1 Background

The fragile population, such as the older adults with disability, was severely impacted by the COVID-19 pandemic. After an initial lock-down phase in 2020, the measures subsequently adopted in Italy to limit the spread of the virus made it impossible for people living in nursing homes to have contact with the outside world. The aim of this paper is to describe how the DAT (Domotica, Ausili, Terapia Occupazionale - Home Automation, Assistive Technology and Occupational Therapy) service of Fondazione Don Carlo Gnocchi (FDG) in Milan, Italy, developed a new remote Assistive Technology (AT) assessment procedure to give continuity to the service dedicated to older adults with disability.

2 Methods

FDG has different facilities distributed throughout Italy, in 12 of these an AT service (SIVA: Servizi di Informazione e Valutazione Ausili-AT Information and Assessment services) is available with a showroom and professionals with a wide experience in AT for the independence of people with disabilities [1]. In the FDG research center (IRCCS Santa Maria Nascente) in Milan the SIVA service is part of DAT. The DAT offers a comprehensive rehabilitation pathway that includes occupational therapy training, individualized AT counselling and education towards independence [2]. The DAT professional team is prepared to help the patients find solutions to problems that they have experienced in daily life (mobility, communication, computer access, personal care, home adaptation…) and in any context (domestic life, school, workplace, social activities…).

In the initial phase of the COVID-19 lockdown in Italy, most of the outpatient services were suddenly interrupted. In such a context, FDG immediately decided to work at implementing Tele-Rehabilitation (TR) services in order to give patients the possibility to continue their rehabilitation pathways. In the very first phase, from March to May 2020, the implemented solution consisted in using some of the most common video-conferencing platforms (e.g. Microsoft Teams and Skype, Google Meet, etc.). Such solutions, although having the advantage that many patients and clinicians were already accustomed to their use, were however not suitable to be used in the long run due to two main limitations. The first one is related to the certification of the platform. The Medical Device Regulation (MDR) of the European Union (EU) requires any software solution that provides information used to take clinical decisions (either diagnostic or therapeutic) to be certified as medical device class IIa. Moreover, according to the rules set out in the General Data Protection Regulation (GDPR) of the EU, special attention has to be paid to the protection of health-related data. The use of cloud-based services for which there is no direct control on where the data centres are based is not recommended for the exchange of health-related data between patients and clinicians. The second limitation is related to the difficulties of integrating general-purpose video-conferencing platforms with the existing Hospital Information Systems (HIS) which is something that, in contrast with the goal of TR to optimize resources and costs, creates additional administration burdens.

FDG therefore started a scouting process to identify the most suitable telemedicine platform among the ones available on the market. A set of selection criteria was defined by involving clinicians working in different areas such as paediatric neuropsychiatry, adult neurological and orthopaedic rehab, home care services and AT. The involved clinicians, by exploiting their previous experiences in the use of general purpose video-conferencing platforms to provide TR services, were able to formulate a set of functional and usability requirements which encompassed both the healthcare professionals’ and patients’ points of view.

The most relevant requirements identified included:

  • the presence of video-communication functionalities, to be able to provide synchronous TR services (i.e. with the telepresence of the clinician/therapist). The video-communication system had to be able to connect multiple people at the same time (e.g. one therapist with two patients or two therapists with one patient);

  • the video-communication system had to be suitable for mobile devices (smartphone and tablet) as well, through the browser or a dedicated app;

  • the possibility to exchange files (e.g. video, images, documents, etc.) between clinicians and patients in a secure way through the platform;

  • the possibility to share the screen and send text messages during the therapeutic session;

  • the possibility to provide asynchronous TR services, by allowing the clinician to set-up a personalized plan of activities for the patient to be performed autonomously at home. The asynchronous TR system should allow the clinician to link specific contents to the exercise (e.g. video, documents, etc.) and to register the patient feedback on the performed activities;

  • the compliance with MDR and GDPR, including the adoption of best practices for data protection such as the encryption of personal and sensitive data;

  • the possibility of integrating the platform with the existing HIS.

This last point includes the possibility of integrating the TR platform with: a) FDG authentication servers (i.e. the possibility for healthcare professionals to log-in with the company credentials), b) the Master Patient Index (MPI) of FDG (i.e. the database of patient personal data), and c) the existing software solutions for managing clinicians’ agendas and producing clinical and administrative/financial reports. All the integration had to be made through HL7 protocols.

