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Original Paper
Perspectives of Rehabilitation Professionals on Implementing a
Validated Home Telerehabilitation Intervention for Older Adults
in Geriatric Rehabilitation: Multisite Focus Group Study
Margriet Pol1,2,3*, PhD; Amarzish Qadeer4, BSc; Margo van Hartingsveldt1, PhD; Mohamed-Amine Choukou5,6*, PhD
1Amsterdam University of Applied Sciences, Research Group Occupational Therapy - Participation and Environment, Faculty of Health, Center of
Expertise Urban Vitality, Amsterdam, Netherlands
2Amsterdam University Medical center, location Vrije Universiteit Amsterdam, Department of Medicine for Older People, Amsterdam, Netherlands
3Amsterdam Public Health, Aging & Later Life, Amsterdam, Netherlands
4Bimedical Engineering graduate program, University of Manitoba, Winnipeg, MB, Canada
5Department of Occupational Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB,
Canada
6Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
*these authors contributed equally
Corresponding Author:
Mohamed-Amine Choukou, PhD
Department of Occupational Therapy
College of Rehabilitation Sciences, Rady Faculty of Health Sciences
University of Manitoba
771 Mcdermot Avenue
Room 111
Winnipeg, MB, R3E 0T6
Canada
Phone: 1 2043334778
Email: amine.choukou@umanitoba.ca
Abstract
Background: Owing to demographic trends and increasing health care costs, quick discharge with geriatric rehabilitation at
home is advised and recommended for older adults. Telerehabilitation has been identified as a promising tool to support rehabilitation
at home. However, there is insufficient knowledge about how to implement a validated home telerehabilitation system in other
contexts. One of the major challenges for rehabilitation professionals is transitioning to a blended work process in which human
coaching is supplemented via digital care.
Objective: The study aimed to gain an in-depth understanding of the factors that influence the implementation of an evidence-based
sensor monitoring intervention (SMI) for older adults by analyzing the perspectives of rehabilitation professionals working in 2
different health ecosystems and mapping SMI barriers and facilitators.
Methods: We adopted a qualitative study design to conduct 2 focus groups, 1 in person in the Netherlands during winter of
2017 and 1 on the web via Zoom (Zoom Video Communications; owing to the COVID-19 pandemic) in Canada during winter
of 2022, to explore rehabilitation providers’perspectives about implementing SMI. Qualitative data obtained were analyzed using
thematic analysis. Participants were a group of rehabilitation professionals in the Netherlands who have previously worked with
the SMI and a group of rehabilitation professionals in the province of Manitoba (Canada) who have not previously worked with
the SMI but who were introduced to the intervention through a 30-minute web-based presentation before the focus group.
Results: The participants expressed different characteristics of the telerehabilitation intervention that contributed to making the
intervention successful for at-home rehabilitation: focus on future participation goals, technology support provides the rehabilitation
professionals with objective and additional insight into the daily functioning of the older adults at home, SMI can be used as a
goal-setting tool, and SMI deepens their contact with older adults. The analysis showed facilitators of and barriers to the
implementation of the telerehabilitation intervention. These included personal or client-related, therapist-related, and
technology-related aspects.
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Conclusions: Rehabilitation professionals believed that telerehabilitation could be suitable for monitoring and supporting older
adults’ rehabilitation at home. To better guide the implementation of telerehabilitation in the daily practice of rehabilitation
professionals, the following steps are needed: ensuring that technology is feasible for communities with limited digital health
literacy and cognitive impairments, developing instruction tools and guidelines, and training and coaching of rehabilitation
professionals.
(JMIR Rehabil Assist Technol 2023;10:e44498) doi: 10.2196/44498
KEYWORDS
aging in place; aging well; digital technology; remote monitoring; activity; sensor; mobile phone
Introduction
The worldwide aging revolution has put the rehabilitation of
older adults high on the agenda of both health care policy and
research [1]. The 2 critical policies in many resource-limited
countries, aging and reducing hospitalization, which particularly
affect older people who are frail, have stimulated the search for
appropriate and cost-effective use of rehabilitation resources.
It is crucial to increase the adoption of digital health care
technologies to support the stakeholders (e, rehabilitation
professionals and older adults and their families) in care
pathways [2,3].
Geriatric rehabilitation (GR) is defined as “a multidimensional
approach of diagnostic and therapeutic interventions, the purpose
of which is to optimize functional capacity, promote activity
and preserve functional reserve and social participation in older
people with disabling impairments”[4]. GR consists of
multidisciplinary care with a focus on function and participation
after acute illness or functional decline [5,6]. In GR, people
over the age of 75 years living with multiple comorbidities are
often categorized into four groups: people with (1) stroke (21%
of people); (2) traumatic orthopedic problems (19% of people);
(3) elective orthopedic surgery (14% of people); and (4) other
conditions (38% of people), for example, cardiac, neurological,
or oncological problems [5,7]. Depending on national policies
and local availability, GR may be offered community service,
hospital service, skilled nursing facility, or intensive day
program. This results in different patient journeys. The aim of
GR is to return home. Once it is safe, based on the condition of
the person and social environment, people are encouraged to
be discharged home [8,9]. This decision does not mean that
these older adults are fully rehabilitated and have reached their
rehabilitation potential. They are often restricted in daily
functioning and still dependent on ongoing support by
rehabilitation professionals and informal care [10-12].
