Review Article Virtual Visits in Home Health Care …downloads.hindawi.com/journals/tswj/2014/689873.pdfReview Article Virtual Visits in Home Health Care for Older Adults AnneMarieLundeHusebøandMarianneStorm

Review ArticleVirtual Visits in Home Health Care for Older Adults

Anne Marie Lunde Husebø and Marianne Storm

Department of Health Studies, Kjell Arholms Hus, Universitetet i Stavanger, 4036 Stavanger, Norway

Correspondence should be addressed to Anne Marie Lunde Husebø; [email protected]

Received 4 July 2014; Revised 1 October 2014; Accepted 2 November 2014; Published 20 November 2014

Academic Editor: Zaheer R. Yousef

Copyright © 2014 A. M. L. Husebø and M. Storm. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Background. This review identifies the content of virtual visits in community nursing services to older adults and explores themanner in which service users and the nurses use virtual visits. Design. An integrative literature review. Method. Data collectioncomprised a literature search in three databases: Cinahl, Medline, and PubMed. In addition, a manual search of reference lists andexpert consultation were performed. A total of 12 articles met the inclusion criteria. The articles were reviewed in terms of studycharacteristics, service content and utilization, and patient and health care provider experience. Results. Our review shows that inmost studies the service is delivered on a daily basis and in combination with in-person visits.The findings suggest that older home-dwelling patients can benefit from virtual visits in terms of enhanced social inclusion and medication compliance. Service usersand their nurses found virtual visits satisfactory and suitable for care delivery in home care to the elderly. Evidence for cost-savingbenefits of virtual visits was not found. Conclusions. The findings can inform the planning of virtual visits in home health care as acomplementary service to in-person visits, in order to meet the increasingly complex needs of older adults living at home.

1. Introduction and Background

According to the United Nations [1], developed countries arefacing a global, demographic challenge from their growingpopulation of older people. Among people 80 years or over,the average annual growth rate is twice as high as it is amongpeople 60 years or older [1]. Although many elderly peoplestay healthy, the increase in life expectancy results in a higherprevalence of chronic diseases, disabilities, and/or reducedactivities of daily living (ADL) skills. These issues reducethe ability to take care of one’s own needs and increasethe need for assistance from family members or informalcaregivers, as well as health care services for older adults.An anticipated lack of health care professionals adds to thechallenge. Recruiting and retaining highly skilled staff incare for the elderly is becoming difficult and highlights theissue of providing adequate care [2]. There is also a growinginterest amongst older individuals to age at home rather thanin a health care facility, and living at home is associatedwith higher quality of life, dignity, and independence [3].The aging population aging at home and qualified staffingtogether constitute a public health concern; in addition,they are of special concern to home health care services

in terms of organizing and providing safe and high-qualityservices. A recent review reports on differences betweenEuropean countries in policies on home care and on theorganization and availability of home care services [4]. ManyEuropean countries will need to reconsider their servicedelivery systems, based on demographic developments andfinancial constraints. The reconsideration would probablyentail attention to organizational change, staff by-in andinnovative approaches to health care service delivery.

European countries are not alone in facing these chal-lenges. In the USA, home care for the elderly is based onefforts of family caregivers [5], and concerns have been raisedas to whether informal health care can accommodate thecomplexity of an aging nation [6]. Finding new solutions tomeet the needs of home-dwelling older people has advancedthe development and implementation of assistive technologyas part of service delivery in the home.

The term “home telehealth” includes application of tele-health innovations such as interactive audio/video transmis-sions, videophone technology, monitoring of the patient’scondition, and physiological parameters such as oxygensaturation, pulse, and respiratory rate in the home envi-ronment [7, 8]. Home telehealth delivered as virtual visits

Hindawi Publishing Corporatione Scientific World JournalVolume 2014, Article ID 689873, 11 pageshttp://dx.doi.org/10.1155/2014/689873

2 The Scientific World Journal

includes the use of real-time audio-visual communicationdevices, in this review acknowledged as videoconference bythe use of videophones, personal computers/laptops, or theTV screen [9]. This means that a traditional in-person visitfrom the care provider is replaced with a virtual visit, used toassess a patient’s health status, monitor medication routines,demonstrate procedures, and provide social contact [10]. Avirtual visit allows for a natural and interactive communica-tion form that can build a trustful relationship between thepatient and the nurse [11]. Virtual visits have been associatedwith patients feeling secure and satisfied with health careinformation services [10].The challenge often lies in the user-friendliness of the technical communication devices [11];technical problems with communication equipment [12]; andmeeting patients’ preferences and care goals [10]. Virtualvisits have also been problematic when the service user hasa cognitive impairment [13].

Previous literature on home telehealth has evaluated theeconomic value of telehealth, considered the integration ofhealth-enabling technology in standard health care services,and assessed the field of home telehealth services for olderpeople suffering from chronic diseases [2, 10, 12, 14]. More-over, it includes a variety of technical devices, such as audio-video communication systems for monitoring of health-related conditions and smart-house technology, includingdevices used in health telecare. There is a lack of focus onpossible tensions in the relationship among the technology,the patient, and the nurse. Savenstedt et al. [15] have noteda dichotomy between dignified (i.e., person-centered) andundignified care, claiming that implementation of technologyin elderly care can promote both dignified and undignifiedcare. The variety in telehealth approaches and methodsimplemented in home care settings makes it difficult toassess the pros and cons of two-way, real-time, audio-visualcommunication in the delivery of daily and/or weekly homecare health services to the elderly.Thus, our study reviews thepublished research on care content and utilization of virtualvisits and in particular how old patients and the health careproviders use a virtual visit and how they experience it.

