) | ||
| White | 15 (72%) | |
| Black or African American | 2 (9.5%) | |
| More than 1 Race | 4 (19%) | |
| Ethnicity, n (%) | ||
| Not Hispanic or Latino | 16 (76%) | |
| Hispanic or Latino | 4 (19%) | |
| Unknown | 1 (4.8%) | |
| Education, n (%) | ||
| High School or equivalent | 2 (9.5%) | |
| Some College or Associate Degree | 11 (52%) | |
| Bachelor’s Degree | 3 (14%) | |
| Post-baccalaureate | 5 (24%) | |
| Military Branch, n (%) | ||
| Air Force | 8 (38%) | |
| Army | 7 (33%) | |
| Marines | 2 (9.5%) | |
| Navy | 3 (14%) | |
| Non-veteran, veteran Spouse | 1 (4.8%) | |
| Telephone MoCA, mean ± SD | 18.2 ± 2.5 | |
| MDPQ-16, mean ± SD | 34.4 ± 6.8 | |
Abbreviations: MDPQ: Mobile Device Proficiency Questionnaire; MoCA: Montreal Cognitive Assessment
Safety
Clinicians completed 317 individual and 122 group sessions. There were 16 safety events and 1 unusual circumstance resulting in deferred treatment; 3 of these events occurred outside of sessions (Table 3). In-session prevalence was 3.2% (0.03 events/session). Most safety events were minor, and those with greater severity were unrelated to the telerehabilitation program.
Table 3.
Safety Events
| Category | Session Type | Protocol Relatedness | Details |
|---|---|---|---|
| Falls (n=3) | |||
| Fall #1 | Group | Probably Related | The Veteran’s left knee buckled during exercise, and he fell back onto the couch without injury. |
| Fall #2 | Individual | Possibly Related | The Veteran with history of PD “froze” during session and fell onto a nearby chair when reaching for it to stabilize himself. He was able to catch himself on the chair though experienced a minor abrasion to his arm. |
| Fall #3 | Group | Definitely Related | Veteran experienced a non-injurious fall when performing a sit to stand exercise, and the chair slid out from behind him causing him to fall to the floor. |
| ED Visit (n=1) | |||
| ED Visit #1 | Outside of session | Definitely Unrelated | The rural Veteran did not show for his scheduled evaluation, and the clinician called patient’s landline to inquire about absence and learned he had fallen earlier in the day. He had severe bruising on the side of his body and was short of breath despite using supplemental oxygen. The clinician advised the patient present to the ED. |
| Hospitalization (n=1) | |||
| Hospitalization #1 | Outside of session | Definitely Unrelated | The Veteran presented to the video session with new onset of facial droop. Stroke was suspected, and the clinician advised patient present to the ED, which resulted in hospitalization. |
| Other (n=11) | |||
| Other Events #1–8 | Individual: 4 Group: 3 Outside of session: 1 |
Probably Related: 1 Possibly Related: 5 Definitely Unrelated: 2 |
Acute exacerbation of chronic condition |
| Other Event #9 | Group | Possibly Related | Hypotension following session, resolved within 5 minutes |
| Other Event #10 | Group | Probably Related | Veteran dropped aerobic step onto his foot, non-injurious event |
| Other Event #11 | Individual | Possibly Related | Desaturation during standing activity in presence of known lung condition and prescribed supplemental O2 |
| Unusual Circumstance (n=1) | |||
| Unusual Circumstance #1 | Group | Definitely Unrelated | Veteran disclosed he was intoxicated at the beginning of the session; session deferred appropriately due to safety concerns |
Abbreviations: ED: emergency department; PD: Parkinson’s disease; UC: unusual circumstance
Feasibility
Mean attendance was 82.2% (14.4), and fifteen participants (71.4%) met attendance adherence criteria. Attendance rate was highest for individual sessions, followed by coaching sessions and then group sessions (Table 4). Eleven of 20 participants (55.0%) were adherent to two-way text messages; proportion of adherence was higher among finishers. Median response rates were similar for the two different two-way text message templates. Twenty individuals enrolled to received Annie text messages; one person was unable to enroll due to cellular carrier restrictions. Fifteen (71.4%) participants successfully enrolled in SMHD; of the 6 who did not enroll, 4 experienced an unknown error, 1 was unable to download the app, and 1 did not have a secure VA log-in.
Table 4.