Owing to demographic trends, quick discharge with GR at home
is advised and recommended. Moreover, rehabilitation at home
is more realistic, and older adults report high satisfaction levels
[13]. Therefore, optimal rehabilitation care beyond discharge
is crucial, with particular attention to the everyday activities
that are meaningful for individuals [12,14]. However, the smooth
transition from inpatient GR to home is challenging [15]. The
first challenge is that only a minority of older adults receive
home-care rehabilitation services after discharge [12]. Second,
the therapist providing in-home rehabilitation is rarely the same
therapist at the institution from which the person received initial
care, which undermines the continuity of the rehabilitation
process. Third, working in the community differs from working
in an inpatient setting and requires other skills and work
routines. Being discharged from inpatient GR to home with a
rehabilitation plan but without continuous support negatively
influences the rehabilitation process. The lack of support has,
for example, negative consequences for adherence to prescribed
exercise routines [16] and leads to a sense of insecurity in older
adults [12]. A fourth challenge is the lack of involvement of the
older adult in decision-making related to home rehabilitation
[17].
In this context, telerehabilitation has been identified as a
promising tool in GR [2]. Previous studies investigating
telerehabilitation in different conditions have yielded
encouraging results [16,18]. A promising and effective home
telerehabilitation intervention is a sensor monitoring intervention
(SMI) for older individuals rehabilitating after hip fracture,
developed at the University of Amsterdam and the Amsterdam
University of Applied Sciences [19-21]. The intervention
consists of a rehabilitation protocol of coaching supported by
sensor monitoring. The coaching is based on the principles of
a cognitive behavioral therapy program concerning falls and
focuses on setting realistic goals for increasing performance in
meaningful daily functioning at home. The sensor technology
consists of a wearable sensor worn on the hip that was used to
assist older adults in obtaining feedback about their daily
physical functioning and as a tool to assist therapists in coaching
[22,23]. The wearable activity monitor (physical activity monitor
[PAM]; [24]) comprises a 3D accelerometer worn on the hip
(68 × 33 × 10 mm). The sensor measures the activity level per
day, expressed as a PAM score, which is the ratio between the
amount of energy used while active and the amount of energy
used while at rest, multiplied by 100. Furthermore, the sensor
gives the number of minutes of daily regular and vigorous
activity [25]. The data collected by the PAM sensor are stored
in the PAM itself and are synchronized with the gateway using
Bluetooth when the client is near the gateway. The PAM sensor
can collect data for 64 days without synchronization and runs
on a single battery for 7 months [23]. This transitional
rehabilitation starts within the geriatric care facility with a
follow-up rehabilitation at home. Figure 1 shows the sensor
monitoring platform’s components and system interactions
diagram.
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Figure 1. The sensor monitoring platform. PAM: physical activity monitor.
The results from a randomized controlled trial (RCT) were
positive. In an RCT including 240 community-dwelling older
adults after hip fracture, older adults in the sensor monitoring
group perceived greater improvements in daily functioning than
those in the care-as-usual group [22]. Although the findings
from the RCT for the SMI are positive for older adults after hip
fracture, there is insufficient knowledge about how to implement
a validated home telerehabilitation system in other contexts.
One of the major challenges for rehabilitation professionals is
the transition to a blended work process in which human
coaching is supplemented by digital care. A systematic
implementation approach will be crucial to understand its fit
within current transitional rehabilitation from different
stakeholder perspectives [26]. Therefore, the purpose of this
study was to depict the factors that influence the implementation
of an evidence-based home telerehabilitation intervention for
older adults from the perspectives of rehabilitation professionals
working in two different health ecosystems—(1) rehabilitation
professionals in the Netherlands who have previously worked
with the SMI and (2) rehabilitation professionals in the province
of Manitoba (Canada) who have not previously worked with
the SMI—by mapping of the barriers to and facilitators of using
the intervention. For the sake of clarity for international readers,
the term “Canada” will refer to the province of Manitoba in this
paper. Our study attempts to answer the following research
questions:
1. From the rehabilitation professionals’ perspectives in both
contexts (the Netherlands and Canada), what are the
characteristics of a successful telerehabilitation intervention
in the transition from inpatient to home rehabilitation?
2. What are the needs and expected roles of
technology-enabled solutions in GR at home in Canada,
and what is the Dutch experience?
3. To what extent are Canada and the Netherlands’ health
ecosystems ready to adopt the SMI?
4. From the rehabilitation professionals’ perspectives in both
contexts, what are the barriers to and facilitators of using
SMI at home?
5. What are the possible next steps to implement SMI in other
contexts in Canada and the Netherlands?
Methods
Design
For this exploratory study, we conducted 2 focus groups (FGs),
1 in person in the Netherlands (winter of 2017) and 1 on the
web via Zoom (Zoom Video Communications; owing to the
COVID-19 pandemic) in Canada (winter of 2022) to explore
rehabilitation professionals’ perspectives about implementing
SMI. This qualitative research approach allows to gain an
in‐depth understanding of the barriers to and facilitators of
using SMI in the Netherlands (FG 1) or introducing SMI in the
Canadian context (FG 2) [27]. The COREQ (Consolidated
Criteria for Reporting Qualitative Research) checklist for
reporting qualitative research was followed [28].
Context
This study was part of an ongoing study of the development,
effectiveness, and implementation of an SMI following the
Medical Research Council framework, a framework for the
development and evaluation of complex interventions [29]. The
first phases of the framework (the development of the
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intervention, feasibility, and evaluation) were conducted earlier
[30]. This study focused on the stage of implementation and
was built on the knowledge gained from the RCT and process
evaluation that we conducted alongside the RCT. There was a
worldwide surge in the use of telerehabilitation technologies
during the COVID-19 pandemic. Therefore, our study
secondarily explored the effect of the pandemic on the
rehabilitation professionals’perspectives about telerehabilitation
before and during the pandemic and using technology to support
remote care.
We conducted this study in 2 international contexts. FG 1 was
conducted in the Netherlands at the Amsterdam University of
Applied Sciences, located in Amsterdam. Participants in this
FG worked at 6 different health care organizations for GR in
the Netherlands’ middle and northwest regions. FG 2 was
conducted in Canada at the University of Manitoba located in
Winnipeg, Manitoba. All participants in this FG work at a public
rehabilitation and long-term care facility.