2. Methods

An integrative review of both quantitative and qualitativeresearchwas performed as outlined byWhittemore andKnafl[16]. The inclusion of studies using multiple methodologicalapproaches can broaden the understanding of the impact ofvirtual visits in future home health care and aid in planninghome telehealth practices.

2.1. Search Strategy. A literature search was carried out priorto the integrative review.The literature search was performedin the electronic databases Cinahl, Medline, and PubMedfor papers published between January 2003 and April 2013.The following search terms were used: video conferencing ORtelecommunications OR telehealth OR ehealth OR telecare.During the search in all three databases the search termswere combined with [AND] elderly OR old OR aged ORsenior OR frail elderly [AND] home care OR home care

Table 1: Data abstraction and analysis∗.

Step 1: data reduction∗ Step 2: data comparison∗ (a sample)

Study characteristics Research designHealth care setting

Service content andutilization

To reduce lonelinessTo enhance medication compliance

Patient experienceDecreased loneliness and enhancedpsychosocial contactSatisfaction with the access andflexibility of the service

Experience of home healthcare nurses

Simplified teaching and informingthe patientConcerns for patient privacy

∗Adopted fromWhittemore and Knafl (2005) [16].

serviceOR home-based careOR community health serviceORcommunity dwelling. The terms videoconferencing, telehealth,ehealth, aged, and elderly are MeSH words in the PubMeddatabase, while home care, home care services, videoconfer-encing, telehealth, and telecommunications are Cinahl head-ings. In addition to the literature searches in the electronicdatabases, reference lists of both the included studies and ofpreviously published reviews on the subject were examinedfor eligible studies. Reference tracking was conducted byconsulting a telehealth expert.

2.2. Study Selection. Titles, abstracts, and full-text articleswere read independently by the two authors (AMLH andMS). Consensus was reached in cases of uncertainty ordisagreement on a study’s eligibility. Studies included in thereview were written in English, had been subject to peerreview, and were published in scientific journals and focusedon virtual visits as part of home care health services forthe elderly. Thirty-two full-text articles were assessed foreligibility. Of these, 12 were included in the review.The searchstrategy and selection process are presented in a flow diagramin Figure 1.

Excluded studies did not meet the inclusion criteria andfocused on either the use of audio-visual communicationbetween elderly living in a nursing home and familymembersor the use of videoconferencing for communication betweenservice providers only, videoconferencing as a peer-drivenintervention, videoconferencing as part of cancer, palliativeor mental health care, or videoconferencing between thepatient and his or her physician’s office.

2.3. Data Abstraction and Analysis. The analysis process ispresented in Table 1. Analysis of the data was carried outto obtain a comprehensive and unbiased interpretation ofthe primary sources [16]. All data addressing the researchtheme of virtual visits in a home health care setting wereindependently extracted from the included articles by thetwo authors (AMLH and MS). After a constant comparisonof the data material, looking for patterns and main themes,consensus was reached. The data were classified in terms ofstudy characteristics, service content and utilization, patient

The Scientific World Journal 3

Records identified throughsearching Cinahl, Medline, andPubMed for the period January2003–April 2013 (n = 247)

Articles identified from searchingreference lists (n = 8), and

consulting telehealth expert(n = 11)

Abstracts read (n = 93)

Full-text articles read andassessed for eligibility

(n = 32)

Abstracts excluded(n = 61)

Full-text articlesexcluded (n = 20)

Articles included in thereview (n = 12)

Figure 1: Flow diagram of study selection process.

experience, and health care provider experience (Table 1, step1: data reduction). Next, the analysis and synthesis processescontinued by reducing the classifications into subgroups(Table 1, step 2: data comparison). This was done to be ableto organize and compare the primary sources on specificsubjects and relationships [16].

2.4. Quality Assessment. Evaluation of quality in integra-tive reviews is difficult due to the inclusion of studieswith multiple methodological approaches [16]. However, theauthors conducted a thorough review of the quality of thequantitative studies, focusing on study design (e.g., samplesize, randomization process). The question of “quality” inqualitative research is debatable, and rigid checklists can beinappropriate to use. This might complicate the attempt tosynthesize and summarize study quality and constitutes asource of heterogeneity [17].

3. Results

3.1. Study Characteristics. Characteristics of the 12 includedstudies are presented in Table 2. The studies were publishedbetween 2003 and 2012, with a peak in 2007-2008. Six of thestudies were conducted in North America, five in Europeancountries, and one in Australia. Four of the studies wererandomized controlled trials, with study samples rangingfrom 20 to 218 subjects [20–22, 29]. One of the studies com-bined a descriptive design with quantitative measurements[25]; three applied a descriptive design with semistructuredinterviews [19, 26, 28]; one combined qualitative interviewswith an observational study [23]; onewas a longitudinal study[24]; one was a cross-sectional study [18]; and one used aquasi-experimental design combined with qualitative data[27]. Elderly individuals (>65 years) were represented in allof the studies, while seven studies also included health careproviders [18, 19, 21, 23, 26, 28]. One study included informal

caregivers as study participants [27]. All of the studies wereconducted in a home care setting.