Primary and secondary feasibility outcomes
| Outcome | Value | |
|---|---|---|
| Session Adherence (attended ≥ 80% sessions), n (%) | ||
| All (n=21) | 15 (72%) | |
| Finishers (n=14) | 12 (86%) | |
| Detailed Attendance, median [IQR] | ||
| Individual Sessions (n=21) | 100% [90%, 100%] | |
| Coaching Sessions (n=20*) | 94% [81%, 100%] | |
| Group Sessions (n=17^) | 78% [67%, 90%] | |
| Technology Adherence (responded ≥ 80% of texts), n (%) | ||
| All participants (n=20), All 2-way Texts | 11 (55%) | |
| Finishers (n=14), All 2-way Texts | 10 (71.4%) | |
| Detailed Text Response Rates, median [IQR] | ||
| All participants (n=20), response to steps only (1×/day) | 84% [62%, 98%] | |
| All participants (n=20), response to falls only (1×/week) | 85% [66%, 100%] | |
| Finishers (n=14), response to steps only (1×/day) | 93% [76%, 99%] | |
| Finishers (n=14), response to falls only (1×/week) | 88% [83%, 100%] | |
| Technology Enrollment, n (%) | ||
| Annie | 20 (95.2%) | |
| Sync My Health Data | 15 (71.4%) | |
| Participant Surveys (n=15), mean (SD) | ||
| Feasibility of Intervention Measure | 4.5 (1.0) | |
| Intervention Appropriateness Measure | 4.4 (1.0) | |
| V-signals (satisfaction) | 4.8 (0.4) | |
| Provider Surveys (n=3), mean (SD) | ||
| Feasibility of Intervention Measure | 3.9 (0.3) | |
| Intervention Appropriateness Measure | 4.7 (0.5) | |
Only 20 are included in coaching attendance because 1 individual completed coaching sessions integrated into individual sessions
4 individuals are missing from the group session adherence because they withdrew prior to starting group sessions
Total enrollment was 21 participants over 5 months (4.2 per month). Retention rate was 66.7% (14 out of 21). Most withdrew prior to starting group sessions due to medical decline (n=4), time conflicts (n=2), and loss to follow-up (n=1).
All finishers and one participant who completed 8 weeks of the program (n=15) completed the FIM, AIM, and satisfaction surveys (Table 4). The other 6 participants did not complete the surveys because they withdrew from the program prior to survey collection (12 weeks). Three out of 5 providers completed the FIM and AIM surveys; the other two providers did not complete the surveys because of 1) minimal involvement in intervention delivery, or 2) direct involvement in development of the intervention protocol.
Patient-Centered Outcomes
Most physical function outcomes and the mental health subscale of the PROMIS measure showed a trend of improvement from pre- to post-program (Table 5). Other patient-centered outcomes did not show a clear trend toward improvement or decline. Only 9 participants had complete data for average daily step counts. Missingness was due to inability to enroll in SMHD (n=6) and study withdrawal (n=6).
Table 5.
Mean or Median Changes from Pre (baseline) to Post Program (12 weeks) for Patient-Centered Outcomes
| Outcome | Pre-Program Value (n=21) | Post-Program Value (n=14) | Change Value (95% CI) (n=14) |
|---|---|---|---|
| 30 Second Sit to Stand, mean (SD) | 11.2 (6.5) | 16.0 (6.6) | 4.7 (2.4 to 7.0) |
| 30 Second Arm Curl Test | |||
| -Right Arm, median [IQR] | 16.5 [12.5, 20.0] n=20 |
23.0 [20.0, 27.0] | 6.0 [4.0 to 9.0] n=13 |
| -Left Arm, median [IQR] | 16.0 [13.0, 22.0] n=20 |
22.5 [19.0, 27.0] | 5.0 [2.0 to 9.0] n=13 |
| 2-Minute Step Test, mean (SD) | 73.0 (25.3) | 101.7 (27.9) | 31.8 (15.9 to 47.7) |
| AM-PAC Outpatient Short Form, median [IQR] | 59.8 [53.1, 62.7] | 61.8 [57.4, 68.5] | 0.6 [−0.6 to 10.4] |
| PROMIS-29+2 Profile v2.1 | |||
| -Physical Health, mean (SD) | 40.1 (7.8) | 46.4 (7.2) | 4.5 (1.0 to 8.1) |
| -Mental Health, median [IQR] | 44.6 [40.9, 50.4] | 53.3 [41.8, 57.9] | 2.8 [−1.9 to 10.8] |
| 3-Item Loneliness, mean (SD) | 5.3 (1.7) | 4.5 (2.0) | −0.7 (−1.6 to 0.2) |
| Self-Efficacy for Exercise Scale, mean (SD) | 55.5 (14.4) n=19 |
54.7 (25.0) | −0.7 (−19.6 to 18.1) |
| Average Daily Step Count, median (IQR) | 6982 [2383, 8878] n=15 |
8625 [5054, 9293] n=9 |
96 [−1592 to 5514] n=9 |
Abbreviations: AM-PAC: Activity Measure for Post-Acute Care, PROMIS: Patient-Reported Outcomes Measurement Information System
DISCUSSION
We demonstrated that Veterans with multimorbidity could safely participate in and potentially benefit from a multicomponent telerehabilitation program. There was a low incidence of safety events, and those that did occur were minor. The program was also feasible based on surveys and good attendance rate, especially among those who completed the program. Veterans rated the program as more feasible than clinicians, but both groups rated the program as appropriate. Physical function measures demonstrated the largest changes for patient-centered outcomes. Findings supported the continuation of the multicomponent telerehabilitation program while identifying opportunities for improvement.