In Italy, the first attempt to provide a legislative framework for the delivery of telemedicine services was made by the Italian Ministry of Health in 2014, with the document entitled “national guidelines on telemedicine” which, however, did not provide a specific definition, nor concrete indications for the implementation of TR services. Although some experiences of TR had been promoted by Italian regional health authorities in experimental form before 2020, it was only in November 2021, that is several months after the pandemic outbreak, that an official document was issued by the Ministry of Health including national indications for the delivery of TR services. In this context, as of 2020, most of the telemedicine platforms available on the market as commercial medical device CE marked products were not specifically focused on TR. Several prototypes, developed within research and innovation projects, existed however, which represented the solid basis for the implementation of specific TR functionalities.

The platform that has eventually been selected is Maia, produced by the Italian company ab medica srl. Maia, formerly known as Telbios Connect and produced by the Italian SEM Telbios, is the result of several research and innovation projects of the company Telbios that involved FDG as clinical partner [3]. All of the functionalities listed in the requirements above have been gradually implemented in the platform, which has been progressively rolled-out in 12 different FDG facilities starting from June 2020.

The roll-out of the new technological system required an initial experimentation period in which organizational solutions were identified that were useful for achieving the maximum effectiveness of the rehabilitation intervention. The system in fact offered a great opportunity but strategies for use, organization and planning had to be identified that would allow to overcome the limits of not having the patient in presence.

In the 2020–2021 period remote AT assessments were organized so that the physiatrist responsible for assistive devices (ADs) prescription, supported by a therapist specialized in AT, could connect remotely from the DAT service to nursing homes in Milan area. In the first phase video-conferencing platforms were used, and subsequently the TR platform described above was adopted.

Before the tele-visit, documentation about the subjects was required which allowed AT experts to get an idea of the possible assistive solutions useful for each of them; this documentation included disability certification, request for AT assessment by the doctor in charge of the subjects, information about diagnosis, functional limitations, the results of the evaluation with clinical scales such as MMSE (Mini-Mental State Examination) and Barthel Index for functional evaluation. Subjects diagnoses were classified using ICD9.

The AT assessment consists of one or more tele-visits. During the first one the assessment team is composed by: the DAT physiatrist, DAT therapist and the nursing home therapist together with the patient. The nursing home rehabilitation professional supports the clinician’s decision for the most adequate assistive solution and takes the measurements useful to set up the appropriate assistive device (AD). During the tele-visit the prescription was entered in the online system provided by the regional health system and the report of the examination was written (see Fig. 1).

Fig. 1.
figure 1

The setting of the tele-visit: the physiatrist, connected remotely to the nursing home, is preforming online the prescription of the ADs identified

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In complex cases a second tele-visit can be performed before prescription in presence of an orthopaedic technician (chosen by the patient).

The prescribed ADs can be provided by the local health authorities warehouse or by a private AT company. An orthopaedic technician delivers the ADs to the nursing home and makes adjustments and customizations on site, in order to improve the fitting. The rehabilitation professional of the nursing home verifies if the ADs delivered are appropriate, if not a prescription revision can be requested and the ADs provided can be rejected and replaced.

The tele-visit is organized so that a maximum of 6 nursing home residents in need for an assistive solution could be evaluated in a single session.

The revised prescriptions, the rejected ADs and a perceived satisfaction questionnaire were chosen as quality indicators of the provided service.

Among AT outcome assessment instruments [4, 5] KWAZO questionnaire [6] was chosen to evaluate the nursing homes therapists’ satisfaction.

KWAZO is composed of seven questions about the quality of the AT service delivery process (Accessibility, Information, Coordination, Knowledge, Efficiency, Participation, Instruction). In the Italian [7] version the respondent is requested to rate his/her degree of satisfaction with each indicator on a 5-point Likert scale (‘not at all satisfied’, ‘not satisfied’, ‘more or less satisfied’, ‘satisfied’, and ‘very satisfied’) (see Table 1).

Table 1. KWAZO questionnaire questions and domains.
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We performed a qualitative descriptive analysis of data of tele-AT assessment performed in 2020 and 2021.