3.2. Content and Utilization of Virtual Visits in Home HealthCare to the Elderly. Content and utilization of the virtualvisits differed substantially among the reviewed studies.Four dominant themes on content of the virtual visits wereidentified: psychosocial and educational interventions toreduce loneliness and increase activity levels, observationand support to enhance medication compliance, support andmonitoring in chronic disease management, and follow-upservice and monitoring medication self-administration toreduce readmissions to hospitals or long-term facilities. Inmost studies [19, 20, 24, 26–28] the virtual visit was deliveredon a daily basis. In four studies [21–23, 29] the virtual visitservice was delivered weekly, and two studies [18, 25] donot mention service delivery frequency. Seven of the studiesreport virtual visits being delivered in combination with in-person visits [19–22, 28, 29].

Prevention of social isolation and increase in socialactivities were studied outcomes in three studies [18, 24, 26].Arnaert and Delesie [18] evaluated a videophone servicefor homebound elderly people, focusing on the relationshipbetween the care and social support received and on healthoutcomes. The virtual visit consisted of psychosocial supportand educational interventions and was delivered by nurses.Principles of social contact, safety and care mediation guidedthe visits. In Savolainen et al. [26], the ACTION study wasdesigned to encourage social networking and to serve asan information center for elderly service users and theirinformal caregivers. A call center with experienced nurs-ing staff operated the videophones, helping the families tomanage their situation while offering support and practicalinformation. Van Der Heide et al. [24] report on the “GoodMorning, Good Evening” service, delivered by nurses andaimed at the patients’ need for increased social contact andactivity. The service was delivered by trained care workers.


Table2:Overviewof

inclu

dedstu

dies

(𝑁=12).

Authors(year)

Aim

Design

Participants

Virtualvisitsprogram

Outcomem

easures

Find

ings

ArnaertandDele

sie(2007)

[18]

Todevelopmeasureso

fchange

inho

mebou

ndeld

erlypeop

les’fun

ctioning

andidentifycharacteris

tics

ofindividu

alsw

hose

functio

ning

improves

with

videop

hone

(VP)

nursing

care

Evaluatio

nof

ahom

eteleh

ealth

program

using

eightd

ifferentassessm

ent

scales

71eld

erlywith

meanageo

f72,70%

livingalon

eand

76%receivingform

alcare

Psycho

socialsupp

ortand

educationalinterventions

Lonelin

essS

cale

GeriatricDepressionScale

SF-15

SocialNetworkScale

Activ

ities

ofdaily

living

Instr

umentalactivities

ofdaily

living

MedicalOutcomeS

tudy

SF-36

GeriatricCenterM

oralScale

TheV

Pnu

rsingcare

redu

cedsociallonelin

essa

ndmelancholiaandim

proved

socialactiv

ityandmem

ory.No

improvem

entinADLwas

repo

rted.Frequ

ency

ofVTcalls

show

edas

ignificantand

positivea

ssociatio

nwith

change

ingeneralh

ealth

functio

ning

inindividu

alsw

ithsm

allsocial

networks

andredu

cedfamily

supp

ort.Timew

atching

televisio

n,po

orsocialnetwork,andage>

75yearsw

ere

significantly

associated

with

improved

self-perceptio

n

Arnaertand

Wainrigth(2008)

[19]

Toun

coverc

halleng

esinvolved

inim

plem

entin

gremotem

onito

ringand

interactivev

ideo

techno

logy

fore

lderlypatie

ntsw

ithchronico

bstructiv

epu

lmon

arydisease(CO

PD)

Feasibilitystu

dyapplying

adescrip

tivea

ndevaluativ

edesig

n

Threen

urses3

4–58

yearso

fage.Th

reep

atients5

6–83

yearso

fage

with

COPD

astheirp

rimarydiagno

sis

Dailyvirtualvisitsfro

ma

telehealth

nursetoexplore

patie

nts’need

ofnu

rsing

interventio

nsfollo

wing

hospita

ldisc

harge

n.a.∗

Repo

rted

challeng

esin

runn

ingtheh

ometele

health

(HTH

)werer

elated

toteam

perfo

rmance,nurse

training

,patient

recruitm

ent,andtechnicalissuesw

ithinsta

llatio

nanduseo

fHTH

.Then

ursesreceivedan

averageo

f11.5

hourso

fHTH

training

priortotheimplem

entatio

nof

HTH

.Thep

atients

experie

nced

difficulties

intro

ubleshoo

tingtechno

logical

issuesa

ndhand

lingmedicaldevices

Bowlese

tal.(2011)

[20]

Tocompare

ahom

etelehealth

(HTH

)interventio

nfore

lderly

patie

ntsfollowingho

spita

ldischargefor

heartfailure

tousualskilledho

mec

are

Rand

omized

controlledtrial

Twohu

ndredandeighteen

heartfailure

patie

nts:102in

interventio

ngrou

pand116

incontrolgroup

.Six-mon

thfollo

w-upof

study

participants

Theinterventiongrou

preceived

acom

binatio

nof

in-personandHTH

daily

mon

itorin

gandinterm

itted

videovisits.

Con

trolgroup

received

usualcare.Th

eprotocol

defin

edam

inim

umof

four

videovisits,daily

useo

fho

med

evice,and5

in-personho

mev

isits

Patie

ntsatisfaction

(question

naire

a )Health

care

utilizatio

n(hom

ecarea

gencyrecords,

andhealth

syste

mdatabase),

accessto

care

(hom

ecare

agency

records)

Ofthe

101p

atientsintheH

THinterventio

n,36

didno

treceiveo

rwantedto

receivea

nyHTH

.You

nger

patie

ntsw

ere

morelikely

toaccept

thetechn

olog

y.Ac

cessto

care,m

ore

in-personcontact,andsatisfactionweres

ignificantly

high

erforH

THpatie

nts.Nosig

nificantd

ifferencesb

etween

interventio

nandcontrolgroup

intim

etoreadmissions

ordeathno

rinem

ergencyvisitsw

erefou

nd

Dem

irise

tal.(2003)

[21]

Toexam

inetechn

ical

prob

lemsthataffectthe

interactionbetweennu

rse

andpatie

ntdu

ringvirtual

visits(VV)a

ndto

assessthe

verbalinteraction

Rand

omized

controlledtrial

Tenpatie

ntsw

ithmeanage

of78;sixpatie

ntsh

adcongestiv

eheartfailu

re,

threeh

adCO

PD,and

one

haddiabetes-related

wou

nds.

