Review: Multiple ways to address telehealth barriers for stroke survivors

While the outpatient management of stroke survivors through telehealth is prone to multiple barriers, it offers many advantages for addressing health equity in stroke survivors, according to a review from UTHealth Houston.

The review – written by Anjail Sharrief, MD, MPH, first author and associate professor of neurology with McGovern Medical School at UTHealth Houston – was published recently in Stroke.

Telehealth has seen rapid expansion into chronic care management over the past several years because of the COVID-19 pandemic, Sharrief said. However, there is limited evidence for the benefits of telehealth in addressing disparities in the chronic care of patients living with stroke.

“As we begin to advance the use of telehealth in stroke and in chronic diseases in general, we must consider the potential advantages and barriers to use in populations at highest risk for disparities,” said Sharrief, who is also director of stroke prevention at the UTHealth Houston Institute of Stroke and Cerebrovascular Disease and director of the Stroke Transitions Education and Prevention (STEP) clinical program. “While telehealth can expand access to care and treatment in many ways, it also has potential to increase disparities in populations with lower levels of digital literacy, limited access to internet, and in whom physical and cognitive limitations pose barriers to telehealth utilization.”

In the paper, Sharrief and other researchers listed the various benefits telehealth offers for a range of stroke complications – such as impaired gait, vision, and cognition – as well as for certain social determinants of health, including economic instability, geographic location, and limited social support.

For example, for patients dealing with stroke-related disabilities, the researchers found that telehealth addresses barriers related to mobility challenges and special equipment needed to access clinic spaces by removing the need for transportation altogether. It also decreases the number of in-person visits required of patients, allowing for better multidisciplinary care and the ability to remotely monitor blood pressure and cardiac arrhythmias.

“One important thing to consider is that while we focus on stroke-related disability, the same principles apply to patients with other neurological diseases,” Sharrief said.

The team also identified key barriers stroke survivors face when it comes to telehealth – including physical disabilities from stroke, cognitive disabilities from stroke, limited access to internet, limited digital literacy, and limited English proficiency – and outlined potential strategies to address them.

Their key recommendations for accommodating stroke survivors with limited internet access and limited digital literacy include:

• Utilize social workers or community health workers to connect patients to available federal programs, such as the Affordable Connectivity Program, which offers discounts for internet access as well as discounts toward the purchase of a laptop, desktop computer, or tablet.
• Provide mobile hotspot devices to patients with limited Wi-Fi access.
• Use community-based telehealth outposts for visits.
• Use cellular devices for telemonitoring (e.g., blood pressure monitoring), instead of services or devices requiring Bluetooth.
• Use texting, secure messaging, smart phone applications, and other tools that do not require high-speed internet.
• Develop digital tools to accommodate patients with impaired literacy or cognitive limitations.
• Provide digital literacy training as a component of interventions.
• Use digital health navigators.
• Include patients with impaired digital literacy in intervention or study design.

“Several of the listed recommendation have shown promise for improving telehealth access and utilization in other chronic disease populations,” Sharrief said. “My group and co-authors on the manuscript are testing these in the stroke population.”

Additionally, to accommodate patients with hemiparesis or incoordination resulting from stroke, the researchers recommend developing telehealth tools and engaging informal caregivers and family members to participate in telehealth interventions. For stroke survivors with cognitive issues, they suggest avoiding the use of some tools, such as platforms and monitoring equipment, that require multiple steps for setup or need regular troubleshooting.

For patients with limited English proficiency, the authors encourage the development of telehealth platforms, telemonitoring tools, and other digital health tools to accommodate patient and caregiver language preferences.

Cheryl Bushnell, MD, MS, with Wake Forest University School of Medicine, was senior author of the review. Other co-authors with McGovern Medical School’s Department of Neurology included Munachi Okpala, MSN, NP-C, DNP, and Mary F. Love, MSN, RN, PhD, who is also with the University of Houston College of Nursing. Amy K. Guzik, MD, and Tamra Ishan Jayendra Ranasinghe, MD, both with Wake Forest University School of Medicine, and Erica Jones, MD, MPH, with The University of Texas Southwestern Medical Center, also co-authored the paper.