Participants
Focus Group 1
We purposefully sampled occupational therapists (OTs) who
delivered the intervention in the RCT (n=34) [22]. Participants
were approached by the main researcher via a recruitment mail
including an information letter.
Focus Group 2
Participants were approached via a recruitment email sent by
the Deer Lodge Centre Foundation to the Deer Lodge Centre
clinical staff. A research team member then contacted the
individuals interested in participating in the study. Eligibility
criteria for this FG were being an OT or physical therapist (PT)
with experience in GR.
Ethics Approval
FG 1 was approved by the Medical Ethics Committee of the
Amsterdam University Medical Center located in the
Netherlands (ID AMC 2015_169). FG 2 was approved by the
University of Manitoba Human Research Ethics Board
(HS24220 [H2020:390]).
FG Sessions
The FG sessions followed the guidelines as described by Kruger
et al [31].
FG 1 was moderated by an experienced independent moderator
and coauthor, MP. The FG lasted 90 minutes. We developed
and tested a topic guide to explore therapists’ experiences and
opinions regarding the use of the telerehabilitation intervention
(Multimedia Appendix 1).
First, participants were asked to introduce themselves and share
their years of experience, where they currently work, and what
type of older adults they deal with. Second, the FG discussion
goals were shared with all the participants. Third, brainstorming
with stick notes was conducted to collect the most important
topics, and questions and discussions were followed according
to the topic guide.
FG 2 was moderated by 2 coauthors (MAC and AQ), was
conducted via Zoom, and lasted 1 hour. The researchers
followed an FG guide (Multimedia Appendix 1). The discussion
started with a general introduction of MAC and AQ. Participants
were also asked to introduce themselves and share their years
of experience, where they currently work, what type of older
adults they deal with, and the focus of their work. Then, the
purpose of the FG discussion was shared with all the
participants, followed by an introduction to SMI. A 5-minute
presentation video was also shown to the participants to give
an overview of the SMI technology, its functionalities, how it
can be used to monitor older adults, and how it can help OTs
and PTs to monitor and coach their older adults.
Data Analysis
Both interviews were audiotaped, transcribed verbatim, and
anonymized before analysis. The transcripts were analyzed
using thematic analysis [31,32]. We used thematic analysis to
understand the barriers to and facilitators of implementing or
introducing SMI. The first stage was familiarization with the
data, followed by initial coding. Codes were organized in
categories (theme identification) and recurring themes (refer to
Multimedia Appendix 2 for an overview of themes, categories,
and some example quotes). The coding, theme identification,
and themes were discussed with MP and MvH (FG 1) and MAC
and AQ (FG 2). Discrepancies were resolved until agreement
was reached. The final themes were discussed with and agreed
upon by the whole research team. The final themes were not
shared with the participants owing to feasibility considerations.
Results
Focus Group 1
Overview
Participants were 9 female OTs, with a median practice
experience of 10 (range 1-18) years (Table 1). Before beginning
the FG session, participants signed an informed consent form.
The participants shared their experiences with the SMI and their
reflections and opinions about delivering the intervention. The
analysis led to five themes:
1. The transition from inpatient rehabilitation to home
rehabilitation
2. Content of the SMI
3. Facilitators of implementing an SMI for rehabilitation
4. Barriers to implementing an SMI for rehabilitation
5. Recommendations for further implementation
Anonymous quotes from participants will be used with the code
of the participant. Table 1 shows the codes and background
information of the participants of the FGs, and Figure 2 provides
a visual summary of the results.
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Table 1. Characteristics of participants in focus groups 1 and 2.
Work locationType of older adultsProfessionExperience (years)Focus group and
participant ID
1
Geriatric rehabilitation center AOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist8A
Geriatric rehabilitation center AOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist14B
Geriatric rehabilitation center BOlder adults with orthopedic
(trauma) and neurological prob-
lems
Occupational therapist1C
Geriatric rehabilitation center BOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist18D
Geriatric rehabilitation center COlder adults with orthopedic
(trauma and elective) problems
Occupational therapist14E
Geriatric rehabilitation center AOlder adults with orthopedic
(trauma and elective) and complex
health problems
Occupational therapist9F
Geriatric rehabilitation center DOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist6G
Geriatric rehabilitation center EOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist7H
Geriatric rehabilitation center FOlder adults with orthopedic
(trauma and elective), neurologi-
cal, and complex health problems
Occupational therapist12I
2
Geriatric rehabilitationOlder adults with fractures and
neurologic conditions
Physiotherapist26J
Geriatric rehabilitationGeriatric older adultsOccupational therapist30K
Geriatric rehabilitation (previous-
ly, acute care and private practice)
Geriatric older adultsOccupational therapist10L
Geriatric rehabilitationGeriatric older adultsOccupational therapist22M
Deer Lodge CentreGeriatric older adultsManager of PRIME Care and for-
mer clinical service lead for occu-
pational therapy
11N
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Figure 2. Summary of the results. PAM: physical activity monitor; SMI: sensor monitoring intervention.
Transition From Inpatient Rehabilitation to Home
Rehabilitation
The participants generally focused on the added value of
at-home rehabilitation, after discharge. They expressed that they
were used to only providing inpatient rehabilitation, and by
conducting this SMI at home, they experienced the added value
of at-home rehabilitation. Participant E said the following:
You can apply some part you practiced in the clinic
at home. There [at home] you can see the bottlenecks,
precisely the things that need to be stimulated. Then
you can apply things much better with someone.
Participant B added the following:
You can practice the task of going to the bathroom
in a rehabilitation department that has been made as
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ideal as possible with a lot of space and adjustments,
but it is often different at home.