10nu

rses

from

oneu

rban

andthreer

uralho

mec

are

agencies

VVwereu

sedfora

ssessin

gthep

atient’sclinicalstatus,

prom

otingmedicationand

treatmentcom

pliance,

psycho

socialissues,and

patie

ntinform

ationand

education

Technicalquality(10-item

questio

nnaire

a )

One

hund

redandtwenty-tw

oVVwerer

eviewed.M

ean

duratio

n21min.Patientsreceivedon

averagetwosessions

with

30-m

inutetraining.Notechnicalproblem

in78

visits.

Besid

estechnicalissuesthe

VVcomprise

dthefollowing

them

es:generalinform

ation,clinicalstatus,psycho

social

issues,education,

prom

otingcompliance,patie

ntsatisfaction,

administrativ

eissues,andaccessibility.Th

enu

rses

repo

rted

theV

Vas

very

useful

oruseful

forp

atient

care

andthatthem

ajority

oftheV

Vwou

ldno

thaveb

een

perfo

rmed

bette

rinperson

Fink

elste

inetal.

(200

4)[22]

Todemon

strateq

uality,

clinicalu

sefulness,and

patie

nts’satisfactionwith

hometele

health

(HTH

)and

virtualvisits(V

V)

Rand

omized

controlledtrial

Fifty

-threep

atientsw

ithheartfailure,C

OPD

,and

chronicw

ound

s,meanage

74andrand

omized

tothree

grou

ps:(1)stand

ardcare

+videocon

ference,(2)

stand

ardcare,

videocon

ference,and

mon

itorin

g,or

(3)con

trol

grou

preceivingsta

ndard

homec

areo

nly

VVconsisted

oftwo-way

audioandvideointeraction

betweennu

rses

andpatie

nts

atho

me,aw

eb-m

essaging

syste

m,and

physiological

mon

itorin

gsyste

m

TelemedicineP

erception

Question

naire

Hom

eCareC

lient

SatisfactionInstr

ument

Atotalof567

VVwerec

ondu

cted,w

ith276by

video.Nurses

repo

rtfewtechnicalproblem

sand

repo

rted

VVuseful

and

times

avingforthe

nurses,but

notfor

thep

atients.Th

evideo/mon

itorin

g-grou

pwas

significantly

morep

ositive

toHTH

after

testing

forseveralweeks.Satisfactio

nwith

homecareincreased

forv

irtualvisitsub

jects.Th

esep

atients

feltsafeandthatthen

ursesp

aidattentionto

theirc

oncerns

andmettheirn

eeds.Th

eVVwerefou

ndto

betim

eflexible

andeasy

toschedu

le


Table2:Con

tinued.

Authors(year)

Aim

Design

Participants


Outcomem

easures

Find

ings

Jonssonand

Willman

(2008)

[23]

Tocompare

conventio

nal

metho

dson

wou

ndho

me

care

with

avirtualcon

cept

forp

atientsw

ithlegwo

unds

Quasi-experim

entalstudy

with

atestg

roup

anda

comparis

ongrou

p.Surveys,field

notes,digital

photos,and

videotaped

observations

Tenpatie

ntsw

ithwou

nds

onlower

leg/foot

andtheir

respon

siblenu

rse.Eight

patie

ntsa

ndnu

rses

inthe

controlgroup

.Sameinclusio

ncriteria

,but

nobroadb

andaccessin

the

controlgroup

Thev

irtualinformationand

consultin

gconcept,

Everyday

Learning—Leg

Wound

sand

Their

Treatm

entcon

sistedof

aweb

applicationcontaining

advice

onnu

trition

,exercise

andwou

ndtre

atment,anda

videop

hone

Interactionbetweenpatie

ntandnu

rse(22-item

questio

nnaire

a )

Patie

ntsinbo

thgrou

psrepo

rted

seeing

staffcarin

gforthem

andreceivinginform

ationandar

apid

replyas

beneficial.

Patie

ntsinthetestg

roup

repo

rted

aneedof

moretim

eto

familiarizethemselves

with

thetechn

ology.Nursesinthetest

grou

pfoun

dthetechn

olog

yuseful

forthem

morethanfor

thep

atients;itwas

humanea

ndecon

omical,w

iththew

ebmaterialasa

neducationalresou

rce.Th

enursesinthetest

grou

phadmorefrequ

entand

longer

traveltim

esdu

etothe

patie

nts’beingin

poorer

cond

ition

than

patie

ntsinthe

controlgroup

VanDer

Heide

etal.(2

012)

[24]

Toestablish

thee

ffectso

favideocommun

ication

syste

m(C

areT

V)o

nlonelin

essa

ndsafetyin

elderly

patients.