Safety results highlighted important areas for program improvement. The observed safety events reinforced the importance of preparing the home environment and monitoring patients throughout each session. Without this close monitoring, multiple safety events might have been missed, potentially leading to patient harm. The events encountered during our program were consistent with those identified during a systematic review of home telecare services [11] and are akin to patient safety risks associated with in-person rehabilitation.
Feasibility outcomes were positive. Adherence, as measured by attendance, was higher when including only those patients who completed the program compared to those who withdrew; this finding is similar with previous studies evaluating barriers to attendance and adherence for exercise interventions [10, 26]. Attendance rate was also lower in the group versus individual sessions, which occurred for a few reasons. First, the program prioritized completion of individual sessions prior to full transition to group sessions. Second, the group sessions occurred on set days and times meaning there were fewer opportunities to reschedule group sessions around participants’ needs. Third, group sessions occurred three days/week compared to two days/week for individual sessions.
The disagreement between Veterans and clinicians about program feasibility prompted program staff to complete exit interviews with the clinicians. During these interviews (unpublished data), clinicians identified two barriers. First, clinicians identified increased administrative burden such as patient scheduling and troubleshooting technology issues, which is also consistent with barriers identified by previous literature [27]. The second consideration was that the medical complexity of this population necessitated increased care coordination and follow-up. For these reasons, our clinicians recommended scheduling no more than 5 one-hour sessions per day. This patient caseload is similar to home health physical therapy, which also involves caring for medically complex patients. An important consideration for future studies is to evaluate whether feasibility can be maintained with larger teams and more Veterans.
We did not see changes for self-reported loneliness. Previous research demonstrated that participation in group exercise programs was associated with reduced loneliness [28], but results from a systematic review described variable changes in loneliness and social isolation following physical activity interventions [29], suggesting that some individuals may respond better to group exercise interventions than others. As such, we recommend considering additional social health and interpersonal outcomes for future studies such as social isolation and social support to help identify those who would benefit most from group interventions.
We also did not see changes for physical activity outcomes. Average daily step change scores had wide confidence intervals suggesting a high degree of variability among our participants, a finding that is consistent with other studies [8]. Variability in our data likely arose due to inaccurate data from a consumer wearable device, especially among those who used an assistive device [30]. While we anticipated this inaccuracy, we sought to explore aspects of data sharing as proof-of-concept for future studies. Less than half of participants successfully enrolled in SMHD; since the completion of this project, a new version of the application was released with the goal of reducing barriers to use. We recommend two changes for future research: 1) use of research grade activity monitor for physical activity data and 2) in-depth assessment of data sharing tools and processes.
Limitations
The program evaluation identified program strengths and weaknesses, but there are limitations to these findings. First, this evaluation was based on a small sample and may not generalize to other settings and patient populations. Feasibility surveys were not sent to patients who withdrew from the program, and this may have led to higher Veteran ratings for these outcomes. Second, we had limited Fitbit data, restricting our ability to interpret these findings. Finally, all physical function tests were collected during routine clinical re-evaluations by the treating physical therapist; while this mimics patient care, there is a risk of collection bias. We mitigated this risk by standardizing the conduct for physical function tests.
CONCLUSION
The multicomponent telerehabilitation program for older adults with multimorbidity was safe, feasible, and demonstrated positive changes in Veterans’ physical function and mental health. Some Veterans demonstrated high engagement with the technology, while others encountered multiple barriers, which limited their ability to engage with the technology. This program evaluation may help clinicians learn from our processes and adapt aspects of the program to meet local needs. Finally, telerehabilitation offers a solution to access barriers, and our findings support that such programs can be safe, feasible, and acceptable for medically complex patient populations.
Supplementary Material
KEY MESSAGES.
What is already known: Older Veterans with multimorbidity experience various health consequences, which may be further complicated by additional physical and social vulnerabilities. These health consequences and vulnerabilities often contribute to barriers accessing in-person rehabilitation services.
What this study adds: This study demonstrates the safety and feasibility of a multicomponent telerehabilitation program to mitigate access barriers while also addressing physical and social vulnerabilities.
How this study might affect research, practice, or policy: Current physical rehabilitation programs may consider integrating and adapting components to augment traditional care, such as virtual care and coaching, to better serve this vulnerable population.
Footnotes
Declaration of Interest: The authors report there are not competing interests to declare.
Data availability statement:
The authors confirm that the data supporting the findings of this study are available within the article.
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.