Participants stated that they became more aware of the added
value of treating the clients in their own environment also, for
the target group orthopedic rehabilitation. Participant B said
the following:
SMI has made me more aware that, I think, with this
target group after hip fracture, it is perhaps just as
important as with the stroke target group. In the past,
we used to see almost no one at home. Still, the idea
of continuing the home-based treatment after
rehabilitation was more common among people with
cognitive problems and stroke older adults because
there were more generalization problems. Now, you
can see more going on at home than you might have
initially expected.
Content of the SMI
After focusing on the benefits of at-home rehabilitation in
general, participants mentioned different aspects of the content
of the SMI specifically.
Most participants indicated that the SMI helped to focus more
on future participation goals that focus on what people want to
do again in the future, rather than focusing on primary activities
of daily living, as illustrated by participant G:
In our regular work, we are much more focused on
practical daily functioning, such as getting in and out
of bed and going to the toilet. The goals in the SMI
are much more oriented towards the future, a few
steps further. For example, revisiting family,
traveling, or cooking, extensive cooking, it is a
different branch of “sport.”
Most participants mentioned that the added value of the
intervention helped to get the clients more involved and take
more ownership. Participant F stated the following:
The coaching procedure; actively return to those
goals each time during the therapy session; where
are we now, and how can we take another step
forward? I thought that worked well to get someone
more involved and in charge of their rehabilitation
process.
Participant H noted the following:
I notice a more responsibility on the client’s part and
more client control. And I notice that the motivation
comes more from the client.
Participants mentioned different aspects of the added value of
the sensor monitoring data that provide them additional insight
and make it more concrete. Participant I said the following:
I liked the sensor- score. Because without the sensor-
score, I sometimes found it quite challenging to shape
coaching properly. The moment you made certain
things clear with the sensor-score, also for the client,
I found it a perfect aid because you could look at it
and say: look here, you did almost nothing for two
days, and on Wednesday, you suddenly did a lot. What
did you do on Wednesday? And how did you make
sure you get more done on the other days? The
objective data makes it more concrete for me. Just a
little more concrete and insightful.
Participant E added the positive value of the sensor data to the
therapist as having more upfront information:
You can very well take that sensor information into
a conversation. The sensors give additional objective
information instead of just a perception. That’s also
very important.
Some of the participants explained that the SMI contributed to
more involvement, motivation, and taking control of the client,
as participant I said the following:
I like it because I had a man who was also cognitively
impaired, and who became very enthusiastic about
the sensor score and asked: “can I log in at home
and keep track of my score?” That motivated him.
And not only to start exercising but also to keep
himself busy with his rehabilitation. I visited him, and
he said: “well, yesterday I had a dip in my graph,
because...but the day before I went there and there,
I needed to rest.”
The visualization of the sensor data was helpful for therapists
to connect to the goals of the client, as participant E illustrated
the following:
Well, if someone has a goal, e.g., I want to exercise
more, I want to build up my condition, then you can
show that to someone, and then you can also say:
gosh, I see that you are indeed building up, you have
planned a rest day, or you have taken a rest day, well
that’s also good for recovery.
Participants experienced the coaching with sensors as providing
a deepening in their contact with the clients, as participant G
explained the following:
I found it does tighten the contact with someone,
where you would otherwise remain more superficial:
can you manage to go to the toilet and wash yourself
and dress, and maybe it is helpful if there is a shower
chair in the shower, you now go more deeply into the
conversation with people I think: gosh, what makes
it so that you can’t do it now or that you have moved
more that day.
Barriers to Implementing an SMI for Rehabilitation
The FG discussion identified some barriers to implementing an
SMI. The barriers identified were categorized into 2 groups:
client-related and therapist-related barriers.
The client-related barriers were (1) the level of vulnerability of
the clients, (2) cognitive limitations, and (3) client’s level of
acceptance and adherence. Most participants experienced
difficulties in conducting the intervention with people with
cognitive limitations, as illustrated by participant G:
I found it very difficult to coach someone with
cognitive limitations. A bit of self-reflection is difficult
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to stimulate, so realistic goal setting is challenging
if one has no insight into his functioning.
Participant B added the following:
Initiative, I think. There are people who at a certain
point in time became very passive sitting in a chair
and couldn’t think of their own way to do their daily
activities and then usually say: “you tell me what I
have to do.” Then it becomes challenging to let
someone be really active with his rehabilitation and
to start thinking about it: how can I do that?
Moreover, participant A mentioned the client’s level of
acceptance or adherence:
Sometimes the client does not understand why they
are wearing a sensor.
The therapist-related barriers were focused on the competence
in using the sensor data in coaching the client. Participant E
said the following:
Yes, I did start thinking very consciously about how
I use the data. If you indeed see that someone has
done a lot one day and very little the next, then you
need to know...how I can discuss this with someone
without sounding like: why did you do so little that
day? Because that is not at all what you want to say.
Facilitators of Implementing an SMI for Rehabilitation
Apart from the barriers, some facilitators of implementing an
SMI for rehabilitation were identified in the FG discussion.
These facilitators were categorized into two groups: (1)
client-related and (2) informal care–related facilitators. The
client-related facilitators were people who were already
interested and motivated and had good cognition. Participant
B said the following:
Some clients were very interested and motivated in
the SMI.
The level of cognitive functioning was mentioned as a facilitator:
The intervention was easy to apply when people had
good cognitive functioning.
Participants stated that they see a shift in seeing more vulnerable
people who did not function independently before admission.
People who were independent before admission found the
intervention easy to apply. Participant C said the following:
The intervention was easy to use with people who
were independent before admission.
Participants mentioned that the involvement of family or
informal caregivers makes SMI easy to use. Participant H said
the following:
The intervention was easy to use when family or
informal caregivers were involved.
Recommendations for Further Implementation
The recommendations for further implementation emanating
from the FG discussion were categorized into three groups: (1)
organization, (2) involvement of the multidisciplinary team,
and (3) training of therapists.
Participant G said the following:
In practice, who is responsible for the technology?