Toevaluatetheu

seof

video

commun

ication(actualu

seandexpectations)a

nduser

satisfactionwith

CareTV

Long

itudinalstudy

with

baselin

edatac

ollectionat

mom

ento

finclusio

n,anda

follo

w-upmeasurement1

year

after

inclu

sion

One

hund

redandthirtyfrail

elderly

clientsof

homec

are

organizatio

ns,m

eanageo

f73

years

Thev

ideoph

one(VP)

serviceo

fthe

CareTV

was

called“G

oodmorning

,Goo

dEv

ening”

and

inclu

dedmedicationservice

used

onad

ailybasis

andan

alarm

functio

nused

less

than

once

perm

onth

TheL

oneliness

Question

naire

Clientsfeelin

gsof

safety

(nine-item

questio

nnaire

a )

Eighty-eight

percento

fthe

clientsweres

atisfi

edwith

theu

seof

theV

P.Technicalproblem

swerer

eportedby

12%of

the

participants.

For6

3%of

thep

artic

ipants,

feeling

sof

lonelin

essd

ecreased

significantly

(𝑃<0.001).Ca

reTV

had

noeffecto

nfeeling

sofsafety,explainedby

technical

prob

lemsa

ndpatie

ntse

xperiencingdeterio

ratin

ghealth

cond

ition

sthrou

ghthes

tudy

Maire

tal.(2005)

[25]

UK

Tocompare

thep

erspectiv

esof

patie

ntsa

ndproviderso

ntelecare

encoun

tersvia

virtualvisitsused

toredu

ceho

spita

lreadm

ission

Descriptiv

e,evaluatio

nstu

dyby

theu

seof

log

repo

rtsa

ndaq

uestion

naire

Twenty-tw

onu

rses

and22

patie

ntsw

ithCO

PD.M

ean

ageo

f71y

ears

Videop

hone

interventio

nto

supp

ortm

anagem

ento

facutee

xacerbations

inCO

PDpatie

ntslivingat

home

Patie

ntandprovider

perspectives

onho

me

telecare

(10-item

questio

nnaire

a )

Nursesc

ompleted

150logs,and

patie

nts145

logs.Th

epatie

ntsc

onsistentlyrepo

rted

significantly

morep

ositive

view

softhe

teleh

ealth

encoun

tersthan

theirh

ealth

care

providers.Ca

reprovidersw

erec

oncerned

abou

tthe

negativ

eeffectsof

telehealth

oncommun

icationandtheira

bilityto

assessthep

atient’smedicalprob

lemsa

ccurately

,and

they

werelessc

omfortablewhenusingthetele

health

syste

m

Savolainen

etal.

(2008)

[26]

Toevaluatethe“Assisting

CarersusingTelematic

Interventio

nsto

meetO

lder

peop

les’Needs”(AC

TION)

syste

m

Semistructured

interviews

anddatalogging

Eightfam

ilyusers

(caregiversa

ndelderly

person

s),w

ithmeanage7

3years.

Four

professio

nalcaregivers

TheA

CTIO

N-projectusing

inform

ationand

commun

icationtechno

logy

toenhanceq

ualityo

flife

and

independ

ence

andredu

cesocialiso

latio

nin

frail

elderlyandfamily

atho

me

n.a.

Averagec

alltim

ewas

40min/m

onth/user;averageinitia

ted

calls

weres

ixperu

ser.Patie

ntsreportedvideop

hone

(VP)

redu

cedlonelin

essa

ndiso

latio

n,assistedwith

makingnew

socialcontacts,

andincreasedsocialactiv

ities

andsafety.

Barrierswereh

avingenou

ghpeop

leto

callandtechnical

start-upprob

lems.Ca

regiversrepo

rted

theV

Pcreated

trustfu

lcom

mun

ication;

thec

ameraw

asuseful

indemon

stratingprocedures

andmakingassessments.

Privacy

issues,technicalproblem

s,andneed

fora

learning

perio

dfor

thefam

ilywerea

concern

Smith

etal.(2007)

[27]

Toassesstechnicalsuccess,

medicationself-

administratio

n,neurop

sychiatricsymptom

s,andmoo

dbu

rden

follo

wing

useo

finteractiv

evideo

techno

logy

tomon

itor

medicationcompliancein

person

swith

mild

dementia

Quasi-experim

entalstudy

with

quantitativeo

utcome

datafro

mpatie

nts.

Assessm

entsof

medication

accuracy

and

neurop

sychiatric

cond

ition

s.Semistructured

interviews

with

patie

ntsa

ndcaregivers

Fourteen

elderly(aged

80–85)

with

mild

dementia

livingalon

e.Eightp

ersons

received

avideo

mon

itorin

gor

atele

phon

eservice.Six

person

sreceivedtelep

hone

serviceo

rstand

ard

unmon

itoredmedication

compliances

ervice

and

actedas

controlgroup

Televideotechno

logy

tomon

itorm

edication

compliance

GeriatricDepressionScale

Neuropsychiatric

Inventory

Medicationaccuracy

records

Participantswith

videoandph

onem

onito

ringwere

contacted4,00

0tim

esby

nursingassistances

ervices

accordingto

theirm

edicationschedu

le.En

dmedication

compliancew

as81%in

thev

ideo-m

onito

redgrou

pcomparedto

80%in

thep

hone-group

,and

66%in

the

control.Com

paris

onof

compliancefrom

initialto

end

ratin

gsshow

sstablec

omplianceinmon

itoredparticipants,

were

redu

cedin

unmon

itoredparticipants.

