At-Home, Internet-Enabled Therapy Sessions Enhance Access to Cognitive Rehabilitation for Traumatic Brain Injury Patients, Leading to High Levels of Patient and Therapist Satisfaction

Problem Addressed

• A common problem, especially in rural areas: Each year, 1.5 million people experience a traumatic brain injury in the United States. The leading causes of traumatic brain injury are falls, motor vehicle crashes, hits to the head, and assaults.² Rural states tend to have higher traumatic brain injury fatalities and disabilities than more urban states and areas.³
• Difficulty accessing rehabilitation services: In some areas, particularly rural ones with cold climates, many patients have limited access to health care, due to the long travel distances required and inclement weather that may occur for many months of the year. The Mayo Clinic, for example, cares for patients from throughout the Midwest portion of the United States, which means that patients often have to travel hours to be seen in person. Frequent bad weather conditions often lead to missed appointments. In addition, patients with traumatic brain injury often face other cognitive difficulties that make lengthy travel to appointments difficult, if not impossible.¹
• Remote therapy a viable option: The use of remote therapy has the potential to reach more patients in rural and distant areas. Remote therapy can also eliminate the need for traumatic brain injury patients to find transportation, navigate parking, and engage in other travel-related activities they may find challenging.

Description of the Innovative Activity

• Patient recruitment: Eligible patients have a moderate-to-severe acquired brain injury, are between the ages of 18 and 65 years old, and have access to a computer, either in their home or at a local library. Patients are recruited through announcements in Mayo's Traumatic Brain Injury newsletter, meetings, and support groups. Moderate-to-severe traumatic brain injury is defined as patients with a Glasgow Coma Scale score below 13, posttraumatic amnesia lasting more than 24 hours, neurologic imaging evidence of trauma-related abnormalities, memory impairment on standardized cognitive testing, complaints of memory impairment, and complaints of reduction in social activity and daily functioning.
• Remote therapy sessions: Using the instant messaging platform, sessions are conducted between the therapist and patient, who participate without family or outside assistance. During the sessions, the therapist and subject work through a memory notebook training program, a commonly used tool that has been a successful part of therapy in the Mayo Clinic for more than 15 years. A memory notebook is an example of an aid used to help traumatic brain injury patients cope with memory loss by compensating for lost memory ability. This training program includes several stages, mainly acquisition, application, and adoption stages, each of which is reviewed and discussed with the patients. To duplicate the ability to "see" facial expressions and other patient emotions (as would occur in face-to-face encounters), "smiley" faces, font color, and font size are used to demonstrate enthusiasm and other emotions the patient may be experiencing.

References/Related Articles

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Results

• High levels of patient satisfaction: A majority of patients reported being satisfied or very satisfied with the therapy. Few, if any, patients reported any distress related to the therapy. All participants believed that the therapist genuinely cared about them. Almost all of the subjects would use the instant messaging platform for therapy again.
• High levels of therapist satisfaction, driven by increased productivity: Participating therapists strongly supported the program, which enabled them to see more patients with fewer cancelations.
• Even patients with severe memory impairment are able to use program after period of training: On an initial efficacy study, after 1 to 2 hours of training on the instant messaging system, in a pilot group of 10 participants, only two missed any therapy sessions for a total miss rate of 4 percent.^1,2,4
• Patients improve functioning after completion of study: After completion of 60 online sessions with a therapist, individuals display significant increases in use of compensation strategies (e.g., calendar use) and were rated by their families as having improved in memory and mood.⁵

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Recruiting and training therapists: Therapists in this study were drawn from the brain rehabilitation team at Mayo. Therapists used the same therapy approach that they use in their day-to-day clinical practice but did so in accordance with the research protocol. The therapists also received brief training on use of the instant messaging system; no additional training was required because the therapy session fell squarely within the scope of their traditional duties.
• Developing the system: The Mayo Clinic worked with OMNIpod (a division of Google) to create a secure, simple instant messaging system that allows patients to click on the icon at their home computer, put in a name and password, and then instantly begin chatting with their therapist and engaging in therapy. The system uses tight security features to protect privileged communications.
• Training patients: Participating patients received training from Mayo Clinic staff on the instant messaging platform; training typically lasted about 2 hours but was not considered complete until participants showed that they can use the system on their own. The purpose of the training is to ensure a smooth transition into therapy at a remote location.

Resources Used and Skills Needed

• Staffing: One therapist led the sessions at first, with a second therapist added later. Other Mayo Clinic staff assisted with program logistics and patient training. A total of 26 patients participated in the project.
• Costs: The costs for the program were low. The time involved in system development was donated by Google. Current rates (2008) for this instant messaging system is $15.00/month for unlimited use. Most participants already had a computer or access to one, so there was no need to purchase computer equipment. Other costs included reimbursement for travel expenses for patients to come to Mayo for assessment and initial training on how to use the instant messaging system.

Funding Sources

National Institute on Disability and Rehabilitation Research; Google

Getting Started with This Innovation

• Seek outside funding for the program; the primary costs relate to building security into the system, something that Google largely donated to Mayo.
• This project was done as a research study, but if being done to deliver actual therapy, licensing requirements for therapists who participate in the program need to be reviewed to ensure compliance with state requirements. Because each state has different licensing regulations and laws, therapists who lead sessions remotely may have to be licensed in each state where their patients reside.
• Work with third-party payers and national advocacy groups (e.g., The American Telemedicine Association) on reimbursement and billing procedures for the services.

Sustaining This Innovation

• Periodically educate staff about the benefits of the program to maintain their ongoing support; sharing information on high levels of patient satisfaction can be helpful in securing this support, which is critical to sustaining the program.

Additional Considerations and Lessons

• People with memory impairment with moderate-to-severe traumatic brain injury are able to reliably and independently use the Internet for therapy sessions. Based on the positive response of program participants, Mayo has expanded the program to people with other types of brain injuries.
• In the current study, the program has expanded the study beyond traumatic brain injury to include all persons with moderate-to-severe acquired brain injury.

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