How do you arrange that, the technical part, the ICT
part? That gives much peace when you have some
clarity on that.
Regarding the involvement of the multidisciplinary team,
participant H said the following:
In terms of implementation, I also think that you have
to take the team with you because, as a
multidisciplinary team, you give advice and direction
to the process with the client.
Regarding the training, participant G mentioned the following:
And I really liked that training of the SMI. I would
have liked to see more examples, something with
videos or something like that.
Participant E told the following:
And on the follow-up training day, there was also a
section on cognitive problems, I found that very
useful. I think that should also be included in the basic
training because that makes up a large part of this
target group.
Focus Group 2
Overview
FG 2 involved 5 participants (n=3, 60% women and n=2, 40%
men) with 10 to 30 years of experience in GR, including 4 (80%)
OTs and 1 (20%) PT (Table 1), who agreed to participate in the
FG study and gave their written consent to participate. They all
signed consent forms electronically before gathering for the
FG. All the participants (5/5, 100%) had experience in the field
of rehabilitation and GR. The thematic analysis enabled patterns
(themes and resulting categories) across the data set to be
constantly compared and drawn together to describe users’
perceptions and perspectives about the usability of the devices
[33]. Primary themes that emerged from the data were
categorized into 2 groups: advantages and barriers. These groups
were further subdivided as follows.
Overall, 8 final categories or subthemes were identified as
advantages of using SMI technology and 7 final categories or
subthemes were identified as barriers to using SMI in Manitoba.
The advantages of using the SMI technology were categorized
into three groups: (1) motivation, (2) other programs, and (3)
client monitoring. The barriers to using SMI technology were
categorized into 3 groups: devices or materials-related,
therapy-related, and personal or client-related barriers.
FG group successfully analyzed the technology and gave
valuable feedback regarding the barriers to and facilitators of
using SMI technology in Manitoba. They effectively provided
information about the current practice and if the new
intervention will be successful in this community. The following
sections show the advantages of and barriers to using SMI.
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Advantages of Using SMI
The advantages identified in the FG discussion were categorized
into three groups: (1) motivation, (2) fit with existing programs,
and (3) monitoring clients.
Motivation
The views of our FG participants about the implementation of
SMI technology in Manitoba and its barriers and facilitators
indicated that this technology has the potential to be useful for
older adults in terms of motivation and goal setting, as stated
by participant N who “sees this technology as a goal-setting
tool” and participant J who mentioned that older adults “could
monitor the activity level that’d be beneficial as a motivator.”
According to them, this intervention is suitable for the younger
population of older adults (aged 65-75 years). They will be able
to see and know how active or inactive they are. The
intervention was found to be suitable as the OTs and PTs will
be able to monitor their clients. OTs and PTs agreed that this
intervention would be easy to implement in the younger
population of older adults and those who are active in terms of
walking and have the habit of staying active. Ensuring that the
older adults walk could be a challenge in the absence of a
caregiver or supporting family member. Nevertheless, this
intervention can be used as a goal-setting approach.
Fit With Existing Programs
Some ongoing programs such as “outpatient programs” and
“priority homes” can benefit from this technology. The
technology was also found to be suitable for personal training
and rehabilitation in general. Those outpatient programs that
see older adults for extended periods and can invest time in
monitoring older adults for long term can benefit from this
intervention. Priority home is another type of rehabilitation
program in Winnipeg, which offers at-home care, and they can
use this technology for GR and monitoring of older adults at
home. They continue to monitor older adults for months after
discharge. Participant K stated that she “could see it definitely
being useful in that type of setting where you are kind of
personal training/rehabbing people.”
Monitoring Clients
Before the COVID-19 pandemic, people used to stay in
rehabilitation centers for months and had time for improvement.
However, now, owing to the COVID-19 context, changes have
been made, and older adults do not stay in rehabilitation centers
for extended periods. The intervention could be helpful in terms
of monitoring older adults after discharge. Furthermore, this
technology will be suitable for specific populations such as the
younger population of older adults and people who live with
their family members to support them. Participant M thinks that
“it might be worth exploring for the right patient like people,
maybe, who are some of our younger geriatrics, maybe more
tech-savvy or have a supportive caregiver.” Moreover, it would
be essential to know the patient history. Implementing this
intervention to monitor older adults can aid in developing the
patient’s history over time. OTs and PTs will know whether the
person is active or inactive and, then, will be able to work with
the person accordingly using the SMI. Using SMI technology,
good awareness of a person’s history can help OTs and PTs
monitor the clients. The intervention was found to be good for
monitoring people by the OTs. Participant M enthusiastically
stated the following:
The idea of being able to monitor how much are
people doing every day is great; we would love that.
Barriers to Using SMI
Apart from the advantages of using SMI technology, some
barriers were also identified during the FG discussion. The
barriers identified in the FG discussion were categorized into
three groups: (1) device or material-related, (2) OT-related, and
(3) patient-related barriers.
Device or Material-Related Barriers
An important point raised during the discussion was that, given
the COVID-19 situation, it would be critical to ensure that the
intervention belt remained sanitized, as the older adults would
be wearing it daily and performing all their daily activities while
wearing the SMI intervention belt. The sensor score states that
one will get a PAM score of 6 with half an hour of walking,
which means a PAM score of 1 will be for 5 minutes of walking.
Ensuring that the person walks for 5 minutes straight to get a
PAM score of 1 could be a challenge. A person might be active
with intervals, for 2 to 3 minutes, probably going from one room
to another, but that might not give the PAM score.
Understanding the scores and numbers could be a challenge.
Moreover, it could be a challenge for OTs and PTs to ensure
that the belt has been placed correctly. Using SMI will not be
a challenge for the younger population of older adults, but for
the older population and those with cognitive impairment, this
could be a challenge; they also need to consider whether the
device is missing.