Rateof

change

betweenvideoandno

-mon

itorin

gwas

significantly

different

(𝑃<0.05).Th

equalitativeinterview

srevealedthatthe

caregiversexperie

nced

lessworry

andthatthetechn

olog

yim

proved

thep

atients’medicationcompliance.Other

perceivedbenefitsfrom

thetechn

olog

ywerep

revented

relocatio

nto

anursin

gho

mea

ndincreasedsocialcontact


Table2:Con

tinued.

Authors(year)

Aim

Design

Participants


Outcomem

easures

Find

ings

Wadee

tal.(200

9)[28]

Toassessthep

racticality,

suitability,safety,and

costs

ofdeliveringdaily

home

medicationmanagem

entb

yvirtualvisits(V

V)

Pilotstudy

Semistructured

interviews

Ninec

lients(aged

61–85

years),sixof

them

with

dementia

andon

ewith

mem

oryloss.Fou

rcall

center

nurses

Twoparticipantsreceived

Dire

ctlyObservedTh

erapy

fortub

erculosis,7

receiving

generalm

edication

managem

ent

n.a.

Averagelengthof

theV

Vwas

nine

minutes

comparedto

19minutes

fora

nequivalent

field

visit.O

nevirtualvisitw

as60%of

thec

osto

fafield

visit.A

llclientsrepo

rted

theV

Veasy

touse,andsix

wou

ldcontinue

use.One

mentio

ned

flexibilityof

servicea

sapo

sitive.Nursesreportedperson

alcontact,continuityof

care,flexibility,and

early

interventio

nas

advantages

∗

n.a.:

notapp

licable,

a scaledevelopedfora

pplicationin

thep

artic

ular

study.


Medication safety was the focus in four of the studies[21, 24, 27, 28]. Demiris et al. [21] found that the nurses spent13% of their communication time in a virtual visit assessing apatient’smedication compliance. In Smith et al. [27] the hometelehealth service was designed to deliver medication man-agement by virtual visits to elderly home-dwelling patientswith mild cognitive impairments. The patients’ compliancewith medication was monitored, and support was offered bymeans of videophones. Support of medication compliancewas also included as part of a telehealth service in thestudy of Van Der Heide et al. [24]. Wade et al. [28] studiedthe efficiency of using videophone to monitor medicationcompliance in elderly patients, in which two of the cases werepart of directly observed tuberculosis treatment. As in Smithet al. [27], the researchers acknowledge limitations in the useof this service due to the physical and cognitive impairmentsof elderly patients.

Support and monitoring of a chronic medical conditionin elderly people receiving home care was the primaryobjective of the home telehealth service in four studies [19, 21,23, 25]. Observing and assessing the patients’ clinical statuswas performed 42% of the time during the virtual visit andwas by far the topic/area on which the nurses spent most oftheir visual communication [21]. Virtual visits delivered byvideophonewere used for observations of the patients’ condi-tion, for real-time transmission of physiological data [19, 25],and for advising the patient in disease self-management [19].

3.3. Elderly Service Users’ Experience of Virtual Visits. Sixof the reviewed studies provided information on patients’experience by means of interviews and/or questionnaires.Decreased loneliness and enhanced psychosocial contactwere important results in half of the studies [18, 20, 21, 24,26, 27]. The patients reported that the visual contact with thehealth care workers made them feel cared for and createda sense of connection. The patients reported feeling lessisolated and indicated an increase in their social activities.The virtual visits also made the patients feel safe and secure[22, 24, 26]. Bowles et al. [20] reported that the patientswho received a virtual visit reported significantly higherlevels of personal contact than did patients receiving theusual home care visits. In the wake of decreased isolationand increased social contact, the patients experienced lessmelancholia and improved memory and attention, especiallyif they had physical and mental health problems [18].

Virtual visits can be used to monitor patients’ medica-tion compliance and to support them in medication self-administration. Although the two studies [27, 28] investi-gating a virtual visit service in medication surveillance werelimited to elders with cognitive impairments, the results maybe generalized to other patient groups. Valuable results fromthe studies are maintained competence and security in self-administration of medication [24, 27] and opportunity formedication review from service providers, thereby reducingthe risk for adverse events related to self-administration ofmedications [28].

Evaluation of the quality of home telehealth showedthat patients receiving a virtual visit and audio-visual

communication with health care providers were more satis-fied with the access and flexibility of the service than wererecipients of standard home care [20, 22, 29]. They wereconfident that the nurses could monitor and assess theirhealth status through the video communication system andprovide them with good quality care. Finkelstein et al. [29]noted that being able to schedule videoconferences on topicsthat they had chosen was of great value to the elders livingat home. Obtaining a rapid response from the nurses andtaking part in planning the care were mentioned as positivefeatures of the technology used to manage the treatment ofchronic leg wounds [23].Themajority of the studies reportedon user-friendly technology and noted minor challenges inthe implementation and use of the communication devices.One exception is the study by Arnaert and Wainrigth [19]in which elderly patients with chronic obstructive pul-monary disease complained that it was difficult tomanipulatethe medical devices and to use the computer mouse andbuttons.

Home telehealth by virtual visits as part of follow-upfrom health care services and after hospitalization showsmixed results for hospital admissions and readmissions. Inthe study by Smith et al. [27], informal caregivers expressedthat monitoring the patient’s medication compliance alsoprevented the elderly person from relocating to a nursinghome. Finkelstein et al. [29] reported that patients whoreceived telehealth had fewer hospital admissions than didpatients with usual home health care. Bowles et al. [20] foundthat the numbers of readmissions at day 30 and at more thansix months were lower for patients in the telehealth group butresults were not significant.

