JCPSLP vol 14 no 3 2012

Technology

What’s the evidence? Use of telerehabilitation to provide specialist

dysphagia services Elizabeth C. Ward and Clare Burns

In this edition of “What’s the evidence?” the scenario explores the challenge of providing specialist rehabilitation services for a rural patient on their return home from a metro­ politan centre following head and neck (H&N) cancer management. Within Queensland, two hospitals located in the capital city provide the majority of the state-wide specialist care services for patients with H&N cancers. Hence many non-metropolitan patients are required to travel significant distances to access these specialist services during and post treatment. As part of their role, the specialist clinicians at the metropolitan centres provide outreach and clinical support to non-metropolitan clinicians who support the patients on their return home. This scenario explores the potential of using telerehabilitation as a service delivery model for a patient located outside the metropolitan centre. It also highlights the use of telehealth to provide mentoring and support for the local clinician. Clinical scenario Mr Jones (58) manages a large cattle property in western Queensland. He presented to his general practitioner with a 4-month history of dysphagia, weight loss, and odynophagia (pain on swallowing). He was subsequently referred to the combined head and neck (H&N) clinic of a large metropolitan hospital (1,400 km away) for specialist services where he was diagnosed with a tumour of the left pyriform fossa with nodal involvement (T2 N1 SCC) and underwent chemoradiotherapy. On completion of treatment Mr Jones continues to experience moderate dysphagia. A modified barium swallow (MBS) assessment establishes he is safe for small amounts of puree diet and moderately thick fluids; however, he requires nasogastric tube (NGT) feeds to meet his hydration and nutritional requirements. Due to financial difficulties and work commitments he is desperate to go home and the team support this, providing adequate speech pathology follow-up can be arranged. Mr Jones requires intensive swallowing intervention to enable transition to full oral intake and removal of the NGT. You are

aware that the speech pathologist working in Mr Jones’ local health service is a recent graduate who has no clinical experience in managing patients with H&N cancer. You contact her and she expresses concern with independent management of this case and requests support. In your role as the specialist clinician in the metropolitan cancer service, you provide mentoring and clinical support to colleagues within your cancer service district. Support is typically provided via email and telephone. However, given (a) the severity of Mr Jones’ dysphagia, and (b) the novice clinician’s request for mentoring, you feel that more direct assistance with his ongoing rehabilitation is needed. To help address these issues, you consider the possibility of a specialist consultation service via telerehabilitation to provide some shared clinical sessions with this patient and his local clinician on his return home. Response to this scenario Addressing the difficulties encountered by patients accessing health care demands the adoption of different modes of service delivery (Bashshur, 1997; Yellowlees & Brooks, 1999). Telehealth, the delivery of health care services using technology, is one mode of health care service delivery that allows patients to access specialist services by alleviating the barriers of distance, immobility, travel time, and cost (Kuo, Delvecchio, Babayan, & Preminger, 2001; Mun & Turner, 1999). Furthermore, it has been suggested that this mode has the potential to help clinicians optimise the timing, intensity, and sequencing of therapy services to help facilitate patient outcomes (Winters & Winters, 2004). This case scenario provides an opportunity to explore telehealth/telerehabilitation services and address questions including: “Is telerehabilitation suitable for this patient?”, “Do I have access to technology to provide the service?”, and then “What’s the evidence?” Recent guidelines note that “the candidacy and appropriateness for telerehabilitation should be determined on a case by case basis with selections firmly based on clinical judgement, client’s informed choice and professional standards of care” (Brennan et al., 2011, p. 664). You consider your patient and his situation, his pressing need for ongoing swallowing rehabilitation, his age and motivation, and the concerns of the remote new graduate clinician and determine that there are multiple factors favouring the use of telerehabilitation. You then consider the issue of equipment availability. You are aware there is general videoconferencing as well as specialist technology available in your metropolitan hospital setting. You contact the local coordinating service and establish that there is

Keywords dysphagia head and neck cancer telehealth tele­ rehabilitation This article has been peer- reviewed

Elizabeth C. Ward (top) and Clare Burns

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JCPSLP Volume 14, Number 3 2012

Journal of Clinical Practice in Speech-Language Pathology