OTs and PTs—Related Barriers
According to our participants, OTs and PTs need time to monitor
the older adults after discharge and to read graphs of their daily
activities while also seeing or monitoring the people who are
physically present. This will require extra time, and the schedule
of OTs and PTs is usually very busy. In addition, it is difficult
to track and stay in contact with the patient on day-to-day basis
after the patient is discharged. Ensuring that older adults stay
in touch with their OTs in regular basis will be a challenge.
Participant K stated the following:
Once the patient is gone from us that bed gets filled
with somebody else, and we don’t have any
interaction with them. Once they’ve been discharged
from Deer Lodge.
Participant K also noted the following:
Days are usually filled, doing a lot of assessments,
so, when the beds are full to the day is filled with and
you’d have to like things like how long this monitoring
would continue.
Another challenge that emerged from our FG discussion is that
SMI will be difficult to use for those older adults who live
independently with no family member or caregiver. Another
challenge that the FG participants stated during the discussion
was the challenge with the older adults with cognitive
impairment. Participant M stated the following:
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It would be difficult to use them with clients with
cognitive impairment, or people have no supports, to
make sure it’s being done properly, etc. those sorts
of things.
Personal or Client-Related Barriers
Another challenge that emerged from our FG discussion is that
the sensor technology will be difficult to use for those clients
who live independently with no family member or caregiver.
A substantial challenge that the FG participants stated during
the discussion was the challenge with the older adults with
cognitive impairment. Participant M stated the following:
It would be difficult to use them with clients with
cognitive impairment, or people have no supports, to
make sure it’s being done properly etc. those sorts of
things.
A general challenge that emerged from our FG was the
practicality of SMI. Participant N thinks that “consistency and
having sensors put on clients” should be considered. In addition,
“not having gone missing” is another challenge according to
participant N. Older adults sometimes might forget to wear the
belt. In that case, OTs and PTs might be unable to monitor their
clients daily. Moreover, the older adults will be discharged and
will be at home, not at the rehabilitation centers; thus, it will be
a challenge to ensure that those people wear the intervention
belt so that the OTs and PTs can monitor them regularly. This
is more of a challenge for people with cognitive impairment.
Figure 2 depicts the factors influencing the implementation of
the SMI. It summarizes the barriers to and facilitators of
implementing SMI for at-home rehabilitation. The figure also
suggests a list of possible next steps to be considered to support
the implementation of SMI.
Discussion
Principal Findings
This study aimed to depict the factors that influence the
implementation of an evidence-based home telerehabilitation
intervention for older adults (SMI). The information gathered
was mapped as barriers to and facilitators of using SMI. We
gathered the perspectives of rehabilitation professionals working
in two different health ecosystems: (1) rehabilitation
professionals in the Netherlands who have previously worked
with SMI (FG 1) and (2) rehabilitation professionals in Manitoba
(Canada) who attended a 30-minute web-based presentation of
SMI before the beginning of the FG but who have not previously
worked and did not have experience in working with SMI (FG
2). The qualitative information collected in both contexts
provided information about their perceptions of SMI
characteristics and the determinants of successful
implementation of this telerehabilitation intervention. The
information also allowed us to identify the barriers to and
facilitators of using SMI.
The participants expressed different characteristics of the
telerehabilitation intervention that contributed to making the
intervention successful in the Netherlands for the at-home
rehabilitation of older adults and potentially successful in
Manitoba:
1. The focus of at-home telerehabilitation intervention is on
future participation goals rather than focusing on primary
activities of daily living.
2. The technology support provides the rehabilitation
professionals with objective and additional insight into the
daily functioning of the older adults at home, and
rehabilitation professionals from both countries find this
promising.
3. The technology contributes to more involvement of the
person in rehabilitation and can be used as a goal-setting
tool underpinning motivation in clients.
4. The coaching, combined with the sensors’ information,
deepens their contact with older adults.
According to the rehabilitation professionals, these intervention
characteristics facilitated the mechanisms supporting older
adults’recovery at home. This result is consistent with previous
studies of the experiences and perspectives of older adults after
hip fracture [12]. The interviewed older people positively valued
SMI and indicated that the technology served as a strategy to
enable independent living. The participants perceived that the
system contributed to their sense of safety as an important
premise for independent living [12]. Older adults mentioned
resources for their recovery, such as coaching, motivation, and
technology, that supported them to become more active in
developing motivation for engaging more fully in their
rehabilitation process [12]. However, different factors influence
the implementation. A recent Cochrane review of people after
hip fracture [34] recommends to continuously evaluate the
effectiveness of the various strategies used for rehabilitating
people with hip fractures. They found little to no difference
between supported discharge and multidisciplinary home
rehabilitation versus usual care for people living in their own
homes and no or minimal difference between multidisciplinary
rehabilitation versus usual care for nursing home residents.
Moreover, a recent systematic review, especially for people in
GR [35], concludes that outpatient GR was as effective as usual
care and possibly more cost-effective. However, in both reviews,
no strategies supported by technology were included.
Digital telerehabilitation solutions such as SMI can allow older
adults to get discharged soon from the facility while their
therapists will still be able to monitor and coach the older adults
from a distance. In the Dutch and Canadian contexts, this study
shows the need for—and interest in—using this technology to
support older adults in their rehabilitation at home.
Rehabilitation professionals stated that they became more aware
of the added value of rehabilitating the clients in their
environment and using this technology to adapt to the pandemic
and postpandemic contexts and demographic trends. Previous
researchers also have identified the benefit of telerehabilitation
in delivering cost-effective home-based interventions, thus
encouraging the transfer and maintenance of the rehabilitation
achievements to the home context [36].