3.4. Home Health Care Nurses’ Experience in DeliveringVirtual Visits. The experience of the nurses who deliveredhealth services through virtual visits was studied in fiveof the studies [19, 21, 23, 25, 26]. In general, the nursesevaluated the virtual visit service positively. It simplifiedtheir efforts in teaching and informing the patients and thusbecame a source for knowledge transfer, which increasedthe patients’ possibilities of self-care. The technology madeit possible to deliver continuous and coordinated care,preventing relapses into poor health. The nurses reportedthat the telehealth was more flexible and easy to arrange,and the communication became trusting and more personalthrough the videoconference system. Another interestingresult is that the nurses in the study of Savolainen et al. [26]found the virtual visits to aid in the prevention of colds andinfections.

The nurses had some concerns in the use of virtualvisits in home care for elders. One concern was for possibleinvasions of patients’ privacy. In addition, Mair et al. [25]noted the nurses in their study were less comfortable withthe videophone than their patients were. The nurses wereconcerned about not being able to observe the patients’ healthcondition through the video screen. None of the studiesrevealed concern amongst nurses regarding the technologyreplacing personal contact or making the service impersonaland task-oriented.


4. Discussion

This integrative review focuses on home telehealth in com-munity health care services for older adults. It provides asystematic overview of the content and utilization of usingvirtual visits in the delivery of health care services to thehome-bound elderly. It also explored the elderly service users’and nurses’ experiences with using virtual visits as part ofhome health care services. The reviewed studies showed avariety in content and purpose of virtual visits in homecare services to older adults and were within the scopeof the review. Thus, one cannot rule out the possibility ofvirtual visits being appropriate for services other than thoseidentified in this review.

One important finding from this literature review isthat virtual visits can reduce social isolation among theelderly. Research shows that one-third of people over 65years of age live alone, and living alone is associated withfunctional impairment, poorer health, and social isolation[30]. Social isolation is a multidimensional concept thatcan be understood as the lack of social support in bothquantity and quality [31]. Virtual visits involve real-timecommunication and contact between service users and healthcare providers by means of videophone or other technicaldevices. It is a personal meeting although the contact is notin person. If well-planned and used in a purposeful way,any audio-video communication service could counteractsocial isolation and increase social inclusion. Ageing at homeis the preferred mode of care by the elderly population inmany countries and is associated with independent living[4]. Research has identified fear of losing one’s independenceas a common concern amongst older people [32]. Use oftechnology at home is suggested to lower older people’s senseof dependence on other people in their daily life and care [33].The challenge for administrators of health care services is increating efficient and high-quality health care services whileensuring dignified care that will promote patient autonomyand integrity [15].

Wade et al. [12] note that real-time video communica-tion has been introduced to reduce costs and to increaseaccess to health care services. Our results imply that real-time video communication in a home health care settingcan contribute to reductions in hospital admissions andpostponement of transfer to nursing homes, but the resultsare not conclusive for cost savings [20, 27, 29]. Bowles etal. [20] reported that telehomecare patients were readmittedless often than usual care patients for all causes; the resultswere not statistically significant. The economic analysis of36 articles using telehealth technology and real-time videocommunication byWade et al. [12] is also inconclusive. Ruralservice delivery using real-time video communication wasreportedly more expensive for health care services, but costsaving for patients who do not need to travel. It is alsosuggested that video communication could be cost-effectivein home care, especially when utilizing low-cost equipmentsuch as the patient’s television or small video units [12].

In this review, one study reported virtual visits to be timesaving for nurses when administering medication; nursessaved asmuch as 60% of the cost compared to a standard field

visit [28]. By fostering medication compliance by identifyinga patient’s barriers to compliance, and including reinforce-ment and reminders, virtual visits can contribute to betterself- management and increased patient satisfaction [21].Virtual visits might be particularly useful and cost-effectivefor patientswho are not in need of any support or nursing careaside from medication compliance. Self-administration ofmedication is also related to the issue of patient safety. Elderlypeople can encounter difficulties in adherence to medicationmanagement and low compliance can put the patient at riskof health deterioration [34]. Virtual visits canmake it possiblefor nurses to monitor patients’ medication compliance andalso to enhance the patients’ knowledge and understandingof theirmedications and to reduce the risk of confusion abouttheir purpose and administration.

One unexpected finding was that few studies reporta concern of reduced quality of care when the in-personencounter in the older person’s house was replaced with avirtual visit and remote communication with health careprofessionals [15]. Botsis andHartvigsen’s review [10] showedthat even though the patients accepted the technology and feltsecure and confident about the nursing assessment, they wereafraid of losing the face-to-face contact with their health careproviders. In Pols’ study [35], nurses were especially worriedthat implementation of virtual visits in home care settingswould result in impersonal care, making the nurses unableto take good care of their patients. In the present review, bothpatients and nurses were generally pleased with the qualityof the communication through videophones; in only onestudy, nurses expressed concern that the technology couldnegatively affect the quality of nurse-patient communicationand jeopardize the nurses’ ability to observe changes in theirpatients’ health [25]. The majority of the studies combinedvirtual visits with in-person visits, which might explain thehigh levels of patient and nurse satisfaction in this review.Implementation of telehealth has proven successful whennurses ensure the link to clinical practice by keeping uptheir traditional nursing style [35]. This is in line with theconclusions ofDemiris et al. [21], claiming that not all nursingactivities are suited to virtual visits and that choosing thisservice in a home care setting should be based upon thepatient’s medical and clinical condition and upon the extentof his or her care needs.