3 Results

During 2020–2021, 12 nursing homes had used the service and 94 residents (73 females and 21 males; mean age 86 years; SD 9.62; range: 47–100) were tele-visited. Among them, 30 had hypokinetic syndrome, 10 hemiplegia, 9 senile dementia, 7 Alzheimer’s disease, 7 cerebral vascular disease, 7 vascular dementia, 5 brain degeneration, 6 Parkinson's disease, 4 cerebrovascular disease and others pathologies or functional limitations. The following mobility ADs were prescribed: 59 tilting push wheelchairs, 33 light self-propelled wheelchairs and 2 electronic wheelchairs. The average cost for the regional health service was respectively of 2343 euros for wheelchairs push tilting, 1217 euros for self-propelled wheelchairs, 1244 euros for electronic wheelchairs (see Table 2).

Table 2. ADs prescribed to the 94 subjects involved in the study KWAZO questionnaire questions and domains.
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In 3 cases (3.2%) it was necessary to review the prescription, since, when the ADs were provided, they were no longer adequate to the resident’s situation; in 2 cases (2.1%) the AD provided was inappropriate and it was rejected.

The KWAZO questionnaire was proposed to the rehabilitation professionals involved in the tele-AT-assessments to evaluate their perceived satisfaction with the service provided. 5 questionnaires were collected, the average score obtained was 4.2. Items which obtained highest scores (4.8) were in information, coordination and know-how domains (items K2, K3, K4). The participation domain (item K6) obtained 4.6, while instruction domain (item K7) obtained 4.4. The efficiency domain (item K5) obtained 3.2 while the lowest score (3.0) was accessibility (item K1) (see Table 3).

Table 3. KWAZO scores obtained from nursing homes (NH) therapists.
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4 interviewees (80%) declared that it might be useful to maintain the remote AT assessments in the future, even when the state of emergency for the COVID-19 pandemic will be finished, 1 did not express any opinion.

4 Discussion

The subjects to whom the tele-AT-assessments were provided were fragile people with comorbidities; while social distancing measures were active they were forbidden to go out of their residences and, even later on, it was safer and more prudent to limit traveling.

The AT tele-assessments, provided by DAT, made it possible to maintain service continuity, to respond to the unmet needs of older people.

The AT assessment consisted of one or more tele-visits. The assessment team was composed by: the DAT physiatrist, DAT therapist and the nursing home therapist in presence of the patient. The nursing home rehabilitation professional supported the clinician’s decision for the most adequate assistive solution and took the measurements useful to set up the appropriate assistive device (AD).

The ADs prescribed during the tele-AT-assessments were found to be appropriate, only a small percentage (3.2%) needed to be reviewed and the prescription was then modified. In 2.1% of cases the device delivered could not be fitted or personalized adequately, was rejected and so substituted.

High levels of satisfaction with the service provided were detected through KWAZO questionnaire in information, coordination, know-how, participation and instruction domains. The main complains were about the waiting time to access the AT tele-assessment, especially in the first period and the length of the process.

The entire AT provision process includes assessment, prescription, delivery, verification and involves many actors (AT services, regional health system, AT companies). The DAT service analysed and improved the phases of the process in which it is involved (assessment and prescription): the aim was to reduce waiting times and to optimize the procedures for information/documents collection and assessment planning. DAT service could not reduce the length of the process due to the case complexity (which needed a higher number of tele-visits) and to the delivery waiting time.

5 Limitations of the Study

Due to time limitation a small number of KWAZO responses could be obtained. In the future greater consideration should be given to the users’ satisfaction with the service, collecting more interviews; the same limitation reduced the possibility to analyse more deeply the outcomes of ATs provided, for example the AT’s effects on the life of the residents or the achievements of the goals of the different stakeholders.

6 Conclusions

The pandemic has forced IT companies to develop remote work tools and healthcare facilities to engage in their use. These remote work tools allow an optimization of available resources and facilitate alternative and accessible ways to deliver rehabilitation services.

During COVID pandemics the availability of a TR platform allowed DAT to ensure AT service continuity, to organize tele-assessments and so to prescribe ADs for nursing homes residents.

The roll-out of the new technological system required an initial experimentation period in which technological and organizational solutions were identified that were useful for achieving the maximum effectiveness of the TR interventions with AT.

Usually AT assessments require the presence of the patient. In this particular situation it was possible to use the TR platform and complete the entire AT process remotely because of the presence, besides the patient, of the nursing home rehabilitation professionals who supported the DAT team in the prescription.

Prescribed ADs were found to be appropriate, interviewed users of the service were satisfied.

The authors and users of the service consider it useful to maintain and, if possible, further expand the possibility of carrying out remote AT assessments using the TR platform available, reducing traveling of frail people.