As expected, the COVID-19 pandemic emerged as an accelerator
for adopting technologies to support remote care, particularly
telerehabilitation. Before the COVID-19 pandemic,
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telerehabilitation had already gained popularity in rehabilitation
and occupational therapy services, enabling independence at
home through person-centered intervention [35]. Therefore, we
are expecting digital technology to take more place to support
telerehabilitation. Therefore, in this study, we inquired about
the role that SMI would play in at-home telerehabilitation and
its acceptance and implementability. Participants in the
Netherlands experienced the added value of using SMI to gain
more insight into the functioning and participation of the older
adult at home. However, the opinions of FG-2 participants about
the acceptance of this technology were mixed. Some found it
helpful, whereas others liked the opportunity of monitoring the
older adults and checking in on them every day. According to
FG 2, the technology can be implemented in some running
programs, such as the “Outpatient Program” and “Priority
Home,” which monitor people in the community after discharge.
“Priority Home” is a person-centered collaborative philosophy
focused on keeping people—specifically older adults with high
needs—safe in their homes for as long as possible with
community support [37].
Before the COVID-19 pandemic, in Canada, older adults used
to stay for more extended periods at rehabilitation centers and
had time for treatment and improvement. Moreover, OTs are
used to ensure that the older adult is physically well before
leaving the facility. This is similar to the context in the
Netherlands. Emerging literature mentions that health care
providers turned to technology to stay in touch with older adults
[2,38,39]. Older adults were discharged sooner than before to
avoid close contact during the COVID-19 pandemic. All the
FG participants in Canada perceived monitoring and coaching
older adults after being discharged as a valuable idea and a safe
practice to standardize beyond the pandemic. They believe it
to be an excellent time to have such technology; older adults
want to be at home, and if that is possible with the help of
portable technology that will connect the older adults to their
health care providers, that technology deserves to undergo an
implementation trial [40]. In Canada, FG participants stated
that while older adults are in the rehabilitation center, they have
a team to monitor them, but once the person is discharged,
therapists have little consistent interaction with their clients.
Therefore, it is beneficial to use telerehabilitation to stay
connected after discharge to ensure that people are doing well,
as experienced during the COVID-19 pandemic. Following the
pandemic, this novel practice should be regarded as a new
standard.
The analysis showed facilitators of and barriers to the
implementation of the telerehabilitation intervention. These
included (1) personal or client-related, (2) therapist-related, and
(3) technology-related aspects. All FG participants noted that
SMI implementation is feasible if therapists can monitor clients
remotely, especially as part of existing programs (eg, outpatient
programs) and if the clients are independent and willing to
engage in a technology-enabled remote monitoring program.
The involvement of a family caregiver has also been noted as
a facilitator of implementing SMI. In terms of the intervention,
it appears that setting up clear participation goals and a
motivational strategy is a key facilitator of remote monitoring.
It is well established that motivation promotes better
telerehabilitation outcomes, as does patient involvement in
decision-making centered on goal setting [41]. Client
participation in telerehabilitation is viewed as a facilitator of
their adherence to the programs, which determines rehabilitation
success. According to the literature, the success of physical
rehabilitation programs depends on clients completing the
planned therapeutic exercises [42]. SMI provides insight into
daily activity, which is thought to promote adherence among
independent clients. The results of the RCT were positive for
the intervention group [22], and the older adults indicated that
the technology served as a strategy to enable independent living
[12]. However, both FG participants noted that client’s level of
vulnerability, cognitive limitations, and level of acceptance and
adherence are the most critical barriers to implementation. Most
participants indicated that older adults with cognitive impairment
would have difficulty in adapting to technology. However, now
and in the future, there will be more people with complex
diagnoses, with a mix of cognitive and physical deficits, and
more people will stay and return to the community. Therefore,
it is important that the technology should be accessible and easy
to use by people with limited digital health literacy [43].
Previous studies demonstrated that older adults with limited
experience could be taught to use technology successfully [44].
Rehabilitation professionals felt less confident and competent
in delivering a telerehabilitation intervention to these older
adults. Our findings are consistent with those of other studies
that found that some rehabilitation professionals perceived older
adults’ lack of confidence in a technology or their old age as a
barrier to using that technology and, as a result, may be hesitant
to incorporate telerehabilitation into their practice with older
adults [45]. These findings must be balanced between the 2 sites
in terms of years of clinical experience and technological use.
A cross-sectional survey was conducted across Canada to
determine Canadian OTs’knowledge and practice of information
and communication technology (ICT) with older adults and
factors associated with its recommendation [46]. Of 387 OTs,
only 12.4% reported recommending ICT in practice. According
to the findings, clinicians with more clinical experience were
more likely to recommend ICT. Surprisingly, Canadian
participants had more experience than their Dutch counterparts
but were more hesitant or reluctant to use the technology with
older adults and people with cognitive limitations. The
difference between the 2 sites could be owing to environmental
differences. According to the same Canadian survey, clinician
services, work environments, and client diagnoses were all
factors associated with ICT recommendation [46]. The Dutch
National Institute for Public Health and the Environment
(Rijksinstituut voor Volksgezondheid en Milieu) conducted the
2021 eHealth monitor survey to monitor the development and
uptake of eHealth across the Netherlands [47]. In comparison
with 2019, an increase in the use of eHealth was reported. For
example, the use of video calling increased greatly in 2021, and
more organizations now have so-called patient portals, apps, or
secured websites for their clients. Although the use of eHealth
has increased substantially, the COVID-19 pandemic has given
it an extra boost. One of the conclusions of the annual report
was that clients and care providers are optimistic about this
increase, but they also mention some concerns. Clients are often
unaware about eHealth options, and rehabilitation professionals
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found that eHealth creates a heavy workload. Better knowledge
and change in working methods are needed to improve this
situation [47]. This is consistent with this study, where the FG
participants suggested proper training on the use of SMI in their
practice [48].