Only one of the reviewed studies [26] included informalcaregivers as informants in their research. Here, interviewswith noncohabiting caregivers provided qualitative data onopinions of telehealth services. Most elderly people expectto be supported and cared for in their homes by theirclosest relatives, and not by professional caregivers [32].Care provided by family members, referred to as “invisiblecare,” is equivalent to one year of work hours provided by ahealth professional [36]. Some countries expect a substantialincrease in the hours of average family eldercare (that iscaring for an elderly family member) from 29 to 41 hoursper week by 2030 [37]. Thus, it is crucial to include informalcaregivers in future research on the use of videophones as partof home telehealth.

The reviewed studies revealed limited attention to train-ing of the older users and nurses prior to, and during use


of, the videophone technology in the person’s home. Tofacilitate use of home telehealth and virtual visits, health careprofessionals need to focus on the benefits of home telehealth,in particular the possibility for closer follow-up from healthcare services and monitoring of the health condition [20, 33].To succeed in changing health care professionals’ embeddedwork practices Grol and Grimshaw [38] have proposed afive-step model: (1) assess their readiness to change, (2)assess barriers to guidelines use, (3) determine the appropri-ate level of intervention, (4) design the dissemination andimplementation strategies, and (5) evaluate the implemen-tation strategies. The model builds on several theoreticalapproaches, including an educational one. Transferred toimplementation of home telehealth, the educational approachsuggests that leaders of health care services use learningprocesses to motivate their workers to change by involvingthem in the planning, implementation, and evaluation of thetechnology.

Successful implementation and use of technology dependon a design that is usable and useful for elderly home-dwelling people in what Rogers and Fisk [39] term thehuman factors principle. Experiences with and acceptance oftechnology and home telehealth amongst the elderly mayvary [20, 40]. Barriers reported are the elderly’s lack of interestin technology use, worries about the cost, and being tooinfirm to use home telehealth and new technology [20, 33]. Tomeet the needs and preferences of these older service users,videophones need a design that is user-friendly, flexible,reliable, and aesthetic [13]. There is also a need for researchinto the design of appropriate training programs and learningskills needed to succeed with virtual visits in a homecaresetting.

4.1. Limitation. The present review is subject to limitations.Although our literature was comprehensive, the challengein the field of home telehealth is the variety of terms usedand the interdisciplinary character of the field (researchperformed in fields such asmedical informatics, engineering,and medical and caring science) [2]. In addition, searchingother relevant databases (e.g., Scopus) might have provideda larger number of eligible articles. There is a risk thatrelevant papers have been overlooked.This review confirmedearlier research, pointing towards the lack of large-scale,controlled trials for hypothesis testing and also longitudinalstudies evaluating the impact of technology from a long-term perspective [41]. Several of the studies included in thisreview can be considered as small-scale implementationsof virtual visits and testing of audio-visual communicationbetween elderly service users and health care provider. Inaddition, five of seven studies [20, 21, 23–25] that collectedquantitative data by questionnaires used scales developedfor the purpose of the particular study. All but one study[20] report inadequately on scale development and testing,making it difficult to review those scales’ reliability andvalidity.

Performing an integrative review allowed for the inclu-sion of studies with substantial methodological diversity.Although considered a strength of integrative reviewsby contributing to a broader perspective on the studied

phenomenon, we acknowledge that sampling and compari-son of heterogeneous studies might lead to the possibility ofbiased conclusions [17].The results should thus be interpretedwith caution.

5. Conclusion

The review identified virtual visits as having the clear advan-tages of enhanced social inclusion and less loneliness for theelderly patient and also providing support and guidance inthe patient’s self-management of medication. Both servicecategories could help postpone admission to long-term facil-ities or the need for substantial in-home care. However, thestudies in this review do not provide strong evidence for costsavings of virtual visits as part of elderly home health careservices. Thus, the review does not support the claim thatvirtual visits can be more than a supplement to traditionalin-person home care visits.

The fact that both patients and nurses, in general, foundthe technology satisfactory might be attributable to themost frequent service models applied in the studied reviews,combining virtual visits with ordinary in-person visits. Theliterature shows a duality in using technology in the homecare services, warning against eliminating in-home visitsbecause of the advantage of virtual visits [10, 14]. This high-lights the discussion of whether virtual visits can compensatefully for in-person visits, especially concerning the socialaspect of the service.The challenges lies in finding the optimalfit between home telehealth and a patient’s specific healthconcerns [41].

Webelieve that this review could informboth administra-tors and cliniciansworking in community health care serviceson how virtual visits can be integrated into home care servicesfor older adults. Moreover, the review can inform furtherdevelopment and implementation of virtual visits in a homehealth care context.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Acknowledgments

Theauthors would like to thank the funders of the project andthe Department of Health Studies, University of Stavanger,for the possibility of carrying out this study. They wouldalso like to thank partners in the Safer@home project:Lyse; Department of Electronic Engineering and ComputerSciences at University of Stavanger; Stavanger municipal-ity; Cisco; DevoTeam; VS-Safety; SINTEF; SAFER/LaerdalMedical; Stavanger University Hospital/SESAM. The studyis part of the project “Smart systems to support safer inde-pendent living and social interaction for elderly at home”(Safer@home). The project is supported by the NorwegianResearch Council under Grant Agreement no. 210799.


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Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

HypertensionInternational Journal of


Prostate CancerHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


Surgical OncologyInternational Journal of

Documents

Review Article Virtual Visits in Home Health Care …downloads.hindawi.com/journals/tswj/2014/689873.pdfReview Article Virtual Visits in Home Health Care for Older Adults AnneMarieLundeHusebøandMarianneStorm