Regarding technology-related barriers, SMI technology does
not tell us the number of steps a person walks, but the PAM
score on SMI technology indicates how much a person moved
per day. The PAM score provides insight into the overall activity
and how well a person is progressing. This information helps
create achievable goals for speedy recovery. PAM sensor
registers the amount of activity and provides insight into the
intensity of the activity performed throughout the day. This
information was perceived as valuable by the rehabilitation
professionals of both FGs. Activity monitors may not accurately
detect steps in older adults who walk slowly, as stated in the
literature [49], but SMI quantifies the intensity of movement,
making it capable of monitoring the activity regardless of the
walking speed. According to literature, long walks last longer
in hospitals than at home after discharge, whereas short walks
are usually more frequent and short at home [50]. It was
mentioned by the FG participants that the therapists would want
the older adults to be active after getting discharged, but once
they leave the facility, they do not do that often. Overall, all the
FG participants believed that telerehabilitation could be helpful
for older adults. It will help OTs and PTs to have more insight
into the daily physical activities of the individuals after getting
discharged and allow older adults to be treated in their own
homes.
Making telerehabilitation beneficial, functional, and feasible
for people with cognitive impairment could be the next
important step in making the telerehabilitation technology better
and more suitable for such a population. We should further
develop the graphs of the sensor technology to give better
information to therapists to help them understand what the
sensor scores mean and how the scores are situated versus the
rehabilitation goals already set up with the older adult. Training
on how to use the telerehabilitation intervention with people
with cognitive impairment and implementing the intervention
in their daily practice is needed. Therefore, we must develop
instructional tools and guidelines with the rehabilitation
professionals and older adults to ensure implementation in their
working routines. Collaboration among all stakeholders in
further developing the telerehabilitation intervention is essential
for its implementation [29]. Our results indicate that the adoption
of telerehabilitation technology may take time. It will be good
to implement this technology not only for the younger
population of older adults (aged 65-75 years) but also to make
it feasible for all different groups of the older population,
including those with low digital health literacy. Although there
will be barriers with some specific populations, such as older
adults with cognitive impairment, the technology can be
implemented successfully in practice with the proper
approaches.
Strengths and Limitations
One of the strengths of our study was the generation of a
valuable understanding of rehabilitation professionals’
experiences and perspectives about implementing a
telerehabilitation intervention and the factors contributing to its
implementation. Another strength is that we included data from
2 different international contexts, before and after the COVID-19
pandemic, and collected data from participants who had
hands-on experience with an SMI and from participants who
had not. Internationally, GR is offered as different services;
therefore, we can only make general recommendations for
implementing an SMI, as obtained from the FG discussions. It
is necessary to test the SMI in a specific context. The 2 studies
did not include the perspectives of older people, their family
members, or decision makers about the SMI technology.
However, we investigated the perspectives of older adults in
the Netherlands previously [12]. The studies concentrated on
rehabilitation professionals because they are involved in both
the individual (care delivery to older adults) and system levels.
However, more studies are needed to understand the factors
influencing SMI implementation from organizational
perspectives (eg, policy makers and decision makers) and
perspectives of older adults and their family members in Canada.
Conclusions
Rehabilitation professionals believed that telerehabilitation
could be suitable for monitoring and supporting older adults’
rehabilitation at home. The analysis showed facilitators of and
barriers to the implementation of the telerehabilitation
intervention. These included (1) personal or client-related, (2)
therapist-related, and (3) technology-related aspects. To better
guide the implementation of telerehabilitation in the daily
practice of rehabilitation professionals, the following steps are
needed: (1) ensuring that technology is feasible for a population
with limited digital health literacy or cognitive impairments,
(2) developing instruction tools and guidelines, and (3) training
and coaching of rehabilitation professionals.
Acknowledgments
The authors thank all the therapists for participating in the 2 focus groups. The authors thank Robert Kruijne for his support during
the focus group in the Netherlands. The study conducted in Manitoba was supported by Deer Lodge Centre Foundation (2020
grant) and Mitacs (project IT22356). The study in the Netherlands was supported by Dutch grant Fonds Nuts Ohra (1401-057).
MP was supported by the Netherlands Organisation for Scientific Research (NWO; project 023.003.059)
Data Availability
The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.
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Conflicts of Interest
None declared.
Multimedia Appendix 1
Topic guide for focus group for exploring occupational therapists’ experience with and opinions about delivering the sensor
monitoring intervention for rehabilitation after hip fracture (SO-HIP).
[DOCX File , 17 KB-Multimedia Appendix 1]
Multimedia Appendix 2
Overview of themes, categories, and quotes from the focus group interviews.
[DOCX File , 25 KB-Multimedia Appendix 2]
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Abbreviations
COREQ: Consolidated Criteria for Reporting Qualitative Research
FG: focus group
GR: geriatric rehabilitation
ICT: information and communication technology
OT: occupational therapist
PAM: physical activity monitor
PT: physical therapist
RCT: randomized controlled trial
SMI: sensor monitoring intervention
Edited by A Mavragani; submitted 21.11.22; peer-reviewed by C Becker, V Zander, J Zhu, A DeVito Dabbs; comments to author
08.03.23; revised version received 24.05.23; accepted 01.06.23; published 18.07.23
Please cite as:
Pol M, Qadeer A, van Hartingsveldt M, Choukou MA
Perspectives of Rehabilitation Professionals on Implementing a Validated Home Telerehabilitation Intervention for Older Adults in
Geriatric Rehabilitation: Multisite Focus Group Study
JMIR Rehabil Assist Technol 2023;10:e44498
URL: https://rehab.jmir.org/2023/1/e44498
doi: 10.2196/44498
PMID:
©Margriet Pol, Amarzish Qadeer, Margo van Hartingsveldt, Mohamed-Amine Choukou. Originally published in JMIR
Rehabilitation and Assistive Technology (https://rehab.jmir.org), 18.07.2023. This is an open-access article distributed under the
terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive
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Technology, is properly cited. The complete bibliographic information, a link to the original publication on https://rehab.jmir